Bipolar Disorder in Children and Adolescents Diagnostic Issues

Bipolar Disorder in Children and Adolescents: Diagnostic Issues and Clinical Case Follow-up James H. Johnson, Ph. D, ABPP/CAP University of Florida *Some material for this presentation provided by NIMH Publication No. 00 -4778 (2003)

Bipolar Disorder: General Introduction Bipolar disorder is a largely biologically based disorder that causes extreme variations in a person's mood and energy and impairs their ability to function. It causes dramatic mood swings - from an overly "high" and/or irritable mood to sad and hopeless mood, and back. In older adolescents and adults there are often periods of normal mood in between. Mood related changes are accompanied by severe variations in energy and behavior. The periods of highs and lows are called episodes of mania and depression.

Symptoms of Bipolar Disorder: Mania/Manic Episode Increased energy, activity, and restlessness. Excessively "high, “ euphoric mood. Extreme irritability. Racing thoughts, talking very fast, jumping from one idea to another. Distractibility, inability to concentrate. Decreased need for sleep. Unrealistic beliefs in one's abilities and powers

Symptoms of Bipolar Disorder: Manic Episode Poor judgment Spending sprees. Increased sexual drive Abuse of drugs, particularly cocaine, alcohol, and sleeping medications. Provocative, intrusive, or aggressive behavior. Denial that anything is wrong. A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for 1 week or longer (? ). If the mood is irritable, four additional symptoms must be present.

Symptoms of Bipolar Disorder: Hypomania A mild to moderate level of mania is called “hypomania”. Hypomania may feel good to the person who experiences it and may be associated with good functioning and enhanced productivity. Without proper treatment, however, hypomania can become more severe or can switch into depression.

Symptoms of Bipolar Disorder: Depressive Episode Sad, anxious, or empty mood Feelings of hopelessness or pessimism Feelings of guilt, worthlessness, or helplessness Loss of interest or pleasure in activities once enjoyed, including sex Decreased energy, a feeling of fatigue or of being "slowed down". Difficulty concentrating, remembering, making decisions. Restlessness or irritability.

Symptoms of Bipolar Disorder: Depressive Episode Sleeping too much, or can't sleep. Change in appetite and/or unintended weight loss or gain Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury Thoughts of death or suicide, or suicide attempts. A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer (? ).

Mood Swings & Symptoms of Psychosis Severe episodes of mania or depression can include symptoms of psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations and delusions. Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time (are mood congruent)

Bipolar Spectrum It’s helpful to think of various mood states in bipolar disorder as a spectrum or continuous range. At one end is severe depression, then moderate depression and then mild low mood. This mild low mood is often short-lived (it’s termed "dysthymia" when chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania.

Bipolar Spectrum Disorders

Bipolar Disorder: Mixed States Symptoms of mania and depression may occur together in a mixed state. Symptoms of a mixed state often include agitation, trouble sleeping, change in appetite, psychosis, and suicidal thinking. This may be accompanied by a sad, hopeless mood while also feeling highly energized.

Diagnosis of Bipolar Disorder Subtypes The classic form of the disorder involves recurrent episodes of both mania and depression (Bipolar I). In some cases the person never develops severe mania, but experiences episodes of hypomania that alternate with depression (Bipolar II). When four or more episodes occur within a 12 -month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than among men.

Child/Adolescent Bipolar Disorder Until recently, the diagnosis of Bipolar Disorder was seen as only appropriate for adults. Indeed, few clinicians would have considered using this diagnostic category with children. Despite continued controversy, it is increasingly common to find clinicians using this diagnosis with both children and adolescents.

Child/Adolescent Bipolar Disorder It is now believed that symptoms of bipolar disorder can emerge in early childhood. Mothers often report that children, later diagnosed with early-onset bipolar disorder, were extremely difficult to soothe and slept erratically. They seemed extraordinarily clingy and, from a very young age, often displayed – uncontrollable, seizure-like tantrums – rage reactions. These often appear to be without obvious provocation.

