Bipolar disorder in the school setting naa conference

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Presentation by Drs. Gabriel Kaplan, Bennett Silver, and Nadezhda Robinson Sexton presented at the '10 annual Sage-NAA Conference

Presentation by Drs. Gabriel Kaplan, Bennett Silver, and Nadezhda Robinson Sexton presented at the '10 annual Sage-NAA Conference

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  • 1. BipolarChildren in the SchoolSettingA Primerof Diagnosis andTreatment Options forSpecialEducation ProfessionalsGabriel Kaplan, M.D.Bennett Silver, M.D.Nadezhda Sexton, Ph.D.
  • 2. NEWJERSEYCHILDRENS SYSTEMOFCARENadezhda Sexton, Ph.D.
  • 3. The History of mental health servicesforNJyouth Get in line Open a case Confined care rules Systemic fragmentation Silencing of families and youth
  • 4. Systemreform resulted in: Dramatic increase in community based services(need-driven, strength-based) Separation of child welfare and mental healthsystems (individualized) Reduction in use of residential, detention, andhospital stays (least restrictive) Maximized funding for effective interventions(outcomes-driven) Empowerment and direct support of familymembers; elevation of youth as consumers(youth and family guided)
  • 5.  Care Management Organizations (CMO) are county-based, non-profit organizations that are responsiblefor face-to-face care management andcomprehensive service planning for youth and theirfamilies with intense complex needs. Family Support Organizations (FSOs) are non-profitorganizations run by families of children in thatcounty with emotional and behavioral challenges.. Mobile Response & Stabilization Services (MRSS)are provided to youth who exhibit emotional orbehavioral challenges that may jeopardize theircurrent living arrangements. They provide face-to-face crisis response within 1 hour of notification. Youth Case Management (YCM) offers face-to-faceservices for moderate-risk youth.System of care agencies
  • 6. About UsOur Directors MessageA brighter, healthier future awaits those who careIn the late 90s, a dedicated group of parents approached the State of New Jersey with a plan to reform childrensmental health. These parents recognized that the system in place at that time was not meeting the needs of childrenwith complex emotional, mental health or behavioral challenges.Under the direction of Governor Christie Whitman, New Jersey launched the Childrens System of Care Initiative.The vision was to create a system of care that focused on family strengths and community resources. Families andyouth work in partnership with public and private organizations to design mental health services and supports that areeffective, that build on the strengths of individuals, and that address each persons cultural and linguistic needs.A system of care helps children, youth and families function better at home, in school, in the community andthroughout life. System of care is not a program — it is a philosophy of how care should be delivered. System of Careis an approach to services that recognizes the importance of family, school and community, and seeks to promote thefull potential of every child and youth by addressing their physical, emotional, intellectual, cultural and social needs.Madeline LozowskiExecutive DirectorFamily Support Organization
  • 7. CSA Contract ServiceAdministrator
  • 8. Checkit out: Toll-Free Access Line1-877-652-7624(Multi-lingual Language Lineavailable)24 hours-a-day, 7 days a weekwww.state.nj.us/dcf/behavioral
  • 9. OVERVIEW OF BIPOLARDISORDER IN CHILDRENAND ADOLESCENTSGabriel Kaplan, M.D.
  • 10. Child’s Ordeal ShowsRisks of Psychosis Drugs forYoung(9/1/10) At 18 months, Kyle started taking a dailyantipsychotic drug on the orders of a pediatriciantrying to quell the boy’s severe temper tantrums Thus began a troubled toddler’s journey from onedoctor to another, from one diagnosis to another,involving even more drugs. Autism, bipolardisorder, hyperactivity, insomnia, oppositionaldefiant disorder The boy’s daily pill regimen multiplied: theantipsychotic Risperdal, the antidepressantProzac, two sleeping medicines and one forattention-deficit disorder. All by the time he was 3.He gained Lb 49
  • 11. Potentially Powerful SideEffects (Published by NYT 9/1/10)Kyle at 3 years old, he started takingantipsychotics at 18 months due to severetantrumsKyle at 6 years old, takes medication forADHD, doing well
  • 12. 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 thesechildren these medicines, you have to have a diagnosis thatsupports your treatment plan. You can’t just give anondiagnosis and give them the atypical antipsychotic.” Dr. Charles H. Zeanah, a Tulane medical professor, whodisagreed with both the diagnosis and the treatment. “I havenever seen a preschool child with bipolar disorder in 30 yearsas a child psychiatrist specializing in early childhood mentalhealth,” Kyle’s new doctors point to his remarkable progress — and amore common diagnosis for children of attention-deficithyperactivity disorder — as proof that he should have neverbeen prescribed such powerful drugs in the first place.
