Early Onset Bipolar Disorder and the Pediatric Behavior Rating Scale

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Early Onset Bipolar Disorderand the Pediatric
Behavior Rating Scale (PBRS)
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Childrens Mental Health

• 5,000,000 (the number of children and
  adolescents in the U.S. suffer from a serious
  mental disorder resulting in significant
  functional impairments at home, at school, and
  with peers.)
• 80 (Americas youth with mental health needs who
  fail to be identified and to receive treatment
  and services.)
• 6-8 years from onset to treatment for mood
  disorders
• CONSEQUENCES (of untreated mental disorders
  include suicide, addictions, school failure, and
  criminal involvement).
• Information obtained from National Alliance on
  Mental Illness web site Aug. 2007

Society benefits when Mental Health is addressed
early
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DIAGNOSIS DU JOUR?

• 1980S ADHD
• 1990S DEPRESSION
• 2000S EOBPD

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RATES OF DIAGNOSIS

• 4,000 increase in rate of EOBPD diagnoses in the
  past 10 years (Frontline, 2008)
• At present, over 1 million American children have
  an EOBPD diagnosis, and the number is steadily
  increasing (Frontline, 2008)

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PROBLEMS IDENTIFYING BPD IN CHILDREN

• EOBPD is not in DSM IV.
• EOPBD looks like other disorders.
• EOBPD has high rates of comorbidity.

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PROBLEM 1 EOBPD isnt in DSM IV

• BIPOLAR DISORDERS
• Bipolar l Disorder
• Mania and major depression
• Bipolar ll Disorder
• Hypomania major depression
• Cyclothymic Disorder
• Hypomania depression/dysthymia

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EOBPD vs. Adult BPD
EOBPD Adult BPD
Mixed Mood Episodes are typical Discrete Mood Episodes are typical
Ultra-Rapid Cycling is common Longer cycles
Symptomatic most of the time Periods of no symptoms between cycles

• (Birmaher et al, 2008 Danielyan et al, 2007
  Kowatch et al, 2005)

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PROBLEM 1 EOBPD isnt in DSM IV

• Bipolar Disorder-Not Otherwise Specified
• Rapid alternation between manic and depressive
  symptoms that do not meet the duration criteria
  for manic, hypomanic, or major depression
• Hypomanic without depression
• Infrequent episodes

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PROBLEM 2 EOBPD mimics other disorders

• Disruptive Behavior Disorders
• ADHD
• 60-93 meet diagnostic criteria for ADHD
  (Biederman, et. al, 2003)
• Mania versus hyperactivity
• More anger, irritability, aggressive temper
  tantrums
• Presence of elation, grandiosity, racing
  thoughts/flight of ideas, decreased need for
  sleep, hypersexuality

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PROBLEM 2 EOBPD mimics other disorders

• ODD
• 77-88 have ODD (Wozniak et. al, 1995)
• More intense irritability and severe emotional
  meltdowns
• CD
• 42-69 have CD (Biederman, et. al, 2003)
• Violent and aggressive behavior lacks intent,
  planning, and premeditation

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PROBLEM 2 EOBPD mimics other disorders

• Anxiety Disorders
• 56-75 have anxiety disorder (Wozniak et. al,
  1995 Masi, et. al, 2001)
• Tourettes Disorder, Schizophrenia, Autism
  Spectrum Disorder

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WHAT WE KNOWSYMPTOMS ASSOCIATED with EOBPD

• Inflexible
• Oppositional
• Irritable
• Explosive rages
• Erratic sleep
• Difficult to soothe
• Separation anxiety
• Night terrors
• Fear of death and annihilation
• Rapid cycling

• Precociousness
• Sensitivity to stimuli
• Problems with peers
• Temperature dysregulation
• Craving for carbs. and sweets
• Bedwetting and soiling
• Hypersexuality
• Hallucinations
• Suicidal ideation

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Frequency of EOBPD Symptoms
Very Often (90-97) Often (60-80) Sometimes (20-35) Infrequent (Less than 10)
Irritability Anxiety Hypersexuality Homicidal Ideas
Mood Lability Racing Thoughts Psychosis Suicidal Acts
Sleep Disorder Pressured Spch Suicidal Ideation
Anger Rage Euphoria, Grandiosity Self-harm
Impulsivity
Agitation
Aggression
From Faedda Austin, 2006 Parenting a bipolar child p. 39.

