Transcript PEDIATRIC BEHAVIOR RATING SCALE

Early Onset Bipolar Disorder
and the
Pediatric Behavior Rating Scale™
(PBRS™)
Children’s Mental Health

5,000,000

80% (America’s youth with mental health needs who fail
(the number of children and adolescents in the U.S.
suffer from a serious mental disorder resulting in significant functional
impairments at home, at school, and with peers.)
to be identified and to receive treatment and services.)

6-8 years – from onset to treatment for mood disorders

CONSEQUENCES
(of untreated mental disorders
include suicide, addictions, school failure, and criminal
involvement).
Information obtained from National Alliance on Mental Illness web site Aug. 2007
Society benefits when Mental Health is addressed early
DIAGNOSIS DU JOUR?
1980’S ADHD
1990’S DEPRESSION
2000’S EOBPD
RATES OF DIAGNOSIS
 4,000% increase in rate of EOBPD
diagnoses in the past 10 years (Frontline,
2008)
 At present, over 1 million American
children have an EOBPD diagnosis, and
the number is steadily increasing
(Frontline, 2008)
PROBLEMS IDENTIFYING
BPD IN CHILDREN
EOBPD is not in DSM IV.
EOPBD looks like other disorders.
EOBPD has high rates of comorbidity.
PROBLEM 1: EOBPD
isn’t in DSM IV

BIPOLAR DISORDERS
•Bipolar l Disorder
•Mania and major depression
•Bipolar ll Disorder
•Hypomania & major depression
•Cyclothymic Disorder
•Hypomania & depression/dysthymia
EOBPD vs. Adult BPD
EOBPD
Adult BPD
Mixed Mood Episodes
are typical
Discrete Mood Episodes
are typical
Ultra-Rapid Cycling is
common
Longer cycles
Symptomatic most of the Periods of no symptoms
time
between cycles
(Birmaher et al, 2008; Danielyan et al, 2007; Kowatch et al, 2005)
PROBLEM 1: EOBPD
isn’t in DSM IV
 Bipolar Disorder-Not Otherwise
Specified
◦ Rapid alternation between manic and
depressive symptoms that do not meet the
duration criteria for manic, hypomanic, or
major depression
◦ Hypomanic without depression
◦ Infrequent episodes
PROBLEM 2: EOBPD mimics
other disorders
Disruptive Behavior Disorders
ADHD
 60-93% meet diagnostic criteria for ADHD
(Biederman, et. al, 2003)
 Mania versus hyperactivity
 More anger, irritability, aggressive temper
tantrums
 Presence of elation, grandiosity, racing
thoughts/flight of ideas, decreased need for
sleep, hypersexuality
PROBLEM 2: EOBPD mimics
other disorders
ODD
 77-88% have ODD (Wozniak et. al, 1995)
 More intense irritability and severe emotional
meltdowns
CD
 42-69% have CD (Biederman, et. al, 2003)
 Violent and aggressive behavior lacks intent,
planning, and premeditation
PROBLEM 2: EOBPD mimics
other disorders
Anxiety Disorders
 56-75% have anxiety disorder (Wozniak et. al, 1995;
Masi, et. al, 2001)
Tourette’s Disorder, Schizophrenia, Autism
Spectrum Disorder
WHAT WE KNOW:
SYMPTOMS ASSOCIATED with EOBPD
Inflexible
 Oppositional
 Irritable
 Explosive rages
 Erratic sleep
 Difficult to soothe
 Separation anxiety
 Night terrors
 Fear of death and
annihilation
 Rapid cycling

Precociousness
 Sensitivity to stimuli
 Problems with peers
 Temperature
dysregulation
 Craving for carbs. and
sweets
 Bedwetting and soiling
 Hypersexuality
 Hallucinations
 Suicidal ideation

Frequency of EOBPD Symptoms
Very Often
(90%-97%)
Often
(60%-80%)
Sometimes
(20%-35%)
Infrequent
(Less than 10%)
Irritability
Anxiety
Hypersexuality
Homicidal Ideas
Mood Lability
Racing Thoughts
Psychosis
Suicidal Acts
Sleep Disorder
Pressured Spch
Suicidal Ideation
Anger; Rage
Euphoria,
Grandiosity
Self-harm
Parenting a bipolar child
p. 39.
Impulsivity
Agitation
Aggression
From: Faedda & Austin, 2006
Psychosis
Tillman et al (2008), 257 EOBPD participants, ages
6-16, funded by NIMH
 Psychosis was present in 76.3% of subjects

