EARLY ONSET EARLY ONSET BIPOLAR BIPOLAR

DISORDER:DISORDER:Epidemiology, Educational Epidemiology, Educational

Implications, and Implications, and InterventionsInterventions

Shelley Hartshelley_hart@charter.net

DIAGNOSIS DIAGNOSIS

DSM-IV-TRDSM-IV-TR

Five types of Five types of episodesepisodes

Four subtypesFour subtypes Four severity levelsFour severity levels Three course Three course

specifiersspecifiers

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision. Washington, DC: Author.

Manic EpisodeManic Episode

Symptoms:Symptoms:1.1. Inflated self-esteem or grandiosityInflated self-esteem or grandiosity

2.2. Decreased need for sleep Decreased need for sleep

3.3. Pressured speech or more talkative than Pressured speech or more talkative than usualusual

4.4. Flight of ideas or racing thoughtsFlight of ideas or racing thoughts

5.5. DistractibilityDistractibility

6.6. Psychomotor agitation or increase in Psychomotor agitation or increase in goal-directed activitygoal-directed activity

7.7. Hedonistic interestsHedonistic interests

Hypomanic EpisodeHypomanic Episode

Similarities with Manic Episode = Similarities with Manic Episode = Same symptomsSame symptoms

Differences = Differences = Length of timeLength of timeImpairment not as severeImpairment not as severe

Major Depressive EpisodeMajor Depressive Episode

Symptoms:Symptoms:

1.1. Depressed mood (in children can be irritable)Depressed mood (in children can be irritable)

2.2. Diminished interest in activitiesDiminished interest in activities

3.3. Significant weight loss or gainSignificant weight loss or gain

4.4. Insomnia or hypersomniaInsomnia or hypersomnia

5.5. Psychomotor agitation or retardationPsychomotor agitation or retardation

6.6. Fatigue/loss of energyFatigue/loss of energy

7.7. Feelings of worthlessness/inappropriate guiltFeelings of worthlessness/inappropriate guilt

8.8. Diminished ability to think or Diminished ability to think or concentrate/indecisivenessconcentrate/indecisiveness

9.9. Suicidal ideation or suicide attempt Suicidal ideation or suicide attempt

Mixed EpisodeMixed Episode

Both Manic and Major Depressive Both Manic and Major Depressive Episode criteria are met nearly every Episode criteria are met nearly every day for a least a one week period. day for a least a one week period.

SubtypesSubtypesBipolar Disorder I = more classic form; clear Bipolar Disorder I = more classic form; clear

episodes of depression & maniaepisodes of depression & mania

Bipolar Disorder II = presents with less intense Bipolar Disorder II = presents with less intense and often unrecognized manic phasesand often unrecognized manic phases

Cyclothymia = chronic moods of hypomania & Cyclothymia = chronic moods of hypomania & depression, often evolves into a more depression, often evolves into a more serious typeserious type

Bipolar Disorder Not Otherwise Specified (NOS) Bipolar Disorder Not Otherwise Specified (NOS) = largest group of individuals= largest group of individuals

Children vs. Adults Children vs. Adults (or early vs. late onset )(or early vs. late onset )

IrritabilityIrritability Depression Depression Lack of mood Lack of mood

reactivity reactivity Rejection Rejection

sensitivitysensitivity Less evident are Less evident are

the “classic” the “classic” symptoms of symptoms of maniamania

EPIDEMIOLOGYEPIDEMIOLOGY

PrevalencePrevalence

Estimated between 3-6%Estimated between 3-6%Subsyndromal bipolar disorderSubsyndromal bipolar disorderEqual distribution across gender Equal distribution across gender

variablesvariablesAverage age @ onset = 20 years oldAverage age @ onset = 20 years old

CourseCourse

Initial cycle typically major depressive Initial cycle typically major depressive episodeepisode

