BEYOND ADHD AND ODD: BIPOLAR SPECTRUM DISORDERS IN CHILDREN AND ADOLESCENTS

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BEYOND ADHD AND ODD BIPOLAR SPECTRUMDISORDERS
IN CHILDREN AND ADOLESCENTS

• Prepared for
• Indiana Deaf Educators Conference
• August 2 3, 2005
• Julie T. Steck, Ph.D., HSPP
• Childrens Resource Group

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CASE STUDIES

• TEDDY
• Diagnosed with ADHD at age 4
• Early speech and language difficulties
• Behavior manageable in kindergarten
• Behavior very problematic in grade one
• Superior non-verbal IQ
• Struggles with reading and paper-pencil
• tasks
• Difficulty with sleep, eating, anger

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CASE STUDIES

• SUZANNE
• Eighth grade
• Extreme separation anxiety and school phobia
• Four previous hospitalizations
• Tried on numerous medications for anxiety and
  depression with no change or worsened symptoms
• Numerous somatic symptoms
• Does well in English, struggles in math

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CASE STUDIES

• DAVID
• Senior in high school
• Difficulty with sleep and attention
• History of substance abuse
• Family history of suicide
• No school problems of note
• Introspective, creative
• Unrealistic goals (be a model in LA)

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EDUCATIONAL ISSUES

• Excessive anxiety
• School phobia/refusal
• Runs out of classroom
• Refuses to talk in class/do presentations
• Frequent absences or trips to nurses office
• Aggression
• Intense hyperactivity

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Autism Spectrum/Pervasive DevelopmentalDisorders

AUTISM/ ASPERGERS
PDD/NOS
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Bipolar Spectrum/Mood Disorder Spectrum
Mood Disorder/NOS Bipolar II Bipolar
I
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Primary Symptom isMood Dysregulation
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Mania
Hypomania
Mood Disorder, NOS Bipolar II
Bipolar I
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Secondary Symptom of Bipolar Spectrum
Disordersis Cognitive Dysregulation

• Working memory
• Visual-spatial reasoning
• Planning/organization
• Attention
• Most noticeable in math and written language

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Bipolar Spectrum DisordersCause Family
Dysregulation

• Marital conflict
• Financial strain
• Difficulty with parents work schedules
• Significant impact on siblings
• Isolation from friends and extended family
• Shame/fear/reliving old memories

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Bipolar Disorder

• Primary symptom is "mood dysregulation"
• One of the most complicated severe of all
  psychiatric disorders
• Also one of the most treatable
• Underrecognized undertreated

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Bipolar Disorder

• Early, accurate diagnosis is a rarity
• DMDA survey 48 did not receive accurate
  diagnosis until they had seen 3 or more
  professionals
• 34 suffered with bipolar disorder for 10 years
  or more before correct diagnosis treatment

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Bipolar Disorder

• High level of morbidity major public health
  problem
• Mortality suicide rate estimated between 23
  41.
• Mortality can be reduced by 80 with appropriate
  treatment

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Bipolar Disorder

• Prevalence estimate 5.7 of adolescents have
  bipolar spectrum disorder
• Lifelong condition with early onset
• DMDA survey 31 experienced first bipolar
  symptoms before age 14 28 between 15-19 years
  of age.

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Bipolar Disorder

• Strong genetic basis
• Underlying biological basis not fully understood
• Dysregulation of neurochemical and neuroendocrine
  pathways
• Oversensitivity of limbic brain

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Cingulate Cortex
Cerebral Cortex
HIGHER BRAIN
Frontal Cortex
Corpus Callosum
Hippocampus
Thalamus
MIDDLE BRAIN
Cerebellum
Hypothalamus
Pons
Amygdala
LOWER BRAIN
Medulla
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Speaking
Smell
Hearing
Taste
Conscious decision making
Generating Speech
Reading
AUTISM/ ASPERGERS SYNDROME
Vision
MOOD DISORDERS
FUNCTIONAL ANATOMY
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Common Symptoms of Early-Onset Bipolar
Disorder(Papolos Papolos, 1999)

• Separation-anxiety
• Rages and explosive temper tantrums
• lasting up to several hours
• Marked irritability
• Oppositional behavior
• Rapid cycling or mood lability
• Distractibility
• Hyperactivity
• Impulsivity

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Diagnostic Challenges in Bipolar Disorder

• Overlaps with many other disorders ADHD, panic,
  generalized anxiety, OCD, Tourettes
• Estimated that 1/3 children diagnosed with ADHD
  actually have bipolar disorder
• 1/3 of children diagnosed with depression will
  eventually manifest bipolar disorder

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Differences between adult childhood bipolar
disorder

• Adults typically have episodes of either mania or
  depression with relatively normal functioning
  between episodes
• Children with bipolar disorder often both manic
  depressed at the same time
• Younger children tend to be irritable, excitable
  explosive
• Children frequently have multiple daily cycles of
  highs lows
• Children often show a more severe, chronic course
  of illness

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Bipolar disorder in adolescents

