Transcript The Bipolar Child - VA Association of Visiting Teachers

The Bipolar Child
Miriam E. Halpern, MD
10/27/2009
What is it?
• Bipolar Disorder
• condition characterized by periods
of high mood and low moods
• Studies show that 1.5% of the
population will have at least one
hypomanic or manic episode in
their adult lives
Hypomanic
• When a person is hypomanic
• Feels unusually good and competent, or
simply irritable
• Thoughts race, speech is often
pressured
• Distractible and flit from topic to topic
• Sleep seems less necessary
• Drive for pleasurable activities with
uncharacteristic disregard for risk
Depression
• the other pole of Bipolar Disorder
• may vary in severity from a relative
decrease in enjoyment and interest, to a
painful lack of pleasure in anything
• disturbances in concentration, sleep,
appetite and energy as well as paralysis
of decision making
• guilt and low self-esteem are common
Definition
• The thought that a child can be too happy,
too cocky, too exuberant, is an anathema
to many people. But when we're talking
about childhood bipolar I disorder, we are
talking about children who are so silly and
giddy that families are asked not to bring
them to church; who are so cocky,
expansive, and grandiose that they go to
the principal's office and tell them to fire
teachers they don't like; bright kids who
fail classes because they are fully
convinced they know it all and don't
study," .
Recent Changes
• Brady Case and Anthony Russo,
researchers at New York University,
reported that the number of children
under 18 who had been diagnosed
with bipolar disorder increased
fourfold between 1999 and 2000
(Groopman, 2007). Another report
shows up to a 600% increase in
children under the age of 13
diagnosed with bipolar disorder in
the past 10 years (Groopman, 2007)
New understanding
• The authors presented a
groundbreaking premise that not
only do children and adolescents
actually develop bipolar disorder in
childhood, but much more commonly
than anyone had conceived. They
also strongly supported the
hypothesis that the symptoms of
bipolar disorder in children are
different than those seen in adults.
Renewed concept
• study contributes to a growing
awareness that serious mental
illnesses do not emerge de novo
when individuals reach
adulthood but rather reflect
early developmental processes.
New awareness
• it is important that physicians
are aware that mania in
children does exist and that
they know, at least at this time,
that outcomes are poor, so that
they can appropriately counsel
families. Arch Gen Psychiatry.
2008;162:1125-3113
In addition
• Childhood sexual and physical abuse
are associated with mental health
problems and psychiatric disorders
in adulthood (MacMillian et al. 2001;
Molnar et al. 2001). Among adults
with SMI, childhood abuse is
associated with greater psychiatric
symptoms, including depression,
psychosis, dissociation, and
posttraumatic stress (Craine et al.
1988; Malow et al. 2006
The Risk
• A conservative estimate of an individual's
risk of having full-blown bipolar disorder is
1 percent. Disorders in the bipolar
spectrum may affect 4-6%.
• When one parent has bipolar disorder, the
risk to each child is l5-30%.
• When both parents have bipolar disorder,
the risk increases to 50-75%.
• The risk in siblings and fraternal twins is
15-25%.
• The risk in identical twins is approximately
70%.
What?????
• In every generation since World War
II, there is a higher incidence and an
earlier age of onset of bipolar
disorder and depression. On
average, children with bipolar
disorder experience their first
episode of illness 10 years earlier
than their parents' generation did.
The reason for this is unknown.
Keep in mind
• The family trees of many
children who develop earlyonset bipolar disorder include
individuals who suffered from
substance abuse and/or mood
disorders (often undiagnosed).
Common Symptoms
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Separation anxiety
Rages & explosive temper tantrums
Marked irritability
Oppositional behavior
Frequent mood swing
Distractibility
Hyperactivity
Impulsivity
Restlessness/ fidgetiness
Silliness, goofiness, giddiness
Common Symptoms
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Racing thoughts
Aggressive behavior
Grandiosity
Carbohydrate cravings
Risk-taking behaviors
Depressed mood
Lethargy
Low self-esteem
Difficulty getting up in the morning
Social anxiety
Oversensitivity to emotional or
environmental triggers
Common Symptoms
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Bed-wetting (especially in boys)
Night terrors
Rapid or pressured speech
Obsessive, perseverative behaviors
Excessive daydreaming
Compulsive behavior
Motor & vocal tics
Learning disabilities (especially nonverbal)
• Poor short-term memory
Common Symptoms
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Lack of organization
Fascination with gore or morbid topics
Hyper-sexuality
Manipulative behavior
Bossiness
Lying
Suicidal thoughts
Destruction of property
Paranoia
Hallucinations & delusions
Less Common
• Migraine headaches
• Binging
• Self-mutilating behaviors
• Cruelty to animals
Children, more than
adults
• experience faster mood swings,
often cycling (changing from
mania to depression) many
times within a day
• exhibit a "mixed" state that is a
mix of mania and depression
Children
• with bipolar disorder are at risk
for school failure, substance
abuse, and suicide.