Prevalence of Child Bipolar Disorder Prevalence of Bipolar Disorder in children is largely unknown as there are no well accepted criteria for the diagnosis of Child Bipolar disorder. This is because DSM IV criteria are often viewed as inadequate for use with younger children, due to a different clinical presentation in childhood. The best guess is that the disorder occurs at least as often as adult bipolar disorder (e. g. , ~1. 2 %) Many believe that this disorder is significantly under diagnosed in in younger individuals.

Clinical Presentation of Child Bipolar Disorder It has been suggested that a significant number of children diagnosed with ADHD at a very early age may actually have early-onset bipolar disorder instead of (or along with) ADHD. According to the American Academy of Child and Adolescent Psychiatry, up to one-third of children and adolescents with depressive disorders may actually have early onset of bipolar disorder. Approximately 20 to 40 % of adults with Bipolar Disorder report a childhood onset of symptoms.

Child/Adolescent Bipolar Disorder: Clinical Presentation As with adults, Bipolar disorder in children is viewed a serious and chronic mental disorder. It is characterized by recurrent episodes of depression, mania, and/or mixed symptom states. It has been suggested that child bipolar disorder may be a more severe form of the illness than older adolescent and adult-onset bipolar disorder.

Child/Adolescent Bipolar Disorder: Clinical Presentation While older adolescents often have a clinical presentation that is similar to that seen with adults. The clinical presentation of early-onset bipolar disorder in children can look quite different than that seen in older individuals. Clinicians may fail to diagnose this disorder when using DSM IV criteria for the diagnosis of this condition.

Child/Adolescent Bipolar Disorder: Clinical Presentation Most cases of child bipolar disorder do not present with the sudden or acute onset often found with adults. Most do not show the improvement between episodes, often found with adult bipolar disorder. With children the symptom onset may be more insidious.

Child/Adolescent Bipolar Disorder: Clinical Presentation With children, – Initial symptoms can be depressive in nature With these being confused with and treated as MDD – In other cases, ADHD like symptoms may appear first with these symptoms being followed by a manic episode. Unlike adults - children in a manic state are more likely to be irritable and prone to destructive outbursts than to be elated or euphoric.

Child/Adolescent Bipolar Disorder: Clinical Presentation Children, more often show – rapid cycling and mixed states rather than clear manic or clearly depressive episodes, and – an “ongoing and continuous mood disturbance that is a mix of mania (or hypomania) and depression”. There may be few clear periods of wellness between episodes.

Child/Adolescent Bipolar Disorder: Clinical Presentation As noted earlier, hyperactivity is often the first manifestation of early-onset bipolar disorder. When children are initially seen because of bipolar symptoms, – approximately 90% of early-onset, and – 30 % of adolescents with bipolar disorder meet criteria for a diagnosis of ADHD. Comorbid conduct disorder is also common.

Bipolar Disorder vs. ADHD Bipolar Disorder (Mania) 1. More talkative than usual, or pressure to keep talking 2. Distractibility 3. Increase in goal directed activity or psychomotor agitation ADHD 1. Often talks excessively 2. Is often easily distracted by extraneous stimuli 3. Is often “on the go” or often acts as if “driven by a motor” Differentiation: Elated mood, Grandiosity, Decreased need for sleep, Hypersexuality, and Irritable mood. Hart (2005)

Child Bipolar Disorder: Comorbidity Attention Deficit Hyperactivity Disorder (ADHD) – Between 30 (adolescents) - 90% (children) display symptoms Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD) – 70 - 75% Substance Abuse (adolescents) – 40 - 50% Anxiety Disorders – 35 - 40%

Treatment of Child Bipolar Disorder Treatment of children with bipolar disorder is generally similar to adults with this disorder. – Although, less is known about the effectiveness & safety of the medications used. – Lithium appears to frequently have a strong prophylactic effect against mania, and is sometimes used with children. – However, in very early onset bipolar disorder, with a heavy family loading, children may not respond as well to lithium as do adults.

Treatment of Child Bipolar Disorder As with adults, anti-convulsants are often used to control rapid cycling and aggressive behavior. – Depakote – an anti-convulsant – used to control rapid cycling. – Tergetol – an anti-convulsant – has anti-manic and antiaggressive qualities. – Other anti-convulsants (Neurontin, Lamictal, Topamax) Sometimes these are used in combination with Lithium. Abilify is another relatively new drug which is being used in the treatment of bipolar disorder in children and adults – Developed as an add-on treatment to antidepressants for Major Depressive Disorder in adults but seems to also have anti-manic effects. – Not FDA approved for children under 18 but is currently being prescribed for children.

