ADHD or Bipolar Disorder?

1. ADHD or Bipolar Disorder? Assessment and Differential Diagnosis ofBipolar Disorder in Children and Adolescents Wanda Fremont MD 1/27/12 Special thanks: The REACH Institute Jointly sponsored by SUNY: Buffalo & NY State Office of Mental Health, in conjunction with The REACH Institute. This activity is supported solely by the joint sponsors, and received no commercial support of any kind.

2. Prevalence in Community Samples of Pediatric Bipolar Disorder:<1%

3. Criteria for Manic Episode (I) DSM criteria written with adults in mind • Distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). • During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: • Inflated self-esteem or grandiosity • Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) • More talkative than usual or pressure to keep talking • Flight of ideas or subjective experience that thoughts are racing • Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) • Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation • Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) (Adapted from DSM-IV-TR, 2000)

4. Bipolar Disorder in Children:The Broad Phenotype • There is a large group of children who show many manic symptoms • Especially the affective storms & rages • Don’t clearly cycle between mood states • May not have bipolar in family pedigree • Severe Mood Dysregulation (Leibenluft et al 2003) • Are these bipolar cases? • Will they grow up to look more classic?

5. Developmental Differences in the Expression of Manic and Depressive Symptoms Weckerly J., Developmental Behav. Ped.,Vol 23, No. 1, 42-56.

6. Developmental Differences in the Expression of Manic and Depressive Symptoms Weckerly J., Developmental Behav. Ped.,Vol 23, No. 1, 42-56.

7. ADHD vs. Bipolar • Irritability is non-specific: • Irritability does not = Bipolar • Geller et al 2002 found irritability in 72% of Children with ADHD and 97.9% of Children with Bipolar Disorder • Again elation,grandiosity, flight of ideas/racing thoughts, decreased need for sleep and hypersexuality provide the best discrimination between ADHD and BD in children and adolescents (Geller et al 2002)

8. The Unipolar Depression vs.Bipolar Distinction • First mood episode of pediatric bipolar disorder is often a depressive episode • MDD in children often associated with high rates of irritability…i.e., children with depression can present with irritable mood, not depressed mood • Children and adolescents with major depressive disorder can have very labile mood • What do you mean by mood swings? • euthymia to depressed vs. depressed to manic or hypomanic

9. Substance Abuse vs.Pediatric Bipolar Disorder • The substance abuse may mimic a bipolar presentation • Check urine drug screens, educate patients and families • There are high rates of co-morbid substance abuse in adolescents with bipolar disorder • The substance abuse must be addressed

10. Conduct Disorder The negative behaviors areoften calculating and predatory Pediatric Bipolar The negative behaviors are secondary to grandiosity and risky, poor judgment Conduct Disorder vs.Pediatric Bipolar Disorder

11. With Pediatric Bipolar DisorderThere Are High Rates ofCo-occurring Psychiatric Conditions • ADHD • ODD • Conduct Disorder • Learning Disabilities • Substance Abuse • Anxiety Disorders Individually orin combination

12. A Family History ofBipolar Disorder • Take a careful family psychiatric history • Bipolar disorder in one parent = 5x odds of bipolar disorder in child (but still only ~5% prevalence; LaPalme et al., 1997), still less than likelihood of ADHD • Bipolar disorder in parents, grandparents, and siblings is clinically meaningful but doesn’t rule out “bad” ADHD • The presence of bipolar disorder in more distant relatives may not confer greater genetic risk • No clear family history doesn’t rule out pediatric bipolar disorder

13. Pediatric Bipolar Rating Scales • Young Mania Rating Scale for Parents P-YMRS (Gracious et al. JAACAP,2002) • the scale can be found at www.healthyplace.com/bipolar/p-ymrs.asp • General Behavioral Inventory, GBI (Findling et al. Bipolar Disorder, 2002) • Self and parent report ages 5-17 • Very long tool 73 mood items • Life Mood Charts • Asking about mood symptoms throughout the patient’s life • Can be found at www.dballiance.org • These rating scales do a better job of ruling out pediatric bipolar disorder then ruling it in • Still very helpful to follow symptoms to assist with diagnosis and to follow symptoms