• May resemble classical adult presentation with
  periods of wellness between episodes
• Puberty is a time of risk for onset
• In girls, onset of menses may trigger the illness
• Alcohol and drug abuse common

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The Many Moods of Bipolar Disorder

• Manic episode
• Hypomanic episode
• Major depressive episode
• Mixed episode

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Symptoms of Mania

• Euphoria or irritability
• Needing little sleep yet having great amounts of
  energy
• Racing thoughts and rapid speech
• Easily distracted
• Grandiosity inflated feeling of power,
• greatness or importance
• Reckless behaviors spending, promiscuity

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Symptoms of Hypomania

• Symptoms similar to mania, but less severe
• No marked impairment in functioning
• Psychotic features never present
• Pleasurable
• Seldom recognized by the patient as problematic

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Symptoms of depression

• Criteria same for childhood adult depression
• Physical symptoms disturbances in sleep,
  appetite, energy, somatic complaints
• Mental symptoms problems with concentration,
  memory
• Emotional symptoms tearfulness, sadness,
  irritability, suicidal thoughts, hopelessness,
  pessimism

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Symptoms of a mixed episode

• Criteria for both mania and depression
  experienced nearly every day for at least one
  week
• Mood alternates rapidly between euphoria,
  sadness, and irritability
• Agitation, appetite disturbance, insomnia,
  psychosis, suicidal ideation are common

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Subtypes of Bipolar Disorder

• Bipolar I at least one manic or mixed episode
• Bipolar II one or more episodes of both major
  depression and hypomania, but no manic or mixed
  episodes
• Bipolar NOS partial criteria
• Cyclothymia numerous episodes of hypomania and
  depression that do not meet criteria for mania
  or major depression

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Bipolar Disorder Summary

• Mood dysregulation disorder
• Early onset, but challenging to diagnose given
  comorbidities developmental issues
• Illness causes significant impairment in
  interpersonal, academic, and emotional
  functioning
• Very treatable

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INTERVENTIONS

• Intervention starts with diagnosis
• Education about the disorder for the
  parent/child/educators
• Appropriate and closely monitored medication
  management
• Therapy (Diagnositic, educational, family,
  cognitive-behavioral, supportive)
• School programming

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Treatment Planning
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SCHOOL CONSIDERATIONS

• Little learning will take place until mood is
  stabilized
• Goals should proceed from attendance to
  participation to production
• Reading comprehension, speed and accuracy of math
  and written expression most affected

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SCHOOL CONSIDERATIONS

• Student cannot complete as much work in same
  amount of time as other students with same
  ability
• Student has difficulty with flexibility so
  teachers/staff must be flexible
• Performance will be variable
• Fatigue, hunger, illness, mild life issues will
  have major impact on functioning

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SCHOOL CONSIDERATIONS

• Environmental issues are important
• (lighting, seating, noise/distractions)
• Periods of transition are taxing
• Communication among those involved with the
  student is critical
• Student needs a safe place and a
• confidante at school

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SCHOOL CONSIDERATIONS

• Behavior should not be interpreted at face
  valueimportant to look at the underlying
  emotions
• Writing assignments and math will be the most
  threatening for these students
• Students may need more than the
• four year plan for high school

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PEARLS . . .

• Treat a Bipolar Spectrum Disorder as a chronic
  illness . . . it will wax and wane but not be
  cured.
• Children do well if they can.
• Ross Greene, 2001.

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Reading List

• The Bipolar Child, Papolos and Papolos, Broadway
  Books, 2002.
• The Bipolar Disorder Survival Guide, Miklowitz
  DJ., The Guilford Press, 2002.
• An Unquiet Mind, Jamison KR, Knopf, 1995.
• Touched with Fire Manic-depressive Illness and
  the Artistic Temperament, Jamison KR, Maxwell
  Macmilllan International
• The Explosive Child, Greene R, Harper Collins,
  2001.

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Reading List

• His Bright Light, Steel D, Delacorte Press, 1998.
• Survival Strategies for Parenting Children with
  Bipolar Disorder, Lynn GT, Jessica Kingsley
  Publishing, 2000.
• Straight Talk About Psychiatric Medication for
  Kids, Wilens TE, Guilford Press, 1998.
• Geller, B. DelBello, M.P. (2003). Bipolar
  Disorder in Childhood and Early Adolescence. New
  York Guilford Press.

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Reading List

• Its Nobodys Fault New Hope for Difficult
  Children. Harold S. Koplewicz. Three Rivers
  Press, 1996.
• When You Worry About the Child You Love
  Emotional and Learning Problems in Children.
  Edward Hallowell. DIANE Publishing, 1999.
• Firstad, M.A., Goldberg Arnold, J.S. (2004).
  Raising a Moody Child how to cope with
  depression and bipolar disorder. New York
  Guilford Press.

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• Julie T. Steck, Ph.D., HSP
• Childrens Resource Group
• 9106 North Meridian, Suite 100
• Indianapolis, IN 46260
• 317/575-9111
• www.childrensresourcegroup.com