This document presents a case study of a 7 year old male, OT, who is exhibiting unpredictable, impulsive, aggressive, and threatening behavior towards family members. His mother reports he has had behavioral issues since age 3 that have continued without improvement. He has a history of suicidal threats and attempts. A psychiatric evaluation finds OT to have poor impulse control, judgment, attention, and concentration. He is started on multiple medications without significant response. The document discusses opinions on diagnosing and treating pediatric bipolar disorder, particularly around issues of rapid cycling and mixed episodes in children.

1. Pallav Pareek M.D.
Revisions made on
9/16/2012

2. Case presentation

3. OT is a 7 yo Caucasian male, who currently
lives with his biological mother & step
father. He attends 2nd grade in special
education
C/C Per OT: “I choked my younger brother”
Per Mother: “OT has been very
unpredictable, impulsive , aggressive
towards family members, and threatening to
kill himself”

4.  Went to doctor’s office for his scheduled appointment, argued,
refused physical
 At his return home, he was upset , argued with mother, broke step
father’s laptop
 Tried to choke his brother PT, when mother tried to interrupt him,
threatened to kill mother, and then kill himself
 No behavioral issues during first 3 years, described as “a very good
baby”
 Behavioral problems started around age 3, after father’s physical
assault on mother
 Patient started exhibiting aggressive behaviors at home and
school, that have continued to the present without any
improvement
 Violent behavior at home, threatening to use knives/toys as his
weapons
 Multiple episodes of suicidal threats in the past (most serious
attempt : trying to grab a knife from the kitchen to kill himself)

5.  History of making threats to hurt others w/wo any accessible weapon
nearby
 Destruction of property : when angry would break anything in his vicinity
 At school, pushing everything off the teacher’s desk. Turning it upside
down
 Mother describes no precipitating factors to his anger and his outbursts
which are episodic. During a typical episode (3-4episodes/week), OT will
scream, curse at others, throwing objects, often threatening to kill
himself and others
 Mother says that he is usually remorseful and apologetic a few hours after
such episodes, and promises to mend his behavior in future
 Mother also reports has had chronic difficulties falling asleep. OT ( if not
medicated) would keep awake till 2 -3 am , and then usually gets up on
his own about 7-7.30 am , and does not report feeling tired
 History of inappropriate sexual behaviors, starting 3 wks before current
admission
 OT is irritable most of the time when he is awake, most days of the week

6.  Per mother , it’s very difficult for OT to focus on a thing
 Usually would not listen to her , when she is talking to him
 It’s very difficult for him to sit still
 Usually talks “superfast”, and jumps from one topic to the other
 Mother denied any symptoms suggestive of grandiosity
 Mother describes occasional episodes , where OT will slow down,
isolates himself, does not talk “that much”, shows reduced
interest in paying video games, would prefer to watch TV. No
explicit sadness or crying has been observed during these episodes.
These episodes are few and far between ( 1-2 times every month)
No problem reported with sleep or appetite. No suicidal ideations
during these times

7.  Multiple (>7) admissions PREVIOUS DIAGNOSES:
between 07 and 09.  Oppositional Defiant Disorder
 Past Medications: Abilify,  Conduct disorder (childhood
Adderall, Cogentin, onset)
Concerta, Depakote, Elavil,
 PTSD
Geodon, Lithium, Risperdal,
Ritalin, Seroquel, Strattera,  Munchausen by proxy
Trileptal syndrome (MBPS)
 Medical: Seasonal asthma,  Mood disorder NOS
occasional use of Albuterol  Adjustment disorder
inhaler  Reactive attachment disorder
 Surgical : Tonsillectomy and  Intermittent Explosive
Adenoidectomy 03/08 Disorder

8.  None
 Patient has more knowledge
about sexual activities than
would be expected for his
age
 Inappropriate sexual
behaviors began about 3 wks
prior to admission, exposing
himself in the unit during
current admission

9.  Mother suspects that  Father had BP per
she has depression mother
(never treated, no  Father has had problems
medications) with Alcohol
 Maternal Aunt has  Father has been in Jail
depression, being about 8 times ( domestic
treated violence, destruction of
property, beating up
people)
 Questionable hx of BP in
Paternal GF
Maternal side Paternal side

10.  OT was born via NSVD. No
post-natal complications
 Developmental milestones
were appropriate for age
 Described as a warm and
cuddly infant
 Aware of Physical violence
towards the mother by
biological father
 No other
physical/emotional/sexual
abuse reported

11.  Problems began during Head start
at around age 4
 Had to change school about twice
 Currently goes to a day
program(Tu,Th,Fr)
 Face to face (M, W)
 Is in the 2nd grade (IEP*)
 Behind in reading and spelling per
mother ( per testing done at
Hawthorn Grade levels are: )
Reading = 1.2
Spelling = 1.0
Math = 1.2
*= Individual Education Plan

12.  OT is a 7 yo Caucasian, slightly obese male, appears
stated age. Fair grooming and hygiene . Pleasant and
co-operative to begin with the interview, soon gets
distracted, infrequently answering the questions in
the first time. Fidgety and restless throughout the
interview. Keeps jumping out of the chair. Speech had
an increased volume and flow, normal syntax and
grammar. Mood anxious and elated, affect labile
.Thought process was logical & goal directed,
whenever he chose to answer, but illogical during
most part of the interview frequently derailing from
the topic. Switching topics often. Denied any
abnormal perceptual experiences. No delusions. AA
Ox3. Memory : on recent recall 2/3 words after 5
minutes, able to recall past events with reasonable
accuracy. Appeared to have average intelligence. Poor
attention & concentration. Poor impulse control,
Judgment poor. No insight into his problem.