◦ 38.9% with delusions
 Grandiose was most common
◦ 5.1% with pathological hallucinations
 Visual hallucinations were most common
◦ 32.3% with both
DEVIANCE


VOLUNTARY - we have a tendency to
attribute misbehavior—especially
noncompliance and disobedience--to
willful disobedience.
INVOLUNTARY - we tend to minimize
this even when it explains the child’s
behavior.
EOBPD and AROUSAL
Children with EOBPD
 are less able to modulate arousal
 live in fear
 are “on alert” for danger
 are primed for “fight/flight” response
And when aroused, aggression is more likely.
WHAT KIND OF
AGGRESSION IS BEING
EXPRESSED?
Predatory-controlled (instrumental)
Defensive-impulsive, reactive (not for gain)
CHARACTERISTIC
DIAGNOSIS
AGGRESSION TYPE
Impulse Control
ADHD
Accidents/ Injuries
Emotional Instability
Bipolar, Borderline, IED
Reactive, affective attack
Irritability
Depression, Dysthymia
Acting Out, Suicide
Anxiety/Low Frustration
Tolerance
Anxiety, PTSD, ASD
Reactive striking out
Impaired Judgment
Substance Abuse,
Psychosis
Inadvertent Aggression
Stimulation Seeking
CD, ODD
Predatory Aggression
REACTIONARY and CONFRONTATIONAL
approaches serve mainly to provoke and
escalate.
GOALS OF INTERVENTIONS
Stabilize
Reduce Symptoms
Opposition
Defiance
Irritability
Aggression
Improve Functioning (academic, social)
TWO WAYS TO ACHIEVE
THESE GOALS
Medications (to make the child “available”)
Psychotherapies (coping & managing)
General Rule for Interventions

Behavioral approaches tend to focus on
consequences.

There are two problems with this…
TWO PROBLEMS
1. By definition, children and adolescents with
deficits in impulse control and selfregulation do not consider consequences
before they act.
2. Behavioral consequences (especially if they
are aversive) introduce provocation,
confrontation…and escalation.
INTERVENTION TARGETS
CHILD
medications
sleep
self-regulation
PARENTS
psychoeducation
medication compliance
ENVIRONMENT (control the pace)
home
school
DRUG TREATMENTS EOBPD
FOUR MAJOR CLASSES of MOOD STABILIZERS
Lithium
Antiepileptics (Mood Stabilizers)
Antidepressants
Antipsychotics
CHARACTERISTIC
DIAGNOSIS
AGGRESSION TYPE
MEDI
Impulse Control
ADHD
Accidents/ Injuries
STIMU
S
ANTIPS
MOOD S
Affective Instability
Bipolar, Borderline,
IED
Reactive, affective
attack
ANTISP
MOOD S
S
Irritability
Depression, Dysthymia
Acting Out, Suicide
S
OT
ANTIDEP
Anxiety/Low
Frustration Tolerance
Anxiety, PTSD, ASD
Reactive striking out
OT
ANTIDPE
S
TE
CLON
Impaired Judgment
Substance Abuse,
Psychosis
Inadvertent
Aggression
ANTIPS
Stimulation Seeking
CD, ODD
Predatory Aggression
MOOD S
NONDRUG INTERVENTIONS
THERE ARE 550
PSYCHOTHERAPIES
(NONMEDICAL
INTERVENTIONS) FOR
TREATING CHILDREN AND
ADULTS
BEYOND BEHAVIORISM
Parent Management Training
Cognitive Behavioral Therapy
Dialectal Behavior Therapy
Choice Theory
Problem-Solving Skills
Health Promoting Environments
RACT
STIC
DIAGNOSIS
AGGRESSION TYPE
PSYCHOTHERAPY
pulse
ntrol
ADHD
Accidents/ Injuries
CBT; DBT
PROBLEM-SOLVING
Parent Training
ctive
ability
Bipolar, Borderline, IED
Reactive, affective attack
CBT; DBT
PROBLEM-SOLVING
Parent Training
ability
Depression, Dysthymia
Acting Out, Suicide
CBT
ty/Low
ration
rance
Anxiety, PTSD, ASD
Reactive striking out
CBT; DBT
PROBLEM-SOLVING
Parent Training
aired
ment
Substance Abuse, Psychosis
Inadvertent Aggression
Cognitive Enhancement
Therapy
ulation
eking
CD, ODD
Predatory Aggression
Parent Training
PSYCHOEDUCATION
•The Bipolar Child (3rd Edition) by Papolos and Papolos (2006)
•Understanding the Mind of Your Bipolar Child by Lombardo
(2006)
•The Bipolar Disorder Survival Guide by Miklowitz (2002)
•The Bipolar Teen by Miklowitz and George (2008)
•www.bpchildren.com
•www.bipolarhelpcenter.com
•www.bipolarkids.org
•www.cabf.org
•www.jbrf.org/juv_bipolar/faq.html
Three-Tier Model of Behavioral
Intervention/Support
Tier III:
Intensive, Individual Interventions
1 - 5%
1-5%
10-15%
Tier II:
Targeted Group Interventions
80 - 90%
Tier I:
Universal Interventions/Supports
80
10- -90%
15%
Tier III: Individual Interventions
 Goal: To develop and implement
interventions for student behaviors that
can not be addressed or remedied via Tier
I or Tier II interventions.
FUNCTIONAL ASSESSMENT
Modified from: Santilli, Nancy, Dodson, W.E., Walton, A.V. (1991)
INTERVENTIONS FOR SIMPLE
Monopharmacy
 Mildly intrusive therapy
individual therapy
group therapy
parent training
 Regular classroom placement
 Favorable RTI