14. Summary • In evaluating pediatric bipolar disorder look for classic criteria • elevated mood, grandiosity, decreased need for sleep, racing thoughts • High rates of psychiatric co-morbidity • Especially ADHD, ODD, Conduct Disorder and Learning disabilities • Careful family history • Focus on first and second degree relatives • Rating scales do a better job of ruling out pediatric bipolar disorder then ruling it in • If significantly concerned get a child psychiatry consultation

15. Bipolar DisorderTreatment Options

16. FDA Pediatric Labeling for BD

17. Updated Treatment Algorithm for Mania/ Hypomania in Children & Adolescents

18. Prepubertal depression  BD • Limited outcome studies • 24/72 (33%) MDD children  BD-I at age 20, 11/72 (11%)  BD-II or hypomania (Geller et al., 2001) • Adolescent depression  BD • Limited studies • 58 MDD inpatients followed up in 24 months • Overall: 5/58 (8.6%)  BD; 0/40 without psychotic symptoms, 5/18 (28%) with psychotic symptoms (Strober et al., 1992) • Epidemiological sample; 275 teens with MDD, < 1%  BD by age 24 (Lewinsohn et al., 2000) • 5/26 (19%) of MDD adolescents had BD after ~7 year follow-up (compared to 0% of controls) (Rao et al.,1995) Depression Switching toBipolar Disorder

19. Antidepressants may induce mania in children with a bipolar diathesis • In a survey of child and adolescent psychiatrists: 10/228 (4.4%) of children under 13 y/o treated by psychiatrists switched to BD (Reichart & Nolen, 2004) • Treatment for Adolescent Depression Study (TADS), of 439 12-17 year olds: 0 switches to BD after 12-week follow-up (2004) • large private insurance database, 5.4% switch rates, increased risk for youth on antidepressants and risk greatest for age group of 10-14 y/o (San Martin et al., 2004) Switching to Bipolar Disorder with Antidepressants:

20. Concerns that stimulants may precipitate mania or destabilize children with bipolar who are not stabilized on other medications • However… • In the Multimodal Treatment Study of Children with ADHD (MTA), children with ADHD and some manic symptoms responded well to stimulants with decrease in ADHD symptoms and without increased rates of developing bipolar disorder (Galanter et al 2003, 2005) • “Follow-back” study of children originally diagnosed and treated for “minimal brain dysfunction.” • Those diagnosed with bipolar spectrum disorders as young adults had responded well to stimulants as children • Those children with more comorbidities did not develop higher rates of bipolar as compared to those with uncomplicated ADHD (Carlson et al 2000) Switching to Bipolar Disorder with Stimulants:

21. CAP PC: Child and Adolescent Psychiatry for Primary Care Providers: Consultation, Education and Linkage/Referral Support: Wanda Fremont MD 1/27/12 Special thanks to David Kaye MD

22. OMH EFFORTS TO ADDRESS THE NEEDS OF PCPs FOR INCREASED SUPPORT FROM CAPs Project TEACH (Training and Education for the Advancement of Children’s Health) Two Project TEACH programs covering NYS: 1. CAPES (Child and Adolescent Psychiatry Education and Support) Northeastern NY State – Jeff Daly MD 2. CAP PC: (Child and Adolescent Psychiatry for Primary Care) Rest of NY State – David Kaye MD , (5 Medical Univ)

23. CAP PC:The program’s intent is to provide support for PCPs to manage children and adolescents with mild-moderate mental health problems and to assist with linkage/referral services for those patients

24. CAP PC Collaboration:$2.6 million 3 yr grantNY State Office of Mental Health American Academy of PediatricsAmerican Academy of Family Medicine (AAFP)NY State Conference of Local Mental Hygiene Directors

25. 5 Academic University Centers:Columbia UniversityLong Island Jewish /NorthshoreSUNY BuffaloSUNY UpstateUniversity of Rochester

26. CAP PC SERVICES 1. Phone consultation/Linkage Referral 2. Website 3. Face to Face Consultation 4. REACH training 5. Outcomes Evaluation

27. Most Common Childhood Problems: 1. ADHD 2. Anxiety 3. Depression 4. Behavioral Problems

28. What CAPPC Grant Does Not Cover: • Childhood Schizophrenia • Bipolar Disorder • Moderate or Greater Intellectual Disability • Substance Abuse • Persons who have had their 22nd birthday • Persons seriously and persistently mentally ill, whatever the diagnosis (es)

29. 1. Phone Consultation and Linkage/referral

30. ANY PCP in the State of New York is eligible to call the 1-855-CAP-PC72 line 1-855-227=7272 (9-5 M-F, excluding holidays) For child psychiatric consultations by phone.

