Pediatric Bipolar Disorder and ADHD

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Pediatric Bipolar Disorder and AD/HD OSCA/WSCA
Conference Kevin Riley, LCSW, CADC III Catherine
Freer Wilderness Therapy Programs March 3, 2007
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Goals

• Clarify diagnostic criteria for Pediatric Bipolar
  Disorder and Attention Deficit Hyperactivity
  Disorder
• Help in distinguishing between PBD and AD/HD
• Provide tools for treatment and discuss some
  accommodations for PBD and ADHD

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DSM Criteria Bi-Polar Disorder, Manic Episode

• 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, three (or
  more) of the following symptoms have persisted
  (four if the mood is only irritable) and have
  been present to a significant degree

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DSM Criteria Manic Episode

• Inflated self-esteem or grandiosity
• Decreased need for sleep (e.g., feels rested
  after only 3 hours of sleep
• More talkative than usual or pressure to keep
  talking
• Flight of ideas or subjective experience that
  thoughts are racing
• Distractibility (i.e., attention too easily drawn
  to unimportant or irrelevant stimuli)
• Increase in goal directed activity (either
  socially, at work, at school, or sexually) or
  psychomotor agitation
• Excessive involvement in pleasurable activities
  that have a high potential for painful
  consequences (unrestrained buying sprees, sexual
  indiscretions, or foolish business investments).

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DSM Criteria Manic Episode
D. The mood disturbance is sufficiently severe to
cause marked impairment in occupational
functioning or in usual social activities or
relationships with others, or to necessitate
hospitalization to prevent harm to self or
others, or there are psychotic features
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DSM Criteria Hypomanic Episode
Same symptoms but can be 4-7 days and not
sufficiently severe to cause marked impairment in
occupational functioning or in usual social
activities or relationships with others, or to
necessitate hospitalization to prevent harm to
self or others, or there are psychotic features
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DSM Criteria Bipolar II Disorder
Major Depression plus one or more hypomanic
episodes
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Pediatric Bipolar 2 major differences

• Rapid Cycling Sometimes within the month, week,
  day or even hour
• 70 cycle within the day
• Explosive Rages!!!!
• Anectodatal s/hes always been like that
• Controllable/Uncontrollable aspect in regards to
  setting

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Prevalence of Bipolar Disorder
Adults .5-2 Worldwide Comparable numbers US
compared to Netherlands 1.6 vs 1.8, but more US
children than Dutch children No definitive study
for pediatric bipolar Schizophrenia 1-2 OCD
1-2 ADHD 5-10 Depression 20
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Bipolar Disorder

• An estimated ¾ million children adolescents
  have bipolar disorder
• Most begin with depression
• 60 of bipolar adults say symptoms started before
  or during adolescence
• National Institute of Mental Health (NIMH)
  estimate 1.5 million children have severe
  depression, perhaps half will develop bipolar
  disorder
• 32 ratio of women to men impacted
• Suicide rate for bipolar 15
• Peter M Lake M.D.

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The Affective Storm
Not just a temper tantrum A loss of emotional
control of major disruptive force in person under
16 years of age, the precipitating factor being
inadequate to explain the degree of emotional
outburst. Such storms are transient, irregular
and occur over hours or minutes.
Davis RE(1979) Manic-Depressive Variant of
Childhood, Am J Psychiatry 136702-705
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Pediatric Bipolar Characteristics

• Super Oppositional
• Extremely Irritable
• Very Inflexible
• See themselves as Victims
• Often will only display the behavior in the home
  (or where safe)

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Affective Storms/Rages

• Duration and intensity, regression and an
  Inability to be soothed by behavioral
  interventions
• Fits vary in time, but may extend for hours
• Children have less remorse, may be amnesiac
  following
• Potential for great violence

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Pediatric Bipolar Can Start Early
Anecdotal difficulties may include Excessive
kicking/ movement in the womb Overly fussy
behavior as infant Sleep less than is prescribed
in books Voracious rooting and sucking
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Pediatric Bipolar Characteristics

• Precociousness
• Magical Children great creativity, spunk
• Very early walking, talking, cognition
• Separation Anxiety longer and more intense than
  other children
• Extreme Nightmares of blood and gore
• Suicidal Ideation / Gestures
• Self-Harm

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Pediatric Bipolar Characteristics

• Sensitivity to stimuli clothes, colors, light,
  sound etc.
• Temperature dysregulation
• Craving carbohydrates, sweets/ food aversions
• Bed wetting and soiling
• Hypersexual
• More rage and irritability, less expansiveness
  and grandiosity than may be seen in adults.