RecoveryRecoveryRelapseRelapseRapid CyclingRapid Cycling

Rapid cycling=4 episodes/yearRapid cycling=4 episodes/yearUltrarapid cycling=5-364 episodes/yearUltrarapid cycling=5-364 episodes/yearUltradian cycling=>365 episodes/yearUltradian cycling=>365 episodes/year

Age at OnsetAge at Onset

Pediatric, prepubertal, or early Pediatric, prepubertal, or early adolescent (prior to age 12)adolescent (prior to age 12)

Adolescent (12 - 18 years)Adolescent (12 - 18 years)Adult onset (+ 18 years)Adult onset (+ 18 years)

IMPAIRMENTSIMPAIRMENTS

ComorbidityComorbidity

Attention Deficit Hyperactivity Attention Deficit Hyperactivity Disorder (ADHD)Disorder (ADHD)Between 60-80%Between 60-80%

Criteria ComparisonCriteria Comparison

Bipolar Disorder Bipolar Disorder (mania)(mania)

1.1. More talkative than More talkative than usual, or pressure to usual, or pressure to keep talkingkeep talking

2.2. DistractibilityDistractibility3.3. Increase in goal Increase in goal

directed activity or directed activity or psychomotor psychomotor agitationagitation

ADHDADHD1.1. Often talks Often talks

excessivelyexcessively

2.2. Is often easily Is often easily distracted by distracted by extraneous stimuliextraneous stimuli

3.3. Is often “on the go” Is often “on the go” or often acts as if or often acts as if “driven by a motor”“driven by a motor”

Differentiation= elated mood, grandiosity, decreased need for sleep, hypersexuality, and irritable mood.

ComorbidityComorbidity(cont.)(cont.)

Oppositional Defiant Disorder Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD)(ODD) & Conduct Disorder (CD)70-75%70-75%

Substance AbuseSubstance Abuse40-50%40-50%

Anxiety DisordersAnxiety Disorders35-40%35-40%

Suicidal BehaviorsSuicidal Behaviors

Prevalence of suicide attemptsPrevalence of suicide attempts40-45%40-45%

Age of first attemptAge of first attemptMultiple attemptsMultiple attemptsSeverity of attemptsSeverity of attemptsSuicidal ideationSuicidal ideation

Cognitive DeficitsCognitive Deficits

Executive FunctionsExecutive FunctionsAttentionAttentionMemoryMemorySensory-Motor IntegrationSensory-Motor IntegrationNonverbal Problem-SolvingNonverbal Problem-SolvingAcademic DeficitsAcademic Deficits

MathematicsMathematics

Psychosocial DeficitsPsychosocial Deficits

Relationships Relationships PeersPeersFamily membersFamily members

Recognition and Regulation of Recognition and Regulation of EmotionEmotion

Social Problem-SolvingSocial Problem-SolvingSelf-EsteemSelf-Esteem Impulse ControlImpulse Control

TREATMENT TREATMENT APPROACHESAPPROACHES

PsychopharmacologicalPsychopharmacological

DEPRESSIONDEPRESSION Mood StabilizersMood Stabilizers

LamictalLamictal Anti-ObsessionalAnti-Obsessional

PaxilPaxil Anti-DepressantAnti-Depressant

WellbutrinWellbutrin Atypical AntipsychoticsAtypical Antipsychotics

ZyprexaZyprexa

MANIAMANIA Mood StabillizersMood Stabillizers

Lithium, Depakote, Lithium, Depakote, Depacon, TegretolDepacon, Tegretol

Aypical AntipsychoticsAypical AntipsychoticsZyprexa, Seroquel, Zyprexa, Seroquel,

Risperdal, Geodon, Risperdal, Geodon, AbilifyAbilify

Anti-AnxietyAnti-AnxietyBenzodiazepinesBenzodiazepines

Klonopin, AtivanKlonopin, Ativan

TherapyTherapy

PsychoeducationPsychoeducationFamily InterventionsFamily InterventionsCognitive-Behavioral TherapyCognitive-Behavioral TherapyRAINBOW Program RAINBOW Program Interpersonal and Social Rhythm Interpersonal and Social Rhythm

