Bipolar Children in the School Setting A Primer

Bipolar Children in the School Setting A Primer of Diagnosis and Treatment Options for Special Education Professionals Gabriel Kaplan, M. D. Bennett Silver, M. D. Nadezhda Sexton, Ph. D.

NEW JERSEY CHILDREN'S SYSTEM OF CARE Nadezhda Sexton, Ph. D.

The History of mental health services for NJ youth Get in line Open a case Confined care rules Systemic fragmentation Silencing of families and youth

System reform resulted in: Dramatic increase in community based services (need- Separation of child welfare and mental health systems Reduction in use of residential, detention, and hospital stays (least restrictive) Maximized funding for effective interventions driven, strength-based) (individualized) (outcomes-driven) Empowerment and direct support of family members; elevation of youth as consumers (youth and family guided)

System of care agencies Care Management Organizations (CMO) are countybased, non-profit organizations that are responsible for face-to-face care management and comprehensive service planning for youth and their families with intense complex needs. Family Support Organizations (FSOs) are non-profit organizations run by families of children in that county with emotional and behavioral challenges. . Mobile Response & Stabilization Services (MRSS) are provided to youth who exhibit emotional or behavioral challenges that may jeopardize their current living arrangements. They provide face-to-face crisis response within 1 hour of notification. Youth Case Management (YCM) offers face-to-face services for moderate-risk youth.

About Us Our Director's Message A brighter, healthier future awaits those who care In the late 90's, a dedicated group of parents approached the State of New Jersey with a plan to reform children's mental health. These parents recognized that the system in place at that time was not meeting the needs of children with complex emotional, mental health or behavioral challenges. Under the direction of Governor Christie Whitman, New Jersey launched the Children's System of Care Initiative. The vision was to create a system of care that focused on family strengths and community resources. Families and youth work in partnership with public and private organizations to design mental health services and supports that are effective, that build on the strengths of individuals, and that address each person's cultural and linguistic needs. A system of care helps children, youth and families function better at home, in school, in the community and throughout life. System of care is not a program — it is a philosophy of how care should be delivered. System of Care is an approach to services that recognizes the importance of family, school and community, and seeks to promote the full potential of every child and youth by addressing their physical, emotional, intellectual, cultural and social needs. Madeline Lozowski Executive Director Family Support Organization

CSA Contract Service Administrator

Check it out: Toll-Free Access Line 1 -877 -652 -7624 (Multi-lingual Language Line available) 24 hours-a-day, 7 days a week www. state. nj. us/dcf/behavioral

OVERVIEW OF BIPOLAR DISORDER IN CHILDREN AND ADOLESCENTS Gabriel Kaplan, M. D.

Child’s Ordeal Shows Risks of Psychosis Drugs for Young (9/1/10) At 18 months, Kyle started taking a daily antipsychotic drug on the orders of a pediatrician trying to quell the boy’s severe temper tantrums Thus began a troubled toddler’s journey from one doctor to another, from one diagnosis to another, involving even more drugs. Autism, bipolar disorder, hyperactivity, insomnia, oppositional defiant disorder The boy’s daily pill regimen multiplied: the antipsychotic Risperdal, the antidepressant Prozac, two sleeping medicines and one for attention-deficit disorder. All by the time he was 3. He gained Lb 49

Potentially Powerful Side Effects (Published by NYT 9/1/10) Kyle at 3 years old, he started taking antipsychotics at 18 months due to severe tantrums Kyle at 6 years old, takes medication for ADHD, doing well

Accurate Diagnosis a Must (Published by NYT 9/1/10) “It’s a controversial diagnosis, I agree with that, ” said Dr. Concepcion. “But if you will commit yourself in giving these children these medicines, you have to have a diagnosis that supports your treatment plan. You can’t just give a nondiagnosis and give them the atypical antipsychotic. ” Dr. Charles H. Zeanah, a Tulane medical professor, who disagreed with both the diagnosis and the treatment. “I have never seen a preschool child with bipolar disorder in 30 years as a child psychiatrist specializing in early childhood mental health, ” Kyle’s new doctors point to his remarkable progress — and a more common diagnosis for children of attention-deficit hyperactivity disorder — as proof that he should have never been prescribed such powerful drugs in the first place.