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Pediatric Bipolar and ADHD can present like

• ADHD
• Anxiety
• Oppositional Defiance Disorder,Conduct Disorder
• Post-Traumatic Stress Disorder
• Pervasive Devel. Disorders/Autism Spectrum
• Severe Food Allergies
• Obsessive Compulsive Disorder
• Borderline Personality Disorder (not diagnosible
  in children)
• Many medical conditions (see physician)

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Unipolar may tend toward Bipolar

• Early depression may indicate later bipolar
  disorder
• 1994 study
• 79 preperbutal children with depression
• Within 2 years 32 had manic episodes
• 7 years later 48.6 diagnosed with bipolar
  disorder

Geller, B. American J Psychiatry 2001
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Substance Abuse
In a study in 1990 of bipolar patients, 61 had
a history of substance abuse 15 used
drugs alone, 20 used alcohol alone and 26 used
both. Another study found that patients with
substance abuse disorder and bipolar disorder
have a much earlier age of onset (7 years), are
more likely to relapse, and have 50 more
hospitalizations. Papalos, The Bipolar Child,
2006 p367
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The apple doesnt fall too far.
In one study sample, 80 of children with early
onset bipolar disorder had substance abuse and
mood disorders on both sides of the family
Papolos, D. The Bipolar Child 2002
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Treatment for Pediatric Bipolar
Medication

• Mood Stabilizers Lithium
• Anticonvulsants Depakote, Tegretol, Trileptal,
  Lamictal, Topamax
• Antipsychotics Clozaril, Zyprexa, Seroquel,
  Risperdal, Geodon
• No definitive SGA studies on children
• Anti-depressants and stimulants are generally
  contraindicated for bipolar disorder unless
  accompanied by a mood stabilizer-very important!

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Alternative Treatments OMEGA-3 FISH OIL

• Fish Oil is being studied as a treatment for mood
  disorders.
• Double-Blind Placebo controlled study at Harvard
• Significantly longer period of remission than the
  placebo group
• For nearly every other outcome measure, the
  omega-3 fatty acid group performed better than
  the placebo group
• Stoll, AL Arch Gen Psychiatry 1999 May

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TreatmentPSYCHOEDUCATION Empowers with vital
information about bipolar disorder, treatment,
side effects Teaches early symptom warning
recognition and coping skills to prevent relapse
May take individual, group, or family formats
Is a key element across all evidence based
psycho-therapies for bipolar
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• Results from controlled studies for
  psychoeducation
• Longer time to manic relapse, fewer relapses
• Increased attitude towards and knowledge of
  medication
• Fewer and shorter hospitalizations
• Fewer relapsed patients, fewer relapses per
  patient
• Longer time to manic, hypomanic, depressive and
  mixed reoccurrences

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Other Recommended Treatments
Family therapy Emphasis on skill building
communication skills, extensive psychosocial
hx Individual group therapy with emphasis on
skills building (DBT) Activities that build
self-efficacy, self-confidence
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• Cognitive Behavioral Therapy
• Mood Monitoring!!!
• Challenge negative thought patterns
• Prevent mood escalation
• Enhance medication compliance
• Behavior!!!
• Sleep-more sleep, structure later sleep-ins
• Diet-more protein, less sugar
• Environment-less stress, stimulation

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More Treatment Ideas PBD

• practicing and teaching relaxation techniques
• using firm restraint holds to contain rages
• prioritizing battles and letting go of less
  important matters
• reducing stress in the home, including learning
  and using good listening and communication skills
  
• using music and sound, lighting, water, and
  massage to assist the child with waking, falling
  asleep, and relaxation
• becoming an advocate for stress reduction and
  other accommodations at school

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More Treatment Ideas PBD

• help the child anticipate and avoid, or prepare
  for stressful situations by developing coping
  strategies beforehand
• engage the child's creativity through activities
  that express and channel their gifts and
  strengths non-competitive, expressive activities
  like drama, swimming, wilderness, 4-H
• provide routine structure and a great deal of
  freedom within limits
• remove objects from the home (or lock them in a
  safe place) that could be used to harm self or
  others during a rage, especially guns keep
  medications in a locked cabinet or box

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School accommodations PBD

• preschool special education testing and services
• small class size (with children of similar
  intelligence) or self-contained classroom with
  other emotionally fragile (not "behavior
  disorder") children for part or all of the day
• one-on-one or shared special education aide to
  assist child in class
• back-and-forth notebook between home and school
  to assist communication
• homework reduced or excused and deadlines
  extended when energy is low
• late start to school day if fatigued in morning
• recorded books as alternative to self-reading
  when concentration is low
• designation of a "safe place" at school where
  child can retreat when overwhelmed
• designation of a staff member to whom the child
  can go as needed
• unlimited access to bathroom and drinking water
• art therapy and music therapy