Treatment of Child Bipolar Disorder As with adults, certain antipsychotic drugs may also be used to control symptoms. Included here atypical antipsychotic medications such as Clozaril®, Zyprexa®, Risperdal®, and Seroquel®. Such drugs have been shown to sometimes function as mood stabilizers in cases were drugs like lithium and anticonvulsants may not work They are used to deal with acute mania, and/or to treat psychotic depression.

Issues in the Pharmacological Treatment of Child Bipolar Disorder Bipolar youth often require multiple medications for mood stabilization, treatment of attention problems, depression, and sometimes psychotic symptoms. There can, however, be risks with drug treatments Problems can arise in cases of misdiagnosis. Sometimes children with undiagnosed bipolar disorder are mistakenly treated for MDD with antidepressants.

Issues in the Pharmacological Treatment of Child Bipolar Disorder Treating such children with antidepressants (in the absence of a mood stabilizer) can actually precipitate or exacerbate manic symptoms. In children with ADHD symptoms, treatment with stimulant drugs (in the absence of a mood stabilizer) can result in manic symptoms and/or worsen symptoms.

Issues in Pharmacological Treatment of Child Bipolar Disorder It is difficult to determine which children will become manic or experience a worsening of symptoms There seems to be a somewhat greater likelihood among children with a strong family history of bipolar disorder. It has been suggested that – if manic symptoms develop or markedly worsen during antidepressant or stimulant use, the diagnosis and treatment for bipolar disorder should be considered. Proper diagnosis of Child Bipolar Disorder is necessary to avoid these problems. Must be aware that bipolar disorder can mimic conditions like ADHD and Depression due to symptom overlap

Additional Treatment Approaches Treatments in addition to medication are often necessary to assist children with bipolar disorder and their families. These interventions may involve – Educating the family about the nature of childhood bipolar disorder and involving the family in treatment. – Insuring that children receive the special educational services necessary to prevent them from falling behind academically – Appropriate classroom accommodations to help them function effectively in the academic environment. – Family and individual approaches to therapy should be provided as necessary.

Case Presentation: ADHD or Bipolar Disorder Bobby – A 12 year – 8 month old male in the 7 th Grade was seen in Clinic during 2002 – Brought to the clinic by his guardians (paternal grandparents) – Always had problems with attention and hyperactivity (from birth) as well as oppositional and socially inappropriate behavior – These and other difficulties had worsened during the months preceding the evaluation. – Diagnosed with ADHD in first grade and has been medicated since then. – Grandparents and school wonder if there may be some disorder in addition to ADHD that my contribute to his problems.

Developmental/School History Mom thought to have used drugs and alcohol during first three months of pregnancy Pregnancy with no complications Reached all milestones on time or early Low grade fevers (undetermined causes) from 1 ½ to 4 years. Hospitalized at age 6 for pneumonia. Diagnosed with ADHD at age 6 Behavioral difficulties in school but average academic performance in most subjects

Recent Behavioral Difficulties During the six months preceding the evaluation had shown a wide range of behavioral variations including Increased oppositional behavior and significant depression Refusal to bathe, brush teeth and Had lost interest in friends and activities Had often stayed bed for several days at a time and was easily irritated More recently has had difficulty sleeping, sometimes going two to three days without sleeping.

Recent Behavioral Difficulties Grandparents noted that some of his behaviors seem to have been the result of medication that did not work as expected Put on hospital homebound school program due to development of tics, secondary to medication change (shouting extreme obscenities at girls – school can’t protect)

Recent Behavioral Difficulties Had been on multiple medications in multiple doses which had not been effective in controlling his behavior (Examples of Medication). Medications typically seemed to work for a while and then stop working or make him much worse Off-meds grandparents described his behavior as sometimes “silly, elated, giddy, happy, and crazy, as if in another world. ” On several occasions has taken off all of his clothes and “run into the streets howling”

