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Pediatric Bipolar Disorder. Mani N Pavuluri, MD, PhD Berger Colbeth Chair in Child Psychiatry Pediatric Brain Research and Intervention Center University of Illinois at Chicago @ copy righted. Overview of the presentation. How does it look? Measurement

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Pediatric bipolar disorder

Pediatric Bipolar Disorder

Mani N Pavuluri, MD, PhD

Berger Colbeth Chair in Child Psychiatry

Pediatric Brain Research and Intervention Center University of Illinois at Chicago

@ copy righted


Overview of the presentation

  • 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
What is a Pediatric Bipolar Disorder?

Central feature:

Elevated, expansive mood or Irritable mood

Pavuluri, 2012


Equivalent description in a child

Excited

Giggly

Silly

Giddy

constantly on the go

laughing fits

joking and feels invincible

“ overwhelming”

“ like wanting to jump on the bed”

Equivalent description in a child

Mood

  • 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
Timeline

  • Ultra Rapid Cycling: Complex Cycling

  • “Mini cycles within a big cycle”

  • 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


Specific to pbd
Specific to PBD

Irritability

77-98%

Rapid Cycling

46-87%

ComorbidADHD

75-98%

Mixed Mania

20-84%

Chronicity

4229 months;

84%

Pavuluri, 2012


Mood spectrum

Normal

Mood Spectrum:

Elevated Mood

Depressed Mood

Time

Pavuluri, 2012


Mood spectrum1

Major Depressive Disorder

Mood Spectrum:

Elevated Mood

Normal

Depressed Mood

Time

Pavuluri, 2012


Mood spectrum2

Mania

Mood Spectrum:

Elevated Mood

Normal

Major Depressive Disorder

Depressed Mood

Time

Pavuluri, 2012


Mood spectrum3

Dysthymia

Mood Spectrum:

Elevated Mood

Mania

Normal

Major Depressive Disorder

Depressed Mood

Time

Pavuluri, 2012


Mood spectrum4

Hypomania

Mood Spectrum:

Elevated Mood

Mania

Normal

Major Depressive Disorder

Depressed Mood

Dysthymia

Time

Pavuluri, 2012


Mood spectrum5

Bipolar Disorder

Mood Spectrum:

Elevated Mood

Mania

Hypomania

Normal

Major Depressive Disorder

Depressed Mood

Dysthymia

Time

Pavuluri, 2012


Mood spectrum6

Pediatric Bipolar Disorder

Mood Spectrum:

Elevated Mood

Depressed Mood

Time

Pavuluri, 2012


Mood spectrum7
Mood Spectrum

Mania

PBD

Elevated Mood

Hypomania

Normal

Major Depressive Disorder

Depressed Mood

Dysthymia

Bipolar

Time

Pavuluri, 2012



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
“Diagnostic fashion runs in cycles!”

Pavuluri, 2012



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.

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

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

4. Believe that he or she has unrealistic abilities or powers that

are unusual, and may try to act upon them, which causes trouble

Never Sometimes Often Very Often

/Rarely

0

0

0

0

1

1

1

1

2

2

2

2

3

3

3

3

Child Mania Rating Scale, Parent Version

Pavuluri et al, aacap 2004

Pavuluri, 2012


How to use it
How to use it? 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.

  • 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
Interpreting the results 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.

  • 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
Reliability 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.

  • Internal Consistency: 0.96

  • Test Re-test Reliability: 0.96

Pavuluri, 2005


CMRS-P Total Score 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.

Pavuluri, 2012


Why should i choose it

PROS 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.

DSM IV basis

Singular item focus

Integrated functionality

Age specific items

Timing of symptoms

Language

Linked examples

Why should I choose it?

Pavuluri, 2012


Diagnosis 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.

Precipitating Factor

Outcome

Family

Friends

Teacher

Interpersonal

Relationships

Functioning

Other…

Why now?

DD 1. (w/3 main symptoms)

2.

3.

Home

School

Background

Maturity

Work

Psychopathology

Mother - Dev. Hx Personality

Father

Personal

Resources

(knowledge, skills, attitude, motivation)

M-F (partnership)

Child

Siblings

Family

Attachment/Goodness of Fit

Parenting

Capacity

Context

Temperament and Personality Style

Strengths

Coping Mechanisms/Defenses

- Support

- stresses

*Central Issue

*EMIC vs. ITIC

*Find the Person/s

Structural (roles, relationships) C – C, M – C, F – C, etc.

Strategic (problem solving, family beliefs)

Systemic (theme)

Formulation


Mania vs adhd
Mania vs. ADHD 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.

  • ADHD

    • Primarily a disorder of attention, not mood

    • Onset before age 7

    • Persistent, not episodic

  • Problem of Comorbidity

Pavuluri, 2012


Pavuluri, 2012 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.


Pavuluri, 2012 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.


Pavuluri, 2012 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.


Pavuluri, 2012 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.


Comorbidity of adhd in pediatric bipolars

Study 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.

n

Mean Age

ADHD

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%

DelBello et al., 2001

34

15.7

65%

Comorbidity of ADHD In Pediatric Bipolars

Pavuluri, 2005


Distinguishing between bipolar and adhd
Distinguishing Between Bipolar 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.and ADHD

Geller & Zimerman 2002.


Pediatric bipolar disorder1

Prepubertal & Early Adolescent Onset Bipolar Disorder (PEA - BD)

Juvenile BD

Atypical BD

Childhood Onset BD

Adolescent Onset Bipolar Disorder (AO-BD)

Pediatric Bipolar Disorder

 12 yr.

> 12 yr.

Pavuluri, 2012



Prevalence of bp in adolescents
Prevalence of BP in Adolescents BD)

Diagnostic interviews with 1709high 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
Age of Symptom Onset BD)NDMDA Survey N=500

Lag to Diagnosis = 8 Years

30%

28%

20%

59%

16%

15%

14%

10%

12%

9%

5%

< 5

5-9

10-14

15-19

20-24

25-29

30+

Years of Age

Pavuluri, 2012

Lish 1994


Recovery and relapse
Recovery and Relapse BD)

Pavuluri, 2012


Developing the language

Symptom BD)

List

FIND

Brain

Disorder

Invisible

Fist

Signature

Developing the language

Pavuluri, 2012


R A I N B O W BD)

R

A

I

N

B

O

W

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


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