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School accommodations PBD

• extended time on tests
• extra set of books at home
• regular sessions with a social worker or school
  psychologist
• social skills groups and peer support groups
• annual in-service training for teachers by
  child's treatment professionals (sponsored by
  school)
• enriched art, music, or other areas of particular
  strength
• curriculum that engages creativity and reduces
  boredom (for highly creative children)
• tutoring during extended absences
• goals set each week with rewards for achievement
• placement in a day hospital treatment program for
  periods of acute illness that can be managed
  without inpatient hospitalization
• placement in a residential treatment center
  during extended periods of illness if a
  therapeutic day school near the family's home is
  not available or is unable to meet the child's
  needs

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Attention Deficit / Hyperactivity Disorder

• Hyperactivity
• Impulsivity
• Inattention

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DSM-IV Criteria Hyperactivity

• often fidgets with hands or feet or squirms in
  seat
• often leaves seat in classroom or in other
  situations in which remaining seated is expected
• often runs about or climbs excessively in
  situations in which it is inappropriate (in
  adolescents or adults, may be limited to
  subjective feelings of restlessness)
• often has difficulty playing or engaging in
  leisure activities quietly
• is often "on the go" or often acts as if "driven
  by a motor"
• often talks excessively

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DSM-IV Criteria Impulsivity

• often blurts out answers before questions have
  been completed
• often has difficulty awaiting turn
• often interrupts or intrudes on others (e.g.,
  butts into conversations or games)

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DSM-IV Criteria Inattention

• often fails to give close attention to details or
  makes careless mistakes in schoolwork, work, or
  other activities
• often has difficulty sustaining attention in
  tasks or play activities
• often does not seem to listen when spoken to
  directly
• often does not follow through on instructions and
  fails to finish schoolwork, chores, or duties in
  the workplace (not due to oppositional behavior
  or failure to understand instructions)

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DSM-IV Criteria Inattention (cont)

• often has difficulty organizing tasks and
  activities
• often avoids, dislikes, or is reluctant to engage
  in tasks that require sustained mental effort
  (such as schoolwork)
• often loses things necessary for tasks or
  activities (e.g., toys, school assignments,
  pencils, books, or tools)
• is often easily distracted by extraneous stimuli
• is often forgetful in daily activities

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Subtypes of AD/HD
         
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Hyperactive / Impulsive Type
Dominating and bossy Want to go
first Annoying Well known but not popular Poor
social boundaries Sneaky Power oriented Life long
problems with intimacy
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Inattentive Type
Indecisive Mild misbehavior Submissive/
passive Daydreamer Wallflower Lost in the
crowd Not socially attractive but will bond
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Hyperactive,Impulsive Inattentive

• I dont have friends most common complaint
• Academics - 1 life long problem
• Peer relations at 5 years old is the 1 indicator
  of emotional success

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Co-morbidity
25 - 80 of kids with AD/HD will end up with
another disorder, primarily due to interaction
with environment Hyperactive more likely
diagnosed ODD, Conduct Disorder Inattentive
more likely Depression, Anxiety Both at high risk
for Substance Abuse Poor peer
relationships Lack of success Conflict with
authority Low self-worth
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AD/HD Kids Are Likely To

• Have more family conflicts, to be held back a
  grade, have lower academic achievement, and
  failed to graduate from high school.
• Greater incidence of conduct problems, antisocial
  acts, substance use and abuse, emotional problems
  and impaired social competence.

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AD/HD Kids Grow into Teens Who

• Have higher likelihood of school expulsion,
  suspension and greater drop-out rate (both
  genders)
• Are more likely to be aggressive and defiant
  (males)
• Are more likely to be withdrawn, anxious,
  depressed, aggressive and irresponsible (missing
  deadlines, lateness and disregard for property
  and rights. (females)
• Fischer/Ackerman, Satterfield studies

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ADHD Treatment / Adaptation
How to teach to AD/HD
Video game approach Bright colors Sounds Shifting
action Movement
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ADHD Treatment / Adaptation
How to teach to AD/HD
Novelty Role Play Dramatization Small groups
Concrete thinking Opposites and
contrasts Multiple choice Dont use sarcasm
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ADHD Treatment / Adaptation
How to teach to AD/HD
Use the body Light touch for attention Hands
on Salt on a table Light exercise Rhythmic
movement -----------------------------------------
---------- 60-80 of kids with AD/HD have some
language deficit
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Treatment A Diet to Optimize Brain
Functioning Give proteins in the morning,
carbohydrates at night Pop Tarts gtgtgtgt Increased
Blood Glucose gtgt Increased InsulingtgtgtReduced
Brain glucosegtgt Increased AD/HD symptoms
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Non AD/HD kids with decreased brain glucose
levels gtgtIncrease epinephrine and norepinephrine
input from adrenal glandsgtgt counteract effect of
increased insulin AD/HD Kids have a 50 less rise
in these hormonesgtgt Increased physical activity
increases norepinephrinegtgtAD/HD kids seek novel/
risk taking situations to up their hormonal
levels to combat insulin levels
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ADHD Treatment
75-80 of kids with AD/HD get more hyper when
exposed to toxic chemicals
Clean Up Their Environment