  • 13. DSM-IV Mood Disorders Unipolar Disorders Major Depression Dysthymic Disorder Bipolar Disorders Bipolar I Bipolar II Cyclothymic Disorder
  • 14. DSM-IV BipolarDisorders Bipolar I One or more Manic episodes (or MixedMania/Depression) usually accompanied byepisodes of Depression (but may not) Bipolar II Major Depressive episodes with Hypomania Cyclothymic Disorder Less than full episodes of Mania and Depression
  • 15. BipolarStats 1% of population will develop One parent with Bipolar 15-30% risk to offspring Both parents 50-75% risk Risk in siblings: 20% Risk in identical twin: 70% 60% of adults report onset before age of 20
  • 16. BipolarEpidemic ? 40-fold increase in outpatient diagnosis1994-2003 Moreno C, Laje G, Blanco C et al. National trends in the outpatient diagnosis and treatmentof bipolar disorder in youth. Arch Ge n 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. Bio lPsychiatry. 2007;62:107–114.
  • 17. Increase in OutpatientDiagnosis
  • 18. DSM-IV Manic Episode A distinct period of abnormally and persistently elevated, expansive, orirritable mood, lasting at least 1 week (or any duration if hospitalization isnecessary).  During the period of mood disturbance, 3 (or more) of the followingsymptoms have persisted (4 if the mood is only irritable) and have beenpresent 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, orsexually) or psychomotor agitation (7) excessive involvement in pleasurable activities that have a highpotential for painful consequences (e.g., engaging in unrestrained buyingsprees, sexual indiscretions, or foolish business investments)
  • 19. Are DSMIV Criteria Applicable toPediatric BP? Criteria were established from adult research at a timewhen PBP was not fully accepted Main problem is criterion A “Distinct Period”, often notpresent in children In youth, BP shows mainly as ongoing mood lability and increased energy, Irritability/aggression, reckless behavior, short lived mood shifts
  • 20. However, DSMisRecommended The “presence” of mood episode –mania-must be determined (elevated, expansive, orirritable) Although its “precise” onset may not beascertained, in order to meet Bipolar criteria, amood episode MUST be distinguished frompersistent other kinds of presentations, i.e.either normal personality style or pathological(ADHD) “B” (developmentally reviewed) symptomsmust be present during the mood episode andbe of an impairing nature
  • 21. Frequency of Pediatric BipolarSymptomsKowatch RA et al. Review and meta-analysis of the phenomenology and clinical characteristics of mania inchildren and adolescents. Bipolar Disord 2005;7:483–496.
  • 22. Normal ora Symptom? Children might present with seemingly manicsymptoms for a variety of reasons Clinicians use the FIND (Frequency, Intensity,Number, and Duration) strategy to make thisdetermination.
  • 23. A real FIND Frequency Symptoms occur most days in a week Intensity Symptoms are severe enough to cause extremedisturbance in one domain or moderate disturbance intwo or more domains Number Symptoms occur three or four times a day Duration Symptoms occur 4 or more hours a day, total, notnecessarily contiguous
  • 24. FINDQualifies Symptoms A child who becomes silly and giggly to a noticeable andbothersome degree for 30 minutes twice per week in schooland 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, andpeers are disrupted N: several times per day D: ‘‘high’’ times last several hours Has crossed the FIND threshold
  • 25. Euphoric/Expansive Mood NORMAL Dec 25th Very happy, giggling Got latest Wii model MANIA Dec 25th Laughinghysterically inChurch Says people dressfunny Parental disapprovaldoes not stop laugh
  • 26. Irritable Mood NORMAL After a long car tripin the summer Hot and hungry MANIA Asked to tie shoes Two hour tantrum
  • 27. Grandiosity NORMAL I am Superman Pretend play, stopswhen its time forsupper MANIA I am Superman Attempts to jump outthe window to provecan fly
  • 28. Decreased Need forSleep NORMAL Anxious about testtomorrow Up till 1 AM, stays inbed Difficult to get up inthe morning andtired all day MANIA No identifiablestressor Up till 1 am runningaround throughouthouse Sleeps only 4 hoursand full of energynext morning
  • 29. Pressured Speech NORMAL Running back hometo tell mom got leadpart in school play MANIA No identifiablereason for broken upfast speech thatlasts for hours
  • 30. Young Mania Rating Scale
  • 31. Young Mania Rating Scale
  • 32. Functional Impairment aggressive behavior, attention problems anxious and depressed symptoms delinquent behavior, social problems withdrawal, poor social skills, no friends, and teased by otherchildren. Substance abuse 39% which when present greatlyworsens severity and prognosisSala R et al Phenomenology, longitudinal course, and outcome ofchildren and adolescents with bipolar spectrum disorders. Child AdolescPsychiatr Clin N Am. 2009 Apr;18(2):273-89
  • 33. Suicidal Ideas and Psychosis NORMAL Not present MANIA May be present
  • 34. Suicide Attempts VariousConditions 0-18 years Mania 44% Major Depression 18% No Disorder 1%Lewinsohn, PM.; Seeley, JR.; Klein, DN. Bipolar disorder in adolescents:epidemiology and suicidal behavior. In: Geller, B.; DelBello, MP., editors.Bipolar Disorder in Childhood and Early Adolescence. New York: Guilford;2003. p. 7-24.