DSM-IV Mood Disorders Unipolar Disorders Major Depression Dysthymic Disorder Bipolar Disorders Bipolar II Cyclothymic Disorder

DSM-IV Bipolar Disorders Bipolar I One or more Manic episodes (or Mixed Mania/Depression) usually accompanied by episodes of Depression (but may not) Bipolar II Major Depressive episodes with Hypomania Cyclothymic Disorder Less than full episodes of Mania and Depression

Bipolar Stats 1% of population will develop One parent with Bipolar Both parents 15 -30% risk to offspring 50 -75% risk Risk in siblings: 20% Risk in identical twin: 70% 60% of adults report onset before age of 20

Bipolar Epidemic ? 40 -fold increase in outpatient diagnosis 1994 -2003 Moreno C, Laje G, Blanco C et al. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007; 64: 1032– 1039 6 -fold increase in hospital diagnosis 1996 -2004 Blader JC, Carlson G. Increased rates of bipolar disorder diagnoses among US child, adolescent, and adult inpatients, 1996– 2004. Biol Psychiatry. 2007; 62: 107– 114.

Increase in Outpatient Diagnosis

DSM-IV Manic Episode A 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, 3 (or more) of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree: (1) inflated self-esteem or grandiosity (2) decreased need for sleep (e. g. , feels rested after only 3 hours of sleep) (3) more talkative than usual or pressure to keep talking (4) flight of ideas or subjective experience that thoughts are racing (5) distractibility (6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (7) 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)

Are DSM IV Criteria Applicable to Pediatric BP? Criteria were established from adult research at a time when PBP was not fully accepted Main problem is criterion A “Distinct Period”, often not present in children In youth, BP shows mainly as ongoing mood lability and increased energy, Irritability/aggression, reckless behavior, short lived mood shifts

However, DSM is Recommended The “presence” of mood episode –mania- must be determined (elevated, expansive, or irritable) Although its “precise” onset may not be ascertained, in order to meet Bipolar criteria, a mood episode MUST be distinguished from persistent other kinds of presentations, i. e. either normal personality style or pathological (ADHD) “B” (developmentally reviewed) symptoms must be present during the mood episode and be of an impairing nature

Frequency of Pediatric Bipolar Symptoms Kowatch RA et al. Review and meta-analysis of the phenomenology and clinical characteristics of mania in children and adolescents. Bipolar Disord 2005; 7: 483– 496.

Normal or a Symptom? Children might present with seemingly manic symptoms for a variety of reasons Clinicians use the FIND (Frequency, Intensity, Number, and Duration) strategy to make this determination.

A real FIND Frequency Intensity Symptoms are severe enough to cause extreme disturbance in one domain or moderate disturbance in two or more domains Number Symptoms occur most days in a week Symptoms occur three or four times a day Duration Symptoms occur 4 or more hours a day, total, not necessarily contiguous

FIND Qualifies Symptoms A child who becomes silly and giggly to a noticeable and bothersome degree for 30 minutes twice per week in school and home Frequency (twice per week), Intensity (mild interference in two domains), Number (one episode per day), Duration (30 minutes) Does not qualify for a BPD A child described as ‘‘too cheerful’’ F: during school days and every day after school I: to the point that relations with teachers, parents, siblings, and peers are disrupted N: several times per day D: ‘‘high’’ times last several hours Has crossed the FIND threshold

Euphoric/Expansive Mood NORMAL 25 th Very happy, giggling Got latest Wii model Dec MANIA 25 th Laughing hysterically in Church Says people dress funny Parental disapproval does not stop laugh Dec

Irritable Mood NORMAL After a long car trip in the summer Hot and hungry MANIA Asked to tie shoes Two hour tantrum

Grandiosity NORMAL I am Superman Pretend play, stops when its time for supper MANIA I am Superman Attempts to jump out the window to prove can fly

Decreased Need for Sleep NORMAL Anxious about test tomorrow Up till 1 AM, stays in bed Difficult to get up in the morning and tired all day MANIA No identifiable stressor Up till 1 am running around throughout house Sleeps only 4 hours and full of energy next morning

Pressured Speech NORMAL Running back home to tell mom got lead part in school play MANIA No identifiable reason for broken up fast speech that lasts for hours

Young Mania Rating Scale

Functional Impairment aggressive behavior, attention problems anxious and depressed symptoms delinquent behavior, social problems withdrawal, poor social skills, no friends, and teased by other children. Substance abuse 39% which when present greatly worsens severity and prognosis Sala R et al Phenomenology, longitudinal course, and outcome of children and adolescents with bipolar spectrum disorders. Child Adolesc Psychiatr Clin N Am. 2009 Apr; 18(2): 273 -89

Suicidal Ideas and Psychosis NORMAL Not present MANIA May be present

Suicide Attempts Various Conditions 0 -18 years Mania Major Depression 44% 18% No Disorder 1% Lewinsohn, PM. ; Seeley, JR. ; Klein, DN. Bipolar disorder in adolescents: epidemiology and suicidal behavior. In: Geller, B. ; Del. Bello, MP. , editors. Bipolar Disorder in Childhood and Early Adolescence. New York: Guilford; 2003. p. 7 -24.

DIFFERENTIAL DIAGNOSIS: IS IT BIPOLAR OR ADHD? Gabriel Kaplan, M. D.