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Psychosis

• Tillman et al (2008), 257 EOBPD participants,
  ages 6-16, funded by NIMH
• Psychosis was present in 76.3 of subjects
• 38.9 with delusions
• Grandiose was most common
• 5.1 with pathological hallucinations
• Visual hallucinations were most common
• 32.3 with both

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DEVIANCE

• VOLUNTARY - we have a tendency to attribute
  misbehaviorespecially noncompliance and
  disobedience--to willful disobedience.
• INVOLUNTARY - we tend to minimize this even when
  it explains the childs behavior.

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EOBPD and AROUSAL

• Children with EOBPD
• are less able to modulate arousal
• live in fear
• are on alert for danger
• are primed for fight/flight response
• And when aroused, aggression is more likely.

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WHAT KIND OF AGGRESSION IS BEING EXPRESSED?

• Predatory-controlled (instrumental)
• Defensive-impulsive, reactive (not for gain)

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CHARACTERISTIC DIAGNOSIS AGGRESSION TYPE
Impulse Control ADHD Accidents/ Injuries
Emotional Instability Bipolar, Borderline, IED Reactive, affective attack
Irritability Depression, Dysthymia Acting Out, Suicide
Anxiety/Low Frustration Tolerance Anxiety, PTSD, ASD Reactive striking out
Impaired Judgment Substance Abuse, Psychosis Inadvertent Aggression
Stimulation Seeking CD, ODD Predatory Aggression
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REACTIONARY and CONFRONTATIONAL approaches serve
mainly to provoke and escalate.
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GOALS OF INTERVENTIONS

• Stabilize
• Reduce Symptoms
• Opposition
• Defiance
• Irritability
• Aggression
• Improve Functioning (academic, social)

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TWO WAYS TO ACHIEVE THESE GOALS

• Medications (to make the child available)
• Psychotherapies (coping managing)

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General Rule for Interventions

• Behavioral approaches tend to focus on
  consequences.
• There are two problems with this

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TWO PROBLEMS

• 1. By definition, children and adolescents with
  deficits in impulse control and self- regulation
  do not consider consequences before they act.
• 2. Behavioral consequences (especially if they
  are aversive) introduce provocation,
  confrontationand escalation.

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INTERVENTION TARGETS

• CHILD
• medications
• sleep
• self-regulation
• PARENTS
• psychoeducation
• medication compliance
• ENVIRONMENT (control the pace)
• home
• school

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DRUG TREATMENTS EOBPD

• FOUR MAJOR CLASSES of MOOD STABILIZERS
• Lithium
• Antiepileptics (Mood Stabilizers)
• Antidepressants
• Antipsychotics

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CHARACTERISTIC DIAGNOSIS AGGRESSION TYPE MEDICATION
Impulse Control ADHD Accidents/ Injuries STIMULANTS SSRI ANTIPSYCHOTIC MOOD STABILIZERS
Affective Instability Bipolar, Borderline, IED Reactive, affective attack ANTISPYCHOTICS MOOD STABILIZERS SSRI
Irritability Depression, Dysthymia Acting Out, Suicide SSRI OTHER ANTIDEPRESSANTS
Anxiety/Low Frustration Tolerance Anxiety, PTSD, ASD Reactive striking out OTHER ANTIDPERESSANTS SSRI TENEX CLONODINE
Impaired Judgment Substance Abuse, Psychosis Inadvertent Aggression ANTIPSYCHOTICS
Stimulation Seeking CD, ODD Predatory Aggression MOOD STABILIZER
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NONDRUG INTERVENTIONS

• THERE ARE 550 PSYCHOTHERAPIES (NONMEDICAL
  INTERVENTIONS) FOR TREATING CHILDREN AND ADULTS

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BEYOND BEHAVIORISM

• Parent Management Training
• Cognitive Behavioral Therapy
• Dialectal Behavior Therapy
• Choice Theory
• Problem-Solving Skills
• Health Promoting Environments

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CHARACT-ERISTIC DIAGNOSIS AGGRESSION TYPE PSYCHOTHERAPY
Impulse Control ADHD Accidents/ Injuries CBT DBT PROBLEM-SOLVING Parent Training
Affective Instability Bipolar, Borderline, IED Reactive, affective attack CBT DBT PROBLEM-SOLVING Parent Training
Irritability Depression, Dysthymia Acting Out, Suicide CBT
Anxiety/Low Frustration Tolerance Anxiety, PTSD, ASD Reactive striking out CBT DBT PROBLEM-SOLVING Parent Training
Impaired Judgment Substance Abuse, Psychosis Inadvertent Aggression Cognitive Enhancement Therapy
Stimulation Seeking CD, ODD Predatory Aggression Parent Training
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PSYCHOEDUCATION