  • 35. DIFFERENTIALDIAGNOSIS:IS IT BIPOLARORADHD?Gabriel Kaplan, M.D.
  • 36. ADHDCriteria
  • 37. ADHDBipolarOverlapDistractibility
  • 38. Manic Specific SymptomsGeller et al, Journal of Child and AdolescentPsychopharmacology 2002; 12:11–25 Elated Mood Grandiosity Flight of Ideas Racing thoughts Decreased need for sleep Hypersexuality
  • 39. Common Diagnostic Dilemma A child with impairing distractibilityand aggression Is it mild Bipolar? Is it severe ADHD? Are both conditions present? (Co-morbidity)
  • 40. ADHDvs Bipolar ADHD Child has always been distractible Family history of ADHD Bipolar Distractibility only occurs in the context of achange of mood that is different from the patient’susual mood. Hypersexual, grandiose, elated, suicidal Co-Moribidity Distractibility persists when mood episode remits
  • 41. TREATMENT OFMANIA IN BIPOLARDISORDERBennett Silver, M.D.
  • 42. What Are Mood Stabilizers? Medications with both antimanic andantidepressant actions Medications that decrease vulnerability tosubsequent episodes of mania or depressionand do not exacerbate the current episode ormaintenance phase of treatment.
  • 43. Mood Stabilizers Used forBipolarDisorder LITHIUM: Lithium Carbonate(Eskalith,Lithobid) ANTICONVULSANTS: Valproic Acid (Depakote) Carbamazepine (Tegretol) Lamotrigine (Lamictal) ATYPICALANTIPSYCHOTICS: Risperidone (Risperdal) Quetiapine (Seroquel) Aripiprazole (Abilify) Olanzapine (Zyprexa) Ziprasidone (Geodon) Asenapine (Saphris) Paliperidone (Invega) Clozapine (Clozaril)
  • 44. How Do Mood StabilizerMedications Work? Nobody really knows for sure but our understanding isgrowing rapidly Effect “first messenger” brain neurotransmitters that actat the synapse between nerve cells, such as dopamine,serotonin, norepinephrine, glutamate, and GABA Effect “second messenger” systems within the nerve cellsuch as cAMP (cyclic AMP) and BDNF (Brain-DerivedNeurotrophic Factor) which can turn on genes within thenerve cell promoting nerve growth (neurogenesis) ornerve atrophy
  • 45. Lithium Oldest mood stabilizer Improves depression and mania Helps prevent future episodes Narrow dosage range (blood levelsrequired) Very dangerous in overdose Side – effects drowsiness, weakness, nausea fatigue, hand tremor, increased thirst increased urination, thyroid underactivity,
  • 46. Anticonvulsants Improve depression and mania Lamictal especially good for depressiveepisodes Help prevent future episodes Narrow dosage range (blood levels required) Work better than Lithium for rapid cyclers andmixed 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
  • 47. 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), involuntarymovements (tardive dyskinesia) - rarely Monitor: weight, blood pressure, blood sugar, cholesterol
  • 48. Commonly Used Antipsychotic Medications (Second-Generation antipsychotics, “Atypicals”)*All of theatypical antipsychotics areserotoninanddopamineantagonists*In2009, Seroquel andAbilifywerenumbers 5and6 respectivelyamongst thetoptendrugs intheU.S. basedonsales (over$4billioneach) 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 (bloodsugar, cholesterol) Geodon – Weight neutral, less sedating Saphris – Recently released, sublingual pill Invega – Recently released Clozaril – Most effective, weight gain, metabolic effects, risk for severe whiteblood cell suppression requires regular blood tests. Used when other medicationsfail.