ADHD Criteria

ADHD Bipolar Overlap Distractibility

Manic Specific Symptoms Elated Mood Grandiosity Flight of Ideas Racing thoughts Decreased need for sleep Hypersexuality Geller et al, Journal of Child and Adolescent Psychopharmacology 2002; 12: 11– 25

Common Diagnostic Dilemma A child with impairing distractibility and aggression Is it mild Bipolar? Is it severe ADHD? Are both conditions present? (Co-morbidity)

ADHD vs Bipolar ADHD Child has always been distractible Family history of ADHD Bipolar Distractibility only occurs in the context of a change of mood that is different from the patient’s usual mood. Hypersexual, grandiose, elated, suicidal Co-Moribidity Distractibility persists when mood episode remits

TREATMENT OF MANIA IN BIPOLAR DISORDER Bennett Silver, M. D.

What Are Mood Stabilizers? Medications with both antimanic and antidepressant actions Medications that decrease vulnerability to subsequent episodes of mania or depression and do not exacerbate the current episode or maintenance phase of treatment.

Mood Stabilizers Used for Bipolar Disorder LITHIUM: Lithium Carbonate (Eskalith, Lithobid) ANTICONVULSANTS: Valproic Acid (Depakote) Carbamazepine (Tegretol) Lamotrigine (Lamictal) ATYPICAL ANTIPSYCHOTICS: Risperidone (Risperdal) Quetiapine (Seroquel) Aripiprazole (Abilify) Olanzapine (Zyprexa) Ziprasidone (Geodon) Asenapine (Saphris) Paliperidone (Invega) Clozapine (Clozaril)

How Do Mood Stabilizer Medications Work? Nobody really knows for sure but our understanding is growing rapidly Effect “first messenger” brain neurotransmitters that act at the synapse between nerve cells, such as dopamine, serotonin, norepinephrine, glutamate, and GABA Effect “second messenger” systems within the nerve cell such as c. AMP (cyclic AMP) and BDNF (Brain-Derived Neurotrophic Factor) which can turn on genes within the nerve cell promoting nerve growth (neurogenesis) or nerve atrophy

Lithium Oldest mood stabilizer Improves depression and mania Helps prevent future episodes Narrow dosage range (blood levels required) Very dangerous in overdose Side – effects drowsiness, weakness, nausea fatigue, hand tremor, increased thirst increased urination, thyroid underactivity, weight gain, decreased kidney function (rarely)

Anticonvulsants Improve depression and mania Lamictal especially good for depressive episodes Help prevent future episodes Narrow dosage range (blood levels required) Work better than Lithium for rapid cyclers and mixed states Side effects: Nausea, headache, double vision, sedation, liver enzyme elevation, weight gain, hormone changes in women (Depakote, e. g. , polycystic ovary syndrome, absence of menstruation)

Atypical Antipsychotics Improve depression and mania Help prevent future episodes Control delusions & hallucinations (psychosis) No blood levels required Side – effects: sedation; metabolic syndrome (some) - weight gain, elevated blood sugar, blood pressure, diabetes, elevated cholesterol; neuromuscular - restlessness, muscle spasms (dystonia), involuntary movements (tardive dyskinesia) - rarely Monitor: weight, blood pressure, blood sugar, cholesterol

Commonly Used Antipsychotic Medications (Second. Generation antipsychotics, “Atypicals”) *All of the atypical antipsychotics are serotonin and dopamine antagonists *In 2009, Seroquel and Abilify were numbers 5 and 6 respectively amongst the top ten drugs in the U. S. based on sales (over $4 billion each) Abilify –weight neutral, less sedating Risperdal – Moderate weight gain, increases prolactin Seroquel – Moderate weight gain, sedating, may have antidepressant properties Zyprexa – Very effective, but significant weight gain, metabolic effects (blood sugar, cholesterol) Geodon – Weight neutral, less sedating Saphris – Recently released, sublingual pill Invega – Recently released Clozaril – Most effective, weight gain, metabolic effects, risk for severe white blood cell suppression requires regular blood tests. Used when other medications fail.

Treatment Considerations Choice of medication depends on an individual’s Bipolar symptoms and pattern of illness (psychosis, rapid cycling, etc. ) Side-effect profile may affect choice of medication Psychotherapy along with medication improves outcome

Principles of Medication Treatment Bipolar Disorder is a chronic, recurring illness and requires chronic, long-term maintenance medication Treatment targets acute episodes and prevention of episodes with maintenance medication Sometimes a single medication is inadequate and a combination of medications is required

Principles of Medication Treatment In fact, research indicates that there is a large group of Bipolar patients who require very complex psychopharmacologic regimens in order to achieve and sustain a good to excellent response * Periodic monitoring of blood levels confirms adequate dosing and compliance Periodic monitoring for metabolic effects (weight, blood sugar, cholesterol), thyroid, kidney & liver function *Post, R , Altshuler, L, et al. Complexity of pharmacologic treatment required for sustained improvement in outpatients with bipolar disorder. J. Clin Psychiatry. 2010: 71(9): 1176 -1186.

