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Pediatric Bipolar Disorder

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Presentation on theme: "Pediatric Bipolar Disorder"— Presentation transcript:

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

22 Pavuluri, 2012

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

31 Pavuluri, 2012

32 Pavuluri, 2012

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34 Pavuluri, 2012

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

38 Pavuluri, 2012

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


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