Family History Mother had been adopted – Little info on her family background – Described as wild, impulsive with multiple monogamous relationships – never married – Began using tobacco, drugs, and alcohol at 13 – Was killed in car accident (when pt was 9) Little information about biological father Paternal GM hospitalized for “Mood Swings” Paternal GF on meds into his 60’s for “activity and attention problems” Paternal Uncle with ADHD. Bobby has lived with Maternal Grandparents most of his life

Behavioral Observations Had not slept for two days prior to evaluation; did not report being tired Flat affect through the evaluation Cooperative throughout the testing but not forthcoming when talking about feelings or responding to personality questionnaires (e. g. , leaving out items, refusing to answer some questions)

Test Results WASI: FSIQ = 107 (Verbal 102; Performance 109) WIAT: Reading GE = 8 – 3; Math GE = 5 – 8; Spelling GE = 8 – 6 (Note. In 7 th Grade) Attention Measures – Conner’s CPT (Confidence Index = 99. 9) – TEA-CH Selective Attention (Above Average)’ Attentional Control (Low Average); Sustained Attention (Significantly Impaired on 4 or 5 tests) – Conner’s: Clinically significant elevations on: – DSM IV Hyperactive/impulsive, DSM IV inattention, DSM IV Total, ADHD index, Social Problems, Oppositional, Restless-Impulsive, and Emotional Lability (High ranging profie)

Test Results (Cont) Personality Inventory for Children Clinically significant elevations on multiple scales: – – – – Psychosis Withdrawal Hyperactivity Social Skills Deficits Depression Delinquency (Behavioral Problems) Anxiety

PIC PROFILE

Child Test Measures Administered child anxiety and depression scales as well as the Roberts Apperception Test and the Incomplete Sentence Schedule Due to patients response set and lack of motivation and involvement, this data is of questionable validity

DIAGNOSIS ?

DIAGNOSES ADHD, Combined type (314. 01) – Long standing history of hyperactiveimpulsive, and inattentive behavior – Poorly Controlled with Medication – Highly significant elevations of Conner’s Parent Report Measure – Significant Confidence Index on CPT – Impairments in Sustained Attention on Tea-Ch

Diagnoses Major Depressive Disorder (296. 2) Grandparents report of symptoms of depression, including: – Highly significant elevations on Personality Inventory for Children – Irritable mood – Anhedonia – Decreased energy – Difficulty sleeping – Problems concentrating

Diagnoses Bipolar Disorder R/O (296) Question? Should this be the superordinate diagnosis? – Grandparents describe the patient’s behavior off of medication as “Crazy, wild, hyperactive” and note that he becomes “silly, elated, and giddy, as if in another world”. – Has taken clothes off and run into the street howling on multiple occasions; this behavior has occurred as far back as 6 years of age and as recently as the past year when medications stop working. – Patient has a history of depression, decreased need for sleep, irritable mood, and severely disinhibited behavior. – This is combined with a paternal grandmother who was hospitalization for “mood swings”, a paternal grandfather who was medicated into his 60’ for attention problems and activity level. – Taken together it is believed that he should be further evaluated for bipolar disorder. – While a definitive diagnosis is difficult at this time because core psychopathology has been clouded over time by multiple doses and combinations of numerous prescription and over-the-counter medications, it appears that this disorder may well account for his erratic and highly impairing and behavior

Six Year Follow-up Patient seen for reevaluation this past year As an adult (18) wanted an evaluation to reconsider the “diagnosis” of bipolar disorder. Was accompanied to the evaluation by his Grandfather and his 25 year old fiancé, with whom he lives.

Clinical Status Update Significant change in treatment since last evaluation, although still under the care of a psychiatrist Changed from stimulants and antidepressants + to mood stabilizers + Some positive effects of mood stabilizers over the years were described but they seemed to have not helped with continuing “major attention problems”.

Clinical Status Update At the time of evaluation was prescribed 2000 mg of Depakote, 400 mg of Seroquel, 300 mg of Wellbutrin and. 01 mg of synthroid. Had gained weight on Seroquel; up to 250 pounds. Said it make him irritable and that he felt drugged Quit taking all meds several months and has now dropped to 140 pounds.