Accurate Diagnosis and Early Intervention Bipolar Disorder is often difficult to diagnose in adolescence, because of the nature of adolescent moodiness, and similarities with other conditions such as ADHD, Schizophrenia, and Addiction to drugs and alcohol Bipolar Disorder can have a spectrum of severity and milder forms are often missed or misdiagnosed (eg. , subthreshold or subsyndromal mania) Misdiagnosis leads to delayed or incorrect treatment

Early Aggressive Intervention Improves Long Term Outcome Research shows that very often there are long lags from the onset of Bipolar illness to first treatment * This delay is longest in those with the earliest onset in childhood and adolescence * Early onset Bipolar Disorder and delay to first treatment are independent risk factors for poor outcome in adulthood ** *Leverich GS, Post RM, Keck PE Jr, et al. The poor prognosis of childhood-onset bipolar disorder. J Pediatr. 2007; 150(5): 485 -490. **Post R, Leverich G, Kupka R, et al. Early onset bipolar disorder and treatment delay are risk factors for poor outcome in adulthood. J Clin Psychiatry. 2010; 71(7): 864 -872.

Diagnostic Ambiguity and Co-Occurring Disorders Correct diagnosis guides treatment and prevents a child from being placed on medications that can worsen the course of the disorder Rarely does bipolar disorder in children occur as a pure entity It is often accompanied by symptoms that suggest other psychiatric disorders, such as ADHD, Depression, Anxiety Disorders, Addiction For example, 61% of individuals with Bipolar Disorder also have a substance abuse disorder – a higher co-occurrence than with any other psychiatric disorder * 1/3 of children who first present with depression will eventually go on to manifest a Bipolar Disorder (risk of misdiagnosis as unipolar depression) ** As a result, a child with Bipolar Disorder may be prescribed antidepressants such as Prozac or Zoloft to treat depressive or anxiety symptoms, or stimulants such as Ritalin or Adderall to treat ADHD * NIMH ** American Academy of Child and Adolescent Psychiatry

Diagnostic Complexity and Choosing the Right Medication Treating a Bipolar child suffering from depression, anxiety or ADHD with an antidepressant or a stimulant alone can cause negative reactions such as rapid cycling, manic, violent, aggressive, or agitated behavior Often such patients seem to do well at first, but after weeks or months of treatment their behavior deteriorates Proper diagnosis prevents the child from being placed on medications that may worsen the course of the disorder Therefore, in a Bipolar child with such co-occurring conditions it is prudent to stabilize the patient first on a mood stabilizer(s) alone, prior to initiating other medications

When Medication Does Not Yield the Expected Improvement Is patient taking the medication as instructed? Re-assess the accuracy of the diagnosis Look for and treat co-occurring conditions such as: substance abuse, anxiety disorders, ADHD, personality disorders, etc. Maximize use of non-pharmacologic treatment modalities such as cognitive, behavioral therapies

The Problem of Non-Compliance (Non. Adherence) with Medication Treatment Non-compliance is the most common reason for failure of medication, relapse and re-admission to the hospital Rates of poor compliance may reach 64% for Bipolar Disorders * * J Clin Psychiatry, 2000 Aug, 61 (8): 549 -55

Why Don’t Patients Take Their Medication? Failure to understand the diagnosis, the chronic nature of Bipolar illness, the prophylactic function of medication & its positive effect on long term outcome A desire to recapture the elevated mood, energy and lack of inhibition associated with hypomanic and manic states Side-effects, especially weight gain and sedation Underestimating the long-term consequences of Bipolar Disorder on school, social and occupational functioning Stigma associated with psychiatric illness & medication Poor relationship between psychiatrist and patient or parents

Countering Non-Compliance Psycho-education regarding medication and Bipolar Disorder Create a treatment partnership between physician, patient and parent(s) Listen and be flexible & responsive to patient complaints about side-effects Group interaction with peers who are at different stages of their treatment experience

Traditional Treatment Model student Psychiatrist Child study team Family peers therapist teachers (Office-based)

Therapeutic School: Integrated Treatment Model for Bipolar Disorder Psychiatrist (In-school consultant) Accurate diagnosis, Education about diagnosis and use of medication Teachers/Therapists (In-school) Education, IEP Address psychiatric disorders, social, family, peer issues Peers Group Therapy, Social Skills Student Family Integration of school and therapeutic environment Family Therapy