INTERVENTIONS FOR COMPROMISED
Polypharmacy (aggression, irritability, comorbidity)
 Intensive child and family therapies
individual therapy
group therapy
family therapy/parent training
 May require Spec. Ed. (EH, SED, OHI)
 Variable RTI

INTERVENTIONS FOR COMPLEX
Polypharmacy
 Intensive Interventions
individual therapy
intensive parent training
alternative educational placements
Acute hospitalization
Self-contained to RTC
Law Enforcement
 Very poor prognosis

Predictors of Outcome
 Worse outcomes are associated with:
◦ Younger age of onset
◦ Long duration of mood symptoms
◦ Low socioeconomic status
◦ Lifetime psychosis
(Birmaher et al, 2006)
PEDIATRIC BEHAVIOR
RATING SCALE
WHY A NEW RATING SCALE?
•
Existing scales came out normal
•
Item analysis told us why
•
The need for differential diagnosis
OTHER SCALES
•
Young Mania Rating Scale–Parent Version (P-YMRS; 11 items)
General Behavior Inventory (GBI; 73 items; age 11; self-report
accuracy)
•
•
Child Mania Rating Scale (CMRS; mania only)
Conners’ Abbreviated Symptom Questionnaire (ASQ; 10
mania items from
the Conners’ Parent Rating Scales [CPRS])
•
Omnibus rating scales (e.g., Clinical Assessment of Behavior
[CAB], Achenbach System of Empirically Based Assessment
[ASEBA], Behavior Assessment System for Children [BASC])
•
PURPOSE
•
For children and adolescents ages 3-18 years
•
Primary function: To assist in the identification of
emotional dysregulation and related disorders,
specifically early onset bipolar disorder (EOBPD)
•
Secondary function: To aid in differential diagnosis,
leading to differential interventions
FEATURES
Sufficient items to identify core features of EOBPD,
such as:
Mood swings
Irritability
Grandiosity
Easily provoked
Explosive outbursts
• Syndromal differentiation (e.g., ADHD vs. EOBPD)
• Identifies areas of concern rather than providing
diagnoses
•
PBRS APPLICATIONS
•
•
•
Clinical
Distinguish between EOBPD and its mimics
Symptom identification and profile analysis
Areas of concern
Educational
Clarify diagnosis using IDEA
More complete symptom profile (intervention)
Research
Defining the disorder in children
Handling comorbidity
Intervention efficacy
COMPONENTS
•
•
Parent Form
PBRS Parent Item Booklet (102 items)
PBRS Parent Response Booklet
PBRS Parent Score Summary/Profile Form
Teacher Form
PBRS Teacher Item Booklet (95 items)
PBRS Teacher Response Booklet
PBRS Teacher Score Summary/Profile Form
SCORES PRODUCED
•
Inconsistency Score
Can I trust the responses?
•
Critical Items
No matter what, these are clinically important
•
Symptom Scales
Each is important, as is the profile
•
Total Bipolar Index
Composite of all 8 symptom scales
CRITICAL ITEMS
These items have special clinical significance and
should be given special attention. Any item with a
score greater than zero should be investigated further
as this suggests a serious problem that must be
addressed or ruled out.
• Self-abuse
• Hallucinations
• Bizarre beliefs
• Expresses violent themes
• Suicidal thoughts
• Aggression
SYMPTOM SCALES
Eight clinical scales and one index
• Atypical (psychotic symptoms)
• Irritability (persistent and chronic)
• Grandiosity (exaggerated sense of self)
• Hyperactivity/Impulsivity (as in ADHD)
• Aggression (toward others, animals, objects)
• Inattention (as in ADHD)
• Affect (mood disturbances, cognitive distortion)
• Social Interactions (interacting with peers)
• Total Bipolar Index
Atypical (ATY) Scale
Bizarre beliefs
 Auditory hallucinations
 Delusions
 Self-harm behaviors
 Excessive fears