• 4 types of chemicals
• Petrochemicals (gas, plastic outgassing,insecticid
  es, food additives
• Phenols (markers, smoked food, perfume)
• Carcinogens (food dyes, nitrates, NutraSweet,
  MSG)
• Neurotoxins (lead, cadmium, aluminum, mercury,
  copper)

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ADHD Treatment The structure of their lives

• Children with ADHD will benefit from an outward
  structure that reflects their unique biological
  adaptations. An evolutionary perspective can
  help.
• Consider physical space, time frames, activity
  levels required for participation, freedoms to
  make impulsive mistakes, realistic expectations.

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ADHD Treatment Stimulants
A NIDA funded study at Harvard found that the use
of stimulant medication in children with ADHD
reduced the risk of Substance Use Disorder by
half. Adolescents on stimulant medication were
5.8 times less likely to abuse drugs than those
not treated (defies myth that Ritalin leads to
drug use in later teen years.)
Wilens, T. Pediatrics January 6, 2002
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Use of Methylphenidate (Ritalin) Worldwide
Millions of daily doses
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ADHD Treatment Combination of Therapies

• Stimulant use alone, without accompanying
  therapies such as behavior modification or family
  counseling was the significant factor in
  institutionalization for boys studied (boys
  studied were vastly from higher socio-economic
  backgrounds.)
• Again, psychoeducation and other counseling are
  imperative to work against decreased self-esteem
  and prevent other co-occurring disorders.
• Dr. James Satterfield, MD, UCLA

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Alternative Treatments for ADHD

• Diet low in sugar, high in Omega-3 and Omega-6
  fatty acids
• High in Protein in am
• Low in artificial ingredients/coloring etc.
• Complex Carbohydrates in pm
• Eliminate allergen foods (chocolate, wheat, corn,
  oranges etc.)
• The ADD Nutrition Solution by Marcia Zimmerman,
  1999

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AD/HD vs Bipolar

• Rapid swings between elation and irritability
• Out-of-control elation, not appropriate for
  context
• Seem to need less than 6 hours of sleep
• Grandiose displacement of adult authority
• Amnesic after rages
• Surreal feelings after nightmares- often full of
  blood and gore
• Regression under stress

• Occasional moodiness
• Elation within normal limits
• Need 9-10 hours of sleep
• Oppositionality
• Remembers and apologizes after rages
• Fully awakes from nightmares- variety of themes
• Anger, agitation under stress

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AD/HD vs Bipolar
9. Sexual precociousness in 40 10. Deliberate
self-harm 11. Some animal cruelty, hateful
destruction, arson, cruelty of intent 12. Rages
can last over 45 minutes to an hour 13. Chronic
feelings of worthlessness 14. Gross distortion/
delusions of interpersonal phenomena
9. Sexual precociousness in small 10. Little or
no deliberate self-harm 11. Seldom violent 12.
Short duration of tantrums 13. Average of one
depressed episode 14. Inattentive reading of
social situations
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Mania Symptoms Differentiation Pediatric Bipolar
vs. AD/HD
Pediatric Bipolar Elated Mood Grandiosity Flight
of ideas, racing thoughts Decreased need for sleep
AD/HD Irritable mood Accelerated
speech Distractibility Increased energy
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How can Catherine Freer Programs help?

• Stabilize behavior and medication compliance
• Develop insight into the condition and the
  psycho-social causes
• Address substance abuse issues
• Increase self-efficacy and self-concept
• Learn cognitive behavioral techniques for
  improving mood
• Improve family functioning, coping
• Create and Teach Ideal learning environments

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Additional Information
Bipolar www.bpkids.org The Bipolar Child, by
Papolos Papolos Intense Minds, by Tracy
Anglada Bipolar Disorder in Childhood and Early
Adolescence Edited by Barbara Geller and Melissa
P. Delbello (January 2003). An Unquiet Mind by
Kay Redfield Jamison, Ph.D. (Random House, 1997).
ADHD Delivered from Distraction by Edward
Hallowell Answers to Distraction by Edward
Hallowell The ADD Nutrition Solution by Marcia
Zimmerman Our Children areWhat our Children Eat
by Laura Thompson www.add-plus.com