• The lifetime mortality rate for
bipolar disorder (from suicide) is
higher than some childhood
cancers.
ADHD
• Since hyperactivity can be seen
in both bipolar disorder and
ADHD, many children who are
diagnosed with “severe ADHD”
may actually have undiagnosed
bipolar disorder.
Academic issues
• The disorder affects learning
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difficulties with sleep
energy
school attendance
concentration
executive function
cognition
Co-occurring Learning
Disorders
• Many of these children are
bright or creative but they often
have co-occurring learning
disabilities.
• Non verbal learning disorders
• Autobiographical narrative issues
Difficulties in
• Paying attention
• Remembering and recalling
information
• Thinking critically, categorizing, and
organizing information
• Employing problem-solving skills
• Coordinating eye-hand movements
Needs
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Consistent scheduling
Planned and unplanned breaks
Seating with few distractions
Providing buffer space and
model children
Needs
• Shortened assignments
• Homework focusing on quality,
not quantity
• Prior notice of transitions or
changes in routine
• Minimizing surprises
Needs
• Scheduling the student’s most
challenging tasks at a time of
day when the child is best
able to perform
• allowing for medication-related
tiredness, hunger, etc.
Needs - continued
• Reduce exposure to stressors
• Help build coping skills
• Structure and predictability
Discipline
• Experts recommend some
praise for all children at least
once every 5 minutes, or 12
positive comments for every
negative statement.
Suggestions
• Focus on facts and solving
problems (rather than blame).
• Inform parents regularly about
how the student is performing.
• via a notebook that goes back and
forth to school with the child, or a
daily chart or e-mail that records
successes, progress, difficulties,
and mood information.
More Suggestions
• Provide opportunities for the
student to move around during
class.
• Work on computers, or use
manipulatives.
• Encourage him/her to get
involved in other interactive
activities.
Don’t forget
• Children in a depressed state find it
extremely hard to wake up in time
for school.
• They should not be penalized for
tardiness that is biologically based.
• Any talk of suicide must be taken
seriously and reported to the child’s
parents.
“No tolerance”
• Defiance and aggression are the
most challenging moods to manage.
• The best strategy:
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Do not take it personally
Keep your composure
Do not get involved in power struggles.
Remain a positive model.
Prompt children who are rude to
rephrase statements politely and try
again.
• Be firm and consistent.
Remember
• Try to ignore inappropriate,
attention-getting behaviors as
much as possible.
• Use “bossiness” to everyone’s
advantage by making the child a
leader or teacher.
Use Social Stories
• Guidelines for writing your own
social stories:
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Picture the goal
Gather information
Tailor the text
Teach with the title
• Additional Resources
• www.thegraycenter.org/socialstories
.cfm
Think Education!
• Build the child’s skills that
lead to appropriate reactions
and behavior, including emotion
labeling, empathy, anger
management, social rules,
nonverbal communication and
making amends
Safe place
• Students with bipolar disorder
need an established “safe”
person—an adult to go to when
feeling overwhelmed—and a
safe place.
Accommodations
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modified time constraints
altered or simpler instructions
oral testing or the use of a scribe
an altered environment (such as a room
with few or no other students)
• multiple-choice or matching rather than
open-ended questions
• tools such as a calculator or word bank
• offering an alternative type of assignment
to reduce the stress of testing
Classification
• An OHI classification clearly
defines the child’s heightened
levels of impulsivity,
distractibility, sensory
integration deficiencies, and
poor decision-making skills as
being due to this neurological
disorder.
Medications
• On June 9, 2004, the task force
of experts and stakeholders,
established in 2003 by NAMI’s
Policy Research Institute
(NPRI), released a report
addressing issues related to the
use of psychotropic
medications for children and
adolescents.
The Bad News
• About 1 in 10 children in the
U.S. suffers from a mental
illness severe enough to cause
impairment.
