The document provides a comprehensive overview of bipolar disorder in children and adolescents, focusing on diagnosis and treatment options for educational professionals. It discusses the historical context of New Jersey's mental health services reform and outlines significant changes in care, emphasizing family and community-based approaches. The text also details diagnostic criteria, treatment modalities, and the challenges in accurately diagnosing and managing pediatric bipolar disorder.

1. BipolarChildren in the School
Setting
A Primerof Diagnosis and
Treatment Options forSpecial
Education Professionals
Gabriel Kaplan, M.D.
Bennett Silver, M.D.
Nadezhda Sexton, Ph.D.

2. NEWJERSEY
CHILDREN'S SYSTEMOF
CARE
Nadezhda Sexton, Ph.D.

3. The History of mental health services
forNJyouth
 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 health
systems (individualized)
 Reduction in use of residential, detention, and
hospital stays (least restrictive)
 Maximized funding for effective interventions
(outcomes-driven)
 Empowerment and direct support of family
members; elevation of youth as consumers
(youth and family guided)

5.  Care Management Organizations (CMO) are county-
based, 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.
System of care agencies

6. 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

7. CSA Contract Service
Administrator

8. Checkit 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

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

10. Child’s Ordeal Shows
Risks of Psychosis Drugs forYoung
(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

11. 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

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 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.

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 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

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 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 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 Outpatient
Diagnosis

18. 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)

19. Are DSMIV 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

20. However, DSMis
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

21. 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.

22. Normal ora 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.

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

24. FINDQualifies 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

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

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

27. 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

28. Decreased Need forSleep
 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

29. 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

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 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

33. Suicidal Ideas and Psychosis
 NORMAL
 Not present
 MANIA
 May be present

34. Suicide Attempts Various
Conditions 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. DIFFERENTIAL
DIAGNOSIS:
IS IT BIPOLARORADHD?
Gabriel Kaplan, M.D.

36. ADHDCriteria

37. ADHDBipolarOverlap
Distractibility

38. Manic Specific Symptoms
Geller et al, Journal of Child and Adolescent
Psychopharmacology 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 distractibility
and 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 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

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

42. 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.

43. Mood Stabilizers Used forBipolar
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)

44. 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 cAMP (cyclic AMP) and BDNF (Brain-Derived
Neurotrophic Factor) which can turn on genes within the
nerve cell promoting nerve growth (neurogenesis) or
nerve atrophy

45. 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,


46. 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

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), involuntary
movements (tardive dyskinesia) - rarely
 Monitor: weight, blood pressure, blood sugar, cholesterol

48. Commonly Used Antipsychotic Medications (Second-
Generation antipsychotics, “Atypicals”)
*All of theatypical antipsychotics areserotoninanddopamine
antagonists
*In2009, Seroquel andAbilifywerenumbers 5and6 respectively
amongst thetoptendrugs intheU.S. basedonsales (over$4billion
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.

49. 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

50. 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

51.  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.
Principles of Medication
Treatment

52. 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

53. 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. JPe diatr. 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. JClin Psychiatry. 2010; 71(7):864-872.

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

60. Traditional Treatment Model

61. Therapeutic School: Integrated Treatment
Model forBipolarDisorder