  • 49. Treatment Considerations Choice of medication depends on anindividual’s Bipolar symptoms and pattern ofillness (psychosis, rapid cycling, etc.) Side-effect profile may affect choice ofmedication Psychotherapy along with medication improvesoutcome
  • 50. Principles of MedicationTreatment Bipolar Disorder is a chronic, recurringillness and requires chronic, long-termmaintenance medication Treatment targets acute episodes andprevention of episodes with maintenancemedication Sometimes a single medication isinadequate and a combination ofmedications is required
  • 51.  In fact, research indicates that there is alarge group of Bipolar patients who requirevery complex psychopharmacologicregimens in order to achieve and sustain agood to excellent response * Periodic monitoring of blood levelsconfirms 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 improvementin outpatients with bipolar disorder. J. Clin Psychiatry. 2010:71(9):1176-1186.Principles of MedicationTreatment
  • 52. Accurate Diagnosis and EarlyIntervention Bipolar Disorder is often difficult to diagnosein adolescence, because of the nature ofadolescent moodiness, and similarities withother conditions such as ADHD,Schizophrenia, and Addiction to drugs andalcohol Bipolar Disorder can have a spectrum ofseverity and milder forms are often missed ormisdiagnosed (eg., subthreshold orsubsyndromal mania) Misdiagnosis leads to delayed or incorrecttreatment
  • 53. Early Aggressive InterventionImproves Long Term Outcome Research shows that very often there are longlags from the onset of Bipolar illness to firsttreatment * This delay is longest in those with the earliestonset in childhood and adolescence * Early onset Bipolar Disorder and delay to firsttreatment are independent risk factors forpoor outcome in adulthood ***Leverich GS, Post RM, Keck PE Jr, et al. The poor prognosis of childhood-onset bipolardisorder. JPe diatr. 2007;150(5):485-490.**Post R, Leverich G, Kupka R, et al. Early onset bipolar disorder and treatment delay arerisk factors for poor outcome in adulthood. JClin Psychiatry. 2010; 71(7):864-872.
  • 54. Diagnostic Ambiguity and Co-Occurring Disorders Correct diagnosis guides treatment and prevents a child from beingplaced 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 psychiatricdisorders, such as ADHD, Depression, Anxiety Disorders, Addiction For example, 61% of individuals with Bipolar Disorder also have asubstance abuse disorder – a higher co-occurrence than with any otherpsychiatric disorder * 1/3 of children who first present with depression will eventually go on tomanifest a Bipolar Disorder (risk of misdiagnosis as unipolardepression) ** As a result, a child with Bipolar Disorder may be prescribedantidepressants such as Prozac or Zoloft to treat depressive or anxietysymptoms, or stimulants such as Ritalin or Adderall to treat ADHD* NIMH** American Academy of Child and Adolescent Psychiatry
  • 55. Diagnostic Complexity and Choosing theRight Medication Treating a Bipolar child suffering from depression,anxiety or ADHD with an antidepressant or astimulant alone can cause negative reactions suchas rapid cycling, manic, violent, aggressive, oragitated behavior Often such patients seem to do well at first, but afterweeks or months of treatment their behaviordeteriorates Proper diagnosis prevents the child from beingplaced on medications that may worsen the courseof the disorder Therefore, in a Bipolar child with such co-occurringconditions it is prudent to stabilize the patient first ona mood stabilizer(s) alone, prior to initiating other
  • 56. When Medication Does Not Yield theExpected Improvement Is patient taking the medication as instructed? Re-assess the accuracy of the diagnosis Look for and treat co-occurring conditions suchas: substance abuse, anxiety disorders,ADHD, personality disorders, etc. Maximize use of non-pharmacologic treatmentmodalities such as cognitive, behavioraltherapies
  • 57. The Problem of Non-Compliance (Non-Adherence) with Medication Treatment Non-compliance is the most commonreason for failure of medication,relapse and re-admission to thehospital Rates of poor compliance may reach64% for Bipolar Disorders ** J Clin Psychiatry, 2000 Aug, 61 (8): 549-55
  • 58. Why Don’t Patients Take TheirMedication? Failure to understand the diagnosis, the chronicnature of Bipolar illness, the prophylactic functionof medication & its positive effect on long termoutcome A desire to recapture the elevated mood, energyand lack of inhibition associated with hypomanicand manic states Side-effects, especially weight gain and sedation Underestimating the long-term consequences ofBipolar Disorder on school, social andoccupational functioning Stigma associated with psychiatric illness &medication Poor relationship between psychiatrist and patient
  • 59. Countering Non-Compliance Psycho-education regarding medication andBipolar Disorder Create a treatment partnership betweenphysician, patient and parent(s) Listen and be flexible & responsive to patientcomplaints about side-effects Group interaction with peers who are atdifferent stages of their treatment experience
  • 60. Traditional Treatment Model
  • 61. Therapeutic School: Integrated TreatmentModel forBipolarDisorder