Treatment Problems
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Not as effective in children
Inadequately studied
Off label use
Medical malpractice
Informed consent
Diagnostic Confusion
• Diagnoses that mimic, mask, or co-occur
with pediatric bipolar disorder include:
• Attention-deficit hyperactivity disorder (ADHD)*
• Depression
• Oppositional-defiant disorder (ODD)
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• Conduct disorder (CD)
Pervasive developmental disorder (PDD)
Generalized anxiety disorder (GAD)
Panic disorder
Obsessive-compulsive disorder (OCD)
Tourette syndrome (TS)
Seizure disorders
Reactive attachment disorder (RAD)
The Dilemma
• It is estimated that 85% of
children with bipolar disorder
also have ADHD and up to 22%
of children with ADHD have
bipolar disorder.
Gold Standard
• Lithium Carbonate
• Eskalith, Lithobid
• Lithium alters sodium transport in
nerve and muscle cells and effects
a shift toward intraneuronal
metabolism of catecholamines
• Excellent anti-manic agent
• Not anti-depressant
Target Symptoms
• pressure of speech, motor
hyperactivity, reduced need for
sleep, flight of ideas,
grandiosity, elation, poor
judgment, aggressiveness, and
possibly hostility
The Other Side
• Lithium toxicity is closely related to
serum lithium levels, and can occur
at doses close to therapeutic levels
• FREQUENT BLOOD MONITORING
• Diarrhea, vomiting, drowsiness,
muscular weakness, and lack of
coordination may be early signs of
lithium intoxication
Common Side Effects
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Thirst
Tremor
Sleepiness
Gastrointestinal upset
Cognitive slowing
Other Mood Stabilizers
• Anti-epileptics
• Anti-psychotics
• Nicotine
Anti-epileptic
• Depakote (divalproex)
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Most studied
Moderately effective in studies
Blood monitoring
Side effects include sedation,
gastrointestinal effects, hepatic
effects (especially young children)
Depakote
• No correlation with therapeutic
range (sometimes have to push
up high)
• Hair loss or thinning
• PCOS in females
• Weight gain
• Osteoporosis
Tegretol, Trileptal
• Not well studied in adolescents
• Well tolerated
• Effectiveness may not relate to
drug levels
• Some evidence of use for ADHD
in Europe
Other AEDs
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Keppra
Neurontin
Lamictal
Topamax
Anti-psychotics
• Atypical neuroleptics
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Risperdal (Risperidone)
Zyprexa (Olanzepine)
Abilify (Aripiprazole)
Geodon (Ziprasidone)
Seroquel (Quetiapine)
Anti-psychotics
• Essentially off label use in
children under age 13 years
• Long term side effects
(metabolic syndrome)
• Efficacy not well studied in
children
Nicotinic Receptor
• Comorbid bipolar disorder in
Tourette’s syndrome responds
to the nicotinic receptor
antagonist mecamylamine
(Inversine)
Omega Fatty Acids
• recognized to have intracellular
effects similar to lithium and
valproate
• well tolerated and improved the
short-term course of illness in a
preliminary study of adults with
bipolar disorder
Co-morbidity
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ADHD
Tic Disorders
Depression
Personality Disorder
Self harming
Mental Retardation
Autism
ADHD
• Controversial usage of
stimulants
• Limited effectiveness over time
of stimulants
• Worsening of symptoms vs.
delayed diagnosis
Tic Disorders
• Co-morbidity between TS and
BD does not appear to be due to
chance co-occurrence of the
two disorders.
• Family history, gene theories
Depression
• Agitated depression is more
common in children and teens
than in adults.
Personality Disorder
• Need a good developmental
model for borderline personality
disorder in children
• Present classification system
not helpful
Self harming
• When present, what
medications are indicated?
• Obsessive compulsive
characteristic?
• Social construct/ group activity
Mental Retardation
• According to the DSM-IV, all types of
disorders are found in mentally retarded
persons, with an incidence at least 3-4x
higher than in the general population.
Rutter, Graham, and Yule (1970), in their
epidemiological study on the Isle of Wight,
found psychiatric problems in 30% to 42%
of retarded children and adolescents, as
opposed to 7% of the children with normal
intelligence levels.
Autism and Familial Major Mood
Disorder: Are They Related?
Robert DeLong, M.D., D.S.
• Medications that proved to be
beneficial are the same as those
used for mood disorder in the nonautistic population, atypical
antipsychotics, and mood stabilizers
(lithium or antiepileptic agents). This
does not prove that autism and mood
disorder are the same, but strongly
suggests that their neurotransmitter
and receptor characteristics must be
similar.
Conclusion
• Childhood Bipolar Disorder is
real and in a school near you
• Medications are not yet the
answer
• CBD has an effect on academic
performance of the child
References
• The Bipolar Child, by Papolos
and Papolos
• www.bipolarchild.com/
• bipolar.about.com/cs/
• www.nimh.nih.gov/health
• www.nami.org