TherapyTherapySchema-focused TherapySchema-focused Therapy

EDUCATIONAL EDUCATIONAL IMPLICATIONSIMPLICATIONS

IDEA ClassificationIDEA Classification

Emotional Disturbance (ED) vs. Other Emotional Disturbance (ED) vs. Other Health Impaired (OHI)Health Impaired (OHI)

ConsiderationsConsiderations

Rapidly changing moods of depression, Rapidly changing moods of depression, irritability, grandiosity, pressured speech, irritability, grandiosity, pressured speech, racing thoughts, etc.racing thoughts, etc.

Need for movementNeed for movement Poor relationshipsPoor relationships Difficulties with concentration and focusDifficulties with concentration and focus Difficulties with task completionDifficulties with task completion Impaired judgment and imulsivityImpaired judgment and imulsivity DisorganizationDisorganization Becoming overwhelmed with stressful Becoming overwhelmed with stressful

situationssituations

Possible Possible Accommodations/ModificationsAccommodations/Modifications

Provide student with a safe place and person to Provide student with a safe place and person to go to when feeling overwhelmed or stressedgo to when feeling overwhelmed or stressed

Shortened day (permit late start as needed)Shortened day (permit late start as needed) Prior notice of transitions Prior notice of transitions Consistent scheduleConsistent schedule Scheduling the student’s most challenging tasks Scheduling the student’s most challenging tasks

at a time of day when the child is best able to at a time of day when the child is best able to performperform

Modified or shortened assignmentsModified or shortened assignments Plan for unstructured times of the dayPlan for unstructured times of the day Adjust for medication needs, dispensing, as well Adjust for medication needs, dispensing, as well

as plans for addressing side effects (e.g., as plans for addressing side effects (e.g., sedation)sedation)

Other ConsiderationsOther Considerations

Educating staffEducating staffCommunicationCommunicationHospitalizationHospitalization

RESOURCESRESOURCESBOOKS/BOOKLETS:BOOKS/BOOKLETS:

Mondimore, F. (1999). Mondimore, F. (1999). Bipolar disorder: A guide Bipolar disorder: A guide for patients and familiesfor patients and families. City: Johns Hopkins . City: Johns Hopkins Press.Press.

Geller, B., & DelBello, M. P. (Eds.). (2003). Geller, B., & DelBello, M. P. (Eds.). (2003). Bipolar disorder in childhood and early Bipolar disorder in childhood and early adolescenceadolescence. New York: Guilford Press.. New York: Guilford Press.

Educating the child with bipolar disorder. Educating the child with bipolar disorder. Available from: www.bpkids.orgAvailable from: www.bpkids.org

Anderson, M., Kubisak, J.B., Field, R., & Anderson, M., Kubisak, J.B., Field, R., & Vogelstein, S. (2003). Vogelstein, S. (2003). Understanding and Understanding and educating children and adolescents with bipolar educating children and adolescents with bipolar disorder: A guide for educatorsdisorder: A guide for educators. .

RESOURCESRESOURCESWEBSITES:WEBSITES:

The Child and Adolescent Bipolar FoundationThe Child and Adolescent Bipolar Foundationwww.bpkids.orgwww.bpkids.org

Depression and Bipolar Support AllianceDepression and Bipolar Support Alliancewww.dbsalliance.orgwww.dbsalliance.org

The Bipolar ChildThe Bipolar Childwww.www.bipolarchildbipolarchild.com.com

Parents of Bipolar ChildrenParents of Bipolar Childrenwww.bpparent.orgwww.bpparent.org

The Gray Center for Social Learning and The Gray Center for Social Learning and UnderstandingUnderstanding

www.thegraycenter.org/Social_Stories.www.thegraycenter.org/Social_Stories.htmhtm National Institute of Mental Health (NIMH)National Institute of Mental Health (NIMH)

www.www.nimhnimh.org.org