Interview Findings Reports currently sleeping 7 – 8 hours per night but reports functioning fine without any sleep. Describes major problem with anger – Frequently extremely irritable – small things set him off – When angry he yells, hits, and breaks things – Numerous physical altercations in and out of school over the years – Got drunk and beat fiancé “really bad”

Interview Findings After previous evaluation he had returned to school but had rough time – Frequently suspended and expelled for fighting and arguing with teachers – Well known to law enforcement in his hometown - fighting, drug use – Feels he can’t go back without being hassled by police – Quit high school after middle of 11 th grade

Interview Findings Describes frequent mood changes – Reports that a couple of times a month will be giddy and laughing for 2 – 3 days at a time – Mood is way beyond just being happy; people notice and comment on his exaggerated mood. – Describes having extreme racing thoughts which “he can’t keep up with” and creates problems in concentrating – Describes problems with hyperactivity, impulsivity and inattention

Interview Findings Grandfather describes him as significantly depressed. Patient also describes himself as “sometimes sad”. Grandfather says he is just like his mother “overly happy, manic and then depressed. ” Pt describes himself as self-medicating almost daily with marijuana to help himself “calm down” Currently has a drug possession charges pending. Grandfather concerned over failure to meet with probation officer for drug testing and having legal difficulties. Patient seemingly not concerned.

Interview Findings Discussed living apart from Grandfather with fiancé. Describes good relationship with fiancé Both unemployed – Got mom’s inheritance when he turned 18 – Stated that he had enough money to last a couple of years without working – Later wants to get GED and learn computers.

Interview Findings “Confidential discussion” regarding inheritance Patient had agreed with grandfather on a budget of $2, 800 per month to live on. Unknown to grandfather - first 6 months after getting inheritance spent over $100, 000. – Two new cars (both for patient – the second car to drive when he was tired of driving the first) – Clothes – Jewelry – Unconcerned about how long money will last!

Test Findings WASI – FSIQ = 98; – VIQ = 97; – PIQ = 99 WIAT II – Word Reading >12. 9 GE – Reading Comp 12. 6 GE – Math 7. 0 (NO) – 7. 2 (MR) GE’s – Written Expression 3. 1 GE (Low Written Expression due to disinterest and impulsiveness in responding)

Test Findings Parent Report Measures: Conner’s 3; BASC – Clinically Significant Elevations on Conner’s Scales: ADHD Inattentive; ADHD Hyperactive/Impulsive; Oppositional Defiant; Aggression; Peer Relations; ADHD Index; Global Index; and Executive Function Scale – Extreme Elevations on Most Scales – Clinically Significant Elevations on the BASC Clinically Significant elevations on Hyperactivity, Conduct Problems, Attention Problems; “At Risk elevations on Depression, Atypicality, and Withdrawal Also, significant impairment in Daily Living Skills, and difficulties in social skills and functional communication

MMPI 2

MMPI FINDINGS Clinically significant elevations on scales reflecting – extremely high levels of manic/hypomanic symptomatology – suspiciousness/distrust – antisocial features – a level of mental confusion that may be reflected in poor judgment in everyday life. Content Scales, composed of critical items associated with depression, suggest significant depressive symptomatology Examples of Critical Items

DIAGNOSIS ?

Diagnoses Attention Deficit Hyperactivity Disorder, Combined Type (314. 01) Bipolar Disorder, Not Otherwise Specified (296. 80) Are both warranted ? ?

Recommendations Given concerns expressed by the patient and his Grandfather regarding his current medication regimen, along with the fact that pt is not taking his medications, continued consultation with his psychiatrist is important. This consultation should include discussion of the undesirable side effects that patient has experienced from this current medications (weight gain, feeling drugged), as well as concerns that his serious attention problems continue to impair his functioning. Hopefully, an approach can be found to optimally address his current mood related difficulties as well as his attention problems and impulse control.

Recommendations It is highly recommended that the Bobby become involved in working with a therapist who can focus on evidence based treatment to help him deal with issues of depression and anger management. It would also be important for Bobby to work with a counselor to assist him in the areas of – financial management, – the development of more adaptive life management and general problem solving skills, – assisting him in planning for the completion of the GED and – the subsequent development of vocational skills in an area related to his interests.

The End