1 / 62

Early Onset Bipolar Disorder and the Pediatric Behavior Rating Scale ™ (PBRS ™ )

Early Onset Bipolar Disorder and the Pediatric Behavior Rating Scale ™ (PBRS ™ ). Children’s Mental Health.

kiley
Download Presentation

Early Onset Bipolar Disorder and the Pediatric Behavior Rating Scale ™ (PBRS ™ )

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Early Onset Bipolar Disorderand the Pediatric Behavior Rating Scale™ (PBRS™)

  2. Children’s Mental Health • 5,000,000 (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.) • 80% (America’s youth with mental health needs who fail 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

  3. DIAGNOSIS DU JOUR? 1980’S ADHD 1990’S DEPRESSION 2000’S EOBPD

  4. 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)

  5. PROBLEMS IDENTIFYING BPD IN CHILDREN EOBPD is not in DSM IV. EOPBD looks like other disorders. EOBPD has high rates of comorbidity.

  6. 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

  7. EOBPD vs. Adult BPD (Birmaher et al, 2008; Danielyan et al, 2007; Kowatch et al, 2005)

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. Frequency of EOBPD Symptoms

  14. 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

  15. 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.

  16. 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.

  17. WHAT KIND OF AGGRESSION IS BEING EXPRESSED? Predatory-controlled (instrumental) Defensive-impulsive, reactive (not for gain)

  18. REACTIONARY and CONFRONTATIONAL approaches serve mainly to provoke and escalate.

  19. GOALS OF INTERVENTIONS Stabilize Reduce Symptoms Opposition Defiance Irritability Aggression Improve Functioning (academic, social)

  20. TWO WAYS TO ACHIEVE THESE GOALS Medications (to make the child “available”) Psychotherapies (coping & managing)

  21. General Rule for Interventions • Behavioral approaches tend to focus on consequences. • There are two problems with this…

  22. TWO PROBLEMS 1. By definition, children and adolescents with deficits in impulse control and self- regulation do not consider consequences before they act. 2. Behavioral consequences (especially if they are aversive) introduce provocation, confrontation…and escalation.

  23. INTERVENTION TARGETS CHILD medications sleep self-regulation PARENTS psychoeducation medication compliance ENVIRONMENT (control the pace) home school

  24. DRUG TREATMENTS EOBPD FOUR MAJOR CLASSES of MOOD STABILIZERS Lithium Antiepileptics (Mood Stabilizers) Antidepressants Antipsychotics

  25. NONDRUG INTERVENTIONS THERE ARE 550 PSYCHOTHERAPIES (NONMEDICAL INTERVENTIONS) FOR TREATING CHILDREN AND ADULTS

  26. BEYOND BEHAVIORISM Parent Management Training Cognitive Behavioral Therapy Dialectal Behavior Therapy Choice Theory Problem-Solving Skills Health Promoting Environments

  27. 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

  28. Three-Tier Model of Behavioral Intervention/Support Tier III: Intensive, Individual Interventions 1 - 5% 1-5% Tier II: Targeted Group Interventions 10-15% 80 - 90% Tier I: Universal Interventions/Supports 10 - 15% 80 - 90%

  29. 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.

  30. FUNCTIONAL ASSESSMENT Modified from: Santilli, Nancy, Dodson, W.E., Walton, A.V. (1991)

  31. INTERVENTIONS FOR SIMPLE • Monopharmacy • Mildly intrusive therapy • individual therapy • group therapy • parent training • Regular classroom placement • Favorable RTI

  32. INTERVENTIONS FOR COMPROMISED • Polypharmacy (aggression, irritability, co-morbidity) • Intensive child and family therapies • individual therapy • group therapy • family therapy/parent training • May require Spec. Ed. (EH, SED, OHI) • Variable RTI

  33. 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

  34. 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)

  35. PEDIATRIC BEHAVIOR RATING SCALE

  36. WHY A NEW RATING SCALE? Existing scales came out normal Item analysis told us why The need for differential diagnosis

  37. 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])

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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

  45. Atypical (ATY) Scale • Bizarre beliefs • Auditory hallucinations • Delusions • Self-harm behaviors • Excessive fears

  46. Irritability (IRR) Scale • Emotional dysregulation • Behavioral/emotional outbursts • Demandingness

  47. Grandiosity (GRAND) Scale • Elevated sense of self and mood • Not taking responsibility for actions • Exaggerating • Stealing

More Related