• The Bipolar Child (3rd Edition) by Papolos and
  Papolos (2006)
• Understanding the Mind of Your Bipolar Child by
  Lombardo (2006)
• The Bipolar Disorder Survival Guide by Miklowitz
  (2002)
• The Bipolar Teen by Miklowitz and George (2008)
• www.bpchildren.com
• www.bipolarhelpcenter.com
• www.bipolarkids.org
• www.cabf.org
• www.jbrf.org/juv_bipolar/faq.html

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Three-Tier Model of Behavioral Intervention/Suppo
rt
Tier III Intensive, Individual Interventions
1 - 5
1-5
Tier II Targeted Group Interventions
10-15
80 - 90
Tier I Universal Interventions/Supports
10 - 15
80 - 90
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Tier III Individual Interventions

• Goal To develop and implement interventions for
  student behaviors that can not be addressed or
  remedied via Tier I or Tier II interventions.

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FUNCTIONAL ASSESSMENT
Modified from Santilli, Nancy, Dodson, W.E.,
Walton, A.V. (1991)
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INTERVENTIONS FOR SIMPLE

• Monopharmacy
• Mildly intrusive therapy
• individual therapy
• group therapy
• parent training
• Regular classroom placement
• Favorable RTI

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INTERVENTIONS FOR COMPROMISED

• Polypharmacy (aggression, irritability,
  co-morbidity)
• Intensive child and family therapies
• individual therapy
• group therapy
• family therapy/parent training
• May require Spec. Ed. (EH, SED, OHI)
• Variable RTI

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INTERVENTIONS FOR COMPLEX

• Polypharmacy
• Intensive Interventions
• individual therapy
• intensive parent training
• alternative educational placements
• Acute hospitalization
• Self-contained to RTC
• Law Enforcement
• Very poor prognosis

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Predictors of Outcome

• Worse outcomes are associated with
• Younger age of onset
• Long duration of mood symptoms
• Low socioeconomic status
• Lifetime psychosis
• (Birmaher et al, 2006)

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PEDIATRIC BEHAVIOR RATING SCALE
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WHY A NEW RATING SCALE?

• Existing scales came out normal
• Item analysis told us why
• The need for differential diagnosis

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OTHER SCALES

• Young Mania Rating ScaleParent Version
  (P-YMRS 11 items)
• General Behavior Inventory (GBI 73 items age
  11 self-report accuracy)
• Child Mania Rating Scale (CMRS mania only)
• Conners Abbreviated Symptom Questionnaire
  (ASQ 10 mania items from the Conners Parent
  Rating Scales CPRS)
• Omnibus rating scales (e.g., Clinical
  Assessment of Behavior CAB, Achenbach System of
  Empirically Based Assessment ASEBA, Behavior
  Assessment System for Children BASC)

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PURPOSE

• For children and adolescents ages 3-18 years
• Primary function To assist in the identification
  of emotional dysregulation and related disorders,
  specifically early onset bipolar disorder (EOBPD)
• Secondary function To aid in differential
  diagnosis, leading to differential interventions

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FEATURES

• Sufficient items to identify core features of
  EOBPD, such as
• Mood swings
• Irritability
• Grandiosity
• Easily provoked
• Explosive outbursts
• Syndromal differentiation (e.g., ADHD vs.
  EOBPD)
• Identifies areas of concern rather than
  providing diagnoses

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PBRS APPLICATIONS

• Clinical
• Distinguish between EOBPD and its mimics
• Symptom identification and profile analysis
• Areas of concern
• Educational
• Clarify diagnosis using IDEA
• More complete symptom profile (intervention)
• Research
• Defining the disorder in children
• Handling comorbidity
• Intervention efficacy

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COMPONENTS

• Parent Form
• PBRS Parent Item Booklet (102 items)
• PBRS Parent Response Booklet
• PBRS Parent Score Summary/Profile Form
• Teacher Form
• PBRS Teacher Item Booklet (95 items)
• PBRS Teacher Response Booklet
• PBRS Teacher Score Summary/Profile Form