31. Coverage is provided :Monday: Upstate Syracuse Tuesday: LIJ/NSU Wednesday: Columbia Thursday: Buffalo Childrens Friday: Rochester (Strong)

32. Regional Site Teams Each site team consists of a: 1. Child/adolescent Psychiatrist 2. Liaison Coordinator (MSW/PhD)

33. Work Flow for Phone Consultations The Liaison Coordinator will take the initial phone call and will respond to all calls within their scope of training and expertise. If a child psychiatrist is appropriate or requested then the covering CAP will return the phone call within 2 hours.

34. HIPPA I Phone calls are considered educationalconsultations to the PCP about patient management, not a clinical service to patients. It is critical that PCPs maintain patient confidentiality and that communications are HIPPA-compliant in these phone calls. Identifying health information will NOT be requested and should not be provided! De-identified demographic information about you and the patient will be requested to provide feedback and evaluation of the project.

35. HIPPA II While informed consent is not required for HIPPA -compliant discussion of patient care issues by telephone, CAP PC encourages PCPs to inform families and obtain verbal consent about these phone consultations

36. PCP Cheat Sheet • Contact information for you • Patient grade in school; support services? • Global assessment of function score • Screens completed: ?Vanderbilt; ?PSC • Insurance • Current mental health treatment • Psychotropic med history • Medical history • Family history of mental illness

37. 2. WEBSITE Cappcny.org

38. Website Contents: • Screening Tools: e.g. Vanderbilt, SCARED, PHQ9, MOAS, PSC17 and 35 • Links: AAP Bright Futures, AACAP Practice • References

39. 3. FACE TO FACE CONSULTSOPENto ALL PCPsin NEW YORK STATE(Direct or Telepsych)

40. Face to Face Consultations Selected cases will be seen for a one time only face-to-face (or telepsychiatric if the patient is geographically distant from one of the program sites) consultation with a program child psychiatrist. Face to face (FTF) evaluations will be scheduled within a few weeks with the local child/adolescent psychiatrist (CAP).

41. Selection of Face to Face Consultations FTF evaluation will be offered for cases which are diagnostically confusing or complex, or it is unclear whether it is appropriate for PCP management.

42. Face to Face Evaluations are Consultations Only Face to face evaluations are consultations only; patients cannot be picked up by the child psychiatrist for ongoing treatment and medication management. Please be sure to educate your patients/families about this.

43. Our Promise Following completion of the FTF evaluation, verbal feedback and a written report will be provided by the evaluating CAP to the referring PCP.

44. Emergency Cases In urgent situations PCPs may call the 1-855 line for assistance with referral to an appropriate emergency service in the region. Face to face evaluations will not be scheduled on an urgent basis and should NOT be looked to for emergency cases!

45. Jumping the Queue for Linkage/Referral Assistance Please note that CAP PC can not provide assistance with referral and linkage services for routine cases. These cases should be referred to local mental health agencies or child mental health professionals in private practice. The same is true for patients/families who have been dismissed from mental health agencies or clinics because of noncompliance or poor attendance.

46. 4. Education:REACH TRAINING

47. About REACH • Yearly three day continuing education workshop • Developed by Peter Jensen, Child Psychiatrist • Interactive dynamic innovative • Open to 20-25 PCPs in each of the 5 sites • Biweekly conference calls for the next 6 months • Up to 32 hours FREE CME

48. 5. Outcomes Assessment

49. Important requirements for the use of the CAP-PC service • Necessity of Evaluation • Required by New York State as part of this program • What is involved- details are still being worked out • Clinician practice questionnaire- • Before this training • End of this training • After phone call meetings • At some future time

50. Important requirements for the use of the CAP-PC service • Evaluation of phone consultations and face-to-face consultations • Brief questionnaire follow-up about ease of access and usefulness of consultations • Brief questionnaire follow-up about further contacts with the child, the implementation of recommendations, and the functioning of the child.