Irritability (IRR) Scale
Emotional dysregulation
 Behavioral/emotional outbursts
 Demandingness

Grandiosity (GRAND) Scale
Elevated sense of self and mood
 Not taking responsibility for actions
 Exaggerating
 Stealing

Hyperactivity/Impulsivity (HYPER) Scale
Classic description of overactivity and
impulsivity
 Difficulty sitting still
 Acts without thinking about consequences
 Always on the go

Aggression (AGG) Scale

Aggression targeting other people, animals, or
objects
Inattention (INATT) Scale
Traditional scale for inattention and
distractibility
 Difficulty focusing
 Difficulty sustaining attention

Affect (AFF) Scale
Mood disturbances
 Suicidal ideation
 Cognitive distortions

Social Interactions (SOC) Scale
Ability to interact with peers
 Ability to make friends
 Relating to others
 Engaging in social interactions

TOTAL BIPOLAR INDEX
•
TBI is a composite of the 8 scales
•
The most robust PBRS score (like g on IQ tests)
T scores >70 are a significant concern for disorders
of emotional dysregulation; T scores >80 suggest
EOBPD
•
The most effective way to differentiate EOBPD from
other diagnoses (especially ADHD)
•
POPULATION
•
Normative sample
Parents n = 541
Teachers n = 610
•
Clinical sample (clinical groups included BPD,
ADHD, CD, ODD, and autism spectrum disorders
[ASD])
Parents n = 224
Teachers n = 194
RELIABILITY
Internal consistency
Coefficient α for PBRS-P = .60 to .89
• Coefficient α for PBRS-T = .75 to .93
•
Coefficient α for PBRS-P TBX = .95
• Coefficient α for PBRS-T TBX = .97
•
RELIABILITY
•
•
Parent-teacher interrater reliability
Coefficient α = .77 to .86
Coefficient α for TBX = .88
Parent-parent interrater reliability
Coefficient α = .67 to .86
Coefficient α for TBX = .85
VALIDITY
Convergent validity: Omnibus rating scales for
similar behaviors
•
•
•
•
PBRS-P with CAB ≈ .50-.80
PBRS-T with CAB ≈ .30-.80
PBRS-P with BASC-2 ≈ .60-.80
PBRS-T with BASC-2 ≈ .70-.80
VALIDITY
Convergent validity: Domain-specific rating scales
• PBRS-P with CMRS = .07 (Affect) to .63 (Aggression)
• PBRS-T with CMRS = -.23 (Affect) to .70
(Hyperactivity/Impulsivity)
• PBRS-T with Conduct Disorder Scale (CDS) = .52 to.74
on four similar scales
• PBRS-T with Conners’ Teacher Rating Scales (CTRS) =
.16 (Cognitive Problems/Inattention with Atypical) to .69
(Hyperactivity with Hyperactivity/Impulsivity)
VALIDITY
Clinical validity
• Normative group compared to clinical groups
(BPD, ADHD, ODD, CD, ASD) on the 8 scales
and the TBX were significant at p < .001.
• The 8 scales and the TBX differentiated the five
clinical groups on all scales except Atypical and
Inattention (Parent) and Irritability and
Inattention (Teacher).