1. 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 1

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

3. Pavuluri, 2012

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

5. 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
Excited
Giggly
Silly
Giddy
constantly on the go
laughing fits
joking and feels invincible
“ overwhelming”
“ like wanting to jump on the bed”
Pavuluri, 2012

6. 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

7. Pavuluri, 2012

8. 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

9. Specific to PBD Rapid Cycling Irritability Comorbid ADHD Chronicity
77-98%
Rapid Cycling
46-87%
Comorbid ADHD
75-98%
Mixed Mania
20-84%
Chronicity
4229 months;
84%
Pavuluri, 2012

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

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

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

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

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

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

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

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

18. Distribution of Bipolar Subjects
Pavuluri, 2005

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

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

21. “Diagnostic fashion runs in cycles!”
Pavuluri, 2012

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23. 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.
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 1 2 3
Never Sometimes Often Very Often
/Rarely
Pavuluri et al, aacap 2004
Pavuluri, 2012

24. How to use it?
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

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

26. Internal Consistency: 0.96 Test Re-test Reliability: 0.96
Pavuluri, 2005

27. CMRS-P Total Score
Pavuluri, 2012

28. 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

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

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

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35. Comorbidity of ADHD In Pediatric Bipolars
98% / 72% 11 60
Geller et al., 2000
93%
6.1 68
Faraone et al., 1997
29% 16 48
Kafantaris et al., 1998
71% 42
Kowatch et al., 2000
15.7
7.9
15.1
Mean Age
65% 34
DelBello et al., 2001
98% 43
Wozniack et al., 1995
57% 14
West et al., 1995
ADHD n
Study
Pavuluri, 2005

36. Distinguishing Between Bipolar and ADHD
In this clinical study, Geller et al sought to optimize generalizability by recruiting consecutive subjects with pediatric BP and ADHD from outpatient pediatric and psychiatric sites. The community control subjects were obtained from a random survey.
Compared with children who had ADHD, those with BP exhibited significantly greater elevated mood, grandiosity, flight and/or racing of ideas, decreased need for sleep, and hypersexuality. The excessive rates of elation and irritability were similar to those found in adults with mania. Features that were common to both groups–and therefore not useful in differentiating the disorders–included irritability, hyperactivity, accelerated speech, and distractibility.
Geller & Zimerman 2002.

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

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39. Prevalence of BP in Adolescents
Diagnostic interviews with 1709 high school students, ages years
Findings
1.0% prevalence of BP (primarily BP II
and cyclothymia)
5.7% prevalence of BP NOS
Few epidemiologic studies of BP in children and adolescents have been conducted. Indeed, no studies have assessed specifically the prevalence of the disorder in prepubertal children.
Lewinsohn et al studied the prevalence of BP in a community sample of 1709 high school students aged 14 through 18 years. Subjects were selected randomly and assessed via diagnostic interviews and questionnaires.
The lifetime prevalence of BP—primarily BP II and cyclothymia—in this sample was approximately 1%. Another 5.7% of subjects reported symptoms consistent with a diagnosis of BP not otherwise specified (NOS).
Lewinsohn 1995

40. Age of Symptom Onset 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
Lish 1994
Pavuluri, 2012

41. Recovery and Relapse
Pavuluri, 2012

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

43. R A I N B O W R A I N B O W CAN DO IT OUTINE FFECT CONTROL
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