Pediatric Bipolar Disorder Mani N Pavuluri MD Ph

Pediatric Bipolar Disorder Mani N Pavuluri, MD, Ph. D Berger Colbeth Chair in Child Psychiatry Pediatric Brain Research and Intervention Center University of Illinois at Chicago @ copy righted

Overview of the presentation v v v v How does it look? Measurement How to differentiate from ADHD Prevalence Onset Follow up Assessment: Big picture Pavuluri, 2012

What is a Pediatric Bipolar Disorder? Central feature: Elevated, expansive mood or Irritable mood Pavuluri, 2012

Equivalent description in a child Mood w w w w w Excited Giggly Silly Giddy constantly on the go laughing fits joking and feels invincible “ overwhelming” “ like wanting to jump on the bed” w w w Constantly irritable Aggressive throwing pot plants slamming doors hard to transition Acidic Abrasive hostile in words Kicking screaming intense & inconsolable out of proportion to the psychosocial stresses around them Pavuluri, 2012

Feeling good about myself 1) Generous gave money to the school’s mission collection 2) Friendly to everyone 3) Share my lunch with my friends getting up every morning at the regular time not tired I eat breakfast, lunch and dinner Pavuluri, 2012

Timeline Ø Ultra Rapid Cycling: Complex Cycling Ø “Mini cycles within a big cycle” Ø Ø Frequency: most days in a week Intensity: severe enough to cause extreme disturbance in one domain or moderate disturbance in two or more domains Number: three or four times a day Duration: four or more hours a day Pavuluri, 2012

Mood Spectrum: Normal Elevated Mood Depressed Mood Time Pavuluri, 2012

Mood Spectrum: Major Depressive Disorder Elevated Mood Normal Depressed Mood Time Pavuluri, 2012

Mood Spectrum: Mania Elevated Mood Normal Major Depressive Disorder Depressed Mood Time Pavuluri, 2012

Mood Spectrum: Dysthymia Elevated Mood Mania Normal Major Depressive Disorder Depressed Mood Time Pavuluri, 2012

Mood Spectrum: Hypomania Elevated Mood Mania Normal Depressed Mood Major Depressive Disorder Dysthymia Time Pavuluri, 2012

Bipolar Mood Spectrum: Disorder Elevated Mood Mania Hypomania Depressed Mood Normal Major Depressive Disorder Dysthymia Time Pavuluri, 2012

Pediatric Mood Spectrum: Bipolar Elevated Disorder Mood Depressed Mood Time Pavuluri, 2012

Mood Spectrum Mania Elevated Mood PBD Hypomania Normal Depressed Mood Dysthymia Bipolar Major Depressive Disorder Time Pavuluri, 2012

Distribution of Bipolar Subjects Pavuluri, 2005

BP-NOS at Intake – Convert to BP-I Mania Hypomania BP-NOS Euthymia Dep-NOS Major Depression Birmaher et al, AACAP, 2003 Pavuluri, 2012

BP-II at Intake – Convert to BP-I Mania Hypomania BP-NOS Euthymia Dep-NOS Major Depression Birmaher et al, AACAP, 2003 Pavuluri, 2012

“Diagnostic fashion runs in cycles!” Pavuluri, 2012

Child Mania Rating Scale, Parent Version The following questions concern your child’s mood and behavior in the past month. Please place a check mark or an ‘x’ in a box for each item. Please consider it a problem if it is causing trouble and is beyond what is normal for your child's age. For example, check ‘never' if the behavior is not causing trouble. Never Sometimes Often Very Often /Rarely 1. Have periods of feeling super happy for hours or days at a time, extremely wound up and excited, such as feeling "on top of the world" 2. Feel irritable, cranky, or mad for hours or days at a time 0 1 2 3 3. Think that he or she can be anything or do anything (e. g. , leader, best basketball player, rap singer, millionaire, princess) beyond what is usual for that age 0 1 2 3 4. Believe that he or she has unrealistic abilities or powers that are unusual, and may try to act upon them, which causes trouble 0 1 2 3 Pavuluri et al, aacap 2004 Pavuluri, 2012

How to use it? Ø Ø Have the parent focus on the child’s behavior in the past month. “Never/Rarely” and “Sometimes” = behavior that is causing minimal or no difficulty “Often” and “Very Often” = behavior that is causing trouble. The child’s score is the sum of all item scores. Pavuluri, 2012

Interpreting the results Ø Ø A cut off score of 15 screens for the manic spectrum A cut off score of 20 is highly specific for mania Pavuluri, 2012

Reliability Internal Consistency: 0. 96 Ø Test Re-test Reliability: 0. 96 Ø Pavuluri, 2005

CMRS-P Total Score Pavuluri, 2012

Why should I choose it? PROS DSM IV basis Singular item focus Integrated functionality Age specific items Timing of symptoms Language Linked examples Pavuluri, 2012

Formulation Diagnosis Precipitating Factor Why now? DD 1. (w/3 main symptoms) 2. 3. Family Interpersonal Friends Relationships Functioning Other… Background Mother - Dev. Hx Outcome Maturity Personality Work Psychopathology Attachment/Goodness of Fit Father Parenting Personal Resources Temperament and Personality Style Strengths Capacity Coping Mechanisms/Defenses (knowledge, skills, attitude, motivation) M-F (partnership) Context Child Siblings Family - Support - stresses *Central Issue *EMIC vs. ITIC Structural (roles, relationships) C – C, M – C, F – C, etc. Strategic (problem solving, family beliefs) Systemic (theme) *Find the Person/s Teacher Home School

Mania vs. ADHD Z Z Primarily a disorder of attention, not mood Z Onset before age 7 Z Persistent, not episodic Problem of Comorbidity Pavuluri, 2012

Comorbidity of ADHD In Pediatric Bipolars Study n Mean Age West et al. , 1995 14 15. 1 57% Wozniack et al. , 1995 43 7. 9 98% Faraone et al. , 1997 68 6. 1 93% Geller et al. , 2000 60 11 98% / 72% Kafantaris et al. , 1998 48 16 29% Kowatch et al. , 2000 42 11 71% Del. Bello et al. , 2001 34 15. 7 ADHD 65% Pavuluri, 2005

Distinguishing Between Bipolar and ADHD Geller & Zimerman 2002.

Pediatric Bipolar Disorder 12 yr. Z Z Prepubertal & Early Adolescent Onset Bipolar Disorder (PEA - BD) Juvenile BD Atypical BD Childhood Onset BD > 12 yr. Adolescent Onset Bipolar Disorder (AO-BD) Pavuluri, 2012

Pavuluri, 2012

Prevalence of BP in Adolescents Diagnostic interviews with 1709 high school students, ages 14 -18 years Findings 1. 0% prevalence of BP (primarily BP II and cyclothymia) 5. 7% prevalence of BP NOS Lewinsohn 1995

Age of Symptom Onset NDMDA Survey N=500 Lag to Diagnosis = 8 Years 30% 28% 20% 59% 10% 12% 16% 15% 14% 9% 5% <5 5 -9 10 -14 15 -19 20 -24 25 -29 30+ Years of Age Lish 1994 Pavuluri, 2012

Recovery and Relapse Pavuluri, 2012

Developing the language Symptom List Brain Disorder Invisible Fist FIND Signature Pavuluri, 2012

OUTINE FFECT CONTROL CAN DO IT O NEGATIVE THOUGHTS; LIVE IN THE NOW E A GOOD FRIEND: BALANCED LIFESTYLE H! HOW CAN WE SOLVE IT? ! AYS TO GET SUPPORT Pavuluri, 2012