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SCORES PRODUCED

• Inconsistency Score
• Can I trust the responses?
• Critical Items
• No matter what, these are clinically important
• Symptom Scales
• Each is important, as is the profile
• Total Bipolar Index
• Composite of all 8 symptom scales

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CRITICAL ITEMS

• These items have special clinical significance
  and should be given special attention. Any item
  with a score greater than zero should be
  investigated further as this suggests a serious
  problem that must be addressed or ruled out.
• Self-abuse
• Hallucinations
• Bizarre beliefs
• Expresses violent themes
• Suicidal thoughts
• Aggression

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SYMPTOM SCALES

• Eight clinical scales and one index
• Atypical (psychotic symptoms)
• Irritability (persistent and chronic)
• Grandiosity (exaggerated sense of self)
• Hyperactivity/Impulsivity (as in ADHD)
• Aggression (toward others, animals, objects)
• Inattention (as in ADHD)
• Affect (mood disturbances, cognitive
  distortion)
• Social Interactions (interacting with peers)
• Total Bipolar Index

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Atypical (ATY) Scale

• Bizarre beliefs
• Auditory hallucinations
• Delusions
• Self-harm behaviors
• Excessive fears

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Irritability (IRR) Scale

• Emotional dysregulation
• Behavioral/emotional outbursts
• Demandingness

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Grandiosity (GRAND) Scale

• Elevated sense of self and mood
• Not taking responsibility for actions
• Exaggerating
• Stealing

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Hyperactivity/Impulsivity (HYPER) Scale

• Classic description of overactivity and
  impulsivity
• Difficulty sitting still
• Acts without thinking about consequences
• Always on the go

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Aggression (AGG) Scale

• Aggression targeting other people, animals, or
  objects

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Inattention (INATT) Scale

• Traditional scale for inattention and
  distractibility
• Difficulty focusing
• Difficulty sustaining attention

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Affect (AFF) Scale

• Mood disturbances
• Suicidal ideation
• Cognitive distortions

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Social Interactions (SOC) Scale

• Ability to interact with peers
• Ability to make friends
• Relating to others
• Engaging in social interactions

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TOTAL BIPOLAR INDEX

• TBI is a composite of the 8 scales
• The most robust PBRS score (like g on IQ tests)
• T scores gt70 are a significant concern for
  disorders of emotional dysregulation T scores
  gt80 suggest EOBPD
• The most effective way to differentiate EOBPD
  from other diagnoses (especially ADHD)

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POPULATION

• Normative sample
• Parents n 541
• Teachers n 610
• Clinical sample (clinical groups included BPD,
  ADHD, CD, ODD, and autism spectrum disorders
  ASD)
• Parents n 224
• Teachers n 194

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RELIABILITY

• Internal consistency
• Coefficient a for PBRS-P .60 to .89
• Coefficient a for PBRS-T .75 to .93
• Coefficient a for PBRS-P TBX .95
• Coefficient a for PBRS-T TBX .97

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RELIABILITY

• Parent-teacher interrater reliability
• Coefficient a .77 to .86
• Coefficient a for TBX .88
• Parent-parent interrater reliability
• Coefficient a .67 to .86
• Coefficient a for TBX .85

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VALIDITY

• Convergent validity Omnibus rating scales for
  similar behaviors
• PBRS-P with CAB .50-.80
• PBRS-T with CAB .30-.80
• PBRS-P with BASC-2 .60-.80
• PBRS-T with BASC-2 .70-.80

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VALIDITY

• Convergent validity Domain-specific rating
  scales
• PBRS-P with CMRS .07 (Affect) to .63
  (Aggression)
• PBRS-T with CMRS -.23 (Affect) to .70
  (Hyperactivity/Impulsivity)
• PBRS-T with Conduct Disorder Scale (CDS) .52
  to.74 on four similar scales
• PBRS-T with Conners Teacher Rating Scales (CTRS)
  .16 (Cognitive Problems/Inattention with
  Atypical) to .69 (Hyperactivity with
  Hyperactivity/Impulsivity)

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VALIDITY

• Clinical validity
• Normative group compared to clinical groups (BPD,
  ADHD, ODD, CD, ASD) on the 8 scales and the TBX
  were significant at p lt .001.
• The 8 scales and the TBX differentiated the five
  clinical groups on all scales except Atypical and
  Inattention (Parent) and Irritability and
  Inattention (Teacher).