13. Axis I : Bipolar
disorderNOS(?)
Hx ADHD (C)
Axis II : None
Axis III : Seasonal Asthma
Obesity
Axis IV : Problem with
primary support group,
Educational problems
Axis V : 20-25

14.  Day 1 : OT has difficulty falling asleep.
 Day 4 : Behavioral issues continue, sent
to the QR 3/4days. Fighting peers,
provoking, not following directions
 Day 6 : Depakote level is 93mmol/liter
 Day 7 : Reports A/V hall. the “Grim
Reaper”
 Day 8 : Geodon is increased to 40mg bid
 Day10: Sexually inappropriate behavior
 Day14: Lithium is added to the
medication regime
 Day15: “My mind runs faster than the
Mustang”
 Day 21: Geodon+ Lithium+ Depakote,
ongoing Rx . No response to medications.
Li+2 level awaited

15.  The essential feature of Bipolar I Disorder
is a clinical course that is characterized by
the occurrence of one or more Manic
Episodes or Mixed Episodes. Often
individuals have also had one or more
Major Depressive Episodes. Episodes of
Substance-Induced Mood Disorder (due to
the direct effects of a medication, or
other somatic treatments for depression, a
drug of abuse, or toxin exposure) or of
Mood Disorder Due to a General Medical
Condition do not count toward a diagnosis
of Bipolar I Disorder. In addition, the
episodes are not better accounted for by
Schizoaffective Disorder and are not
superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional
Disorder, or Psychotic Disorder Not
Otherwise Specified

16.  The essential feature of Bipolar II
Disorder is a clinical course that is
characterized by the occurrence of
one or more Major Depressive
Episodes accompanied by at least
one Hypomanic Episode. Hypomanic
Episodes should not be confused with
the several days of euthymia that
may follow remission of a Major
Depressive Episode. Episodes of
Substance- Induced Mood Disorder
(due to the direct effects of a
medication, or other somatic
treatments for depression, a drug of
abuse, or toxin exposure) or of Mood
Disorder Due to a General Medical
Condition do not count toward a
diagnosis of Bipolar I Disorder. In
addition, the episodes are not better
accounted for by Schizoaffective
Disorder and are not superimposed on
Schizophrenia, Schizophreniform
Disorder, Delusional Disorder, or
Psychotic Disorder Not Otherwise
Specified.

18.  A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at
least 1 week (or any duration if hospitalization is necessary).
 B. 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:
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 (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
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)
 C. The symptoms do not meet criteria for a Mixed 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.
 E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse,
a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism).
 Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g.,
medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I
Disorder.

20.  A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4
days, that is clearly different from the usual nondepressed mood.
 B. 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:
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 (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
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)
 C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the
person when not symptomatic.
 D. The disturbance in mood and the change in functioning are observable by others.
 E. The episode is NOT severe enough to cause marked impairment in social or occupational functioning, or
to necessitate hospitalization, and there are NO psychotic features.
 F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
 Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g.,
medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II
Disorder.

21.  A. The criteria are met both for a Manic Episode
and for a Major Depressive Episode (except for
duration) nearly every day during at least a 1-
week period.
 B. 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.
 C. The symptoms are not due to the direct
physiological effects of a substance (e.g., a drug
of abuse, a medication, or other treatment) or a
general medical condition (e.g., hyperthyroidism).

22.  The Bipolar Disorder NOS category includes disorders with Bipolar feature
that do not meet criteria for any specific Bipolar Disorder.
 Examples include
1. Very rapid alternation (over days) between manic symptoms and
depressive symptoms that meet symptom threshold criteria but not
minimal duration criteria for Manic, Hypomanic, or Major Depressive
Episodes
2. Recurrent Hypomanic Episodes without intercurrent depressive symptoms
3. A Manic or Mixed Episode superimposed on Delusional Disorder, residual
Schizophrenia, or Psychotic Disorder NOS
4. Hypomanic Episodes, along with chronic depressive symptoms, that are too
infrequent to qualify for a diagnosis of Cyclothymic Disorder
5. Situations in which the clinician has concluded that a Bipolar Disorder is
present but is unable to determine whether it is primary, due to a GMC, or
substance induced

24. From: Recent Progress in Understanding Pediatric Bipolar Disorder
Arch Pediatr Adolesc Med. 2012;166(4):362-371. doi:10.1001/archpediatrics.2011.832
Figure. Risks of false-positive and false-negative diagnoses of bipolar disorder. ADHD indicates attention-deficit/hyperactivity
disorder.
Copyright © 2012 American Medical
Date of download: 9/20/2012
Association. All rights reserved.

26. Opinion 1 : Trying to use the course modifier
“rapid cycling” , because children often do
not have clearly demarcated episodes, but
seem to be chronically cycling1-4
1. Pediatric bipolar disorder: emerging diagnostic and treatment approaches: Kowatch RA, DelBello MP.Child Adolesc
Psychiatr Clin N Am. 2006 Jan;15(1):73-108. Review.
2. Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender,
puberty and comorbid attention deficit hyperactivity disorder :Geller B, Zimerman B, Williams M, Bolhofner K,
Craney JL, Delbello MP, Soutullo CA. J Child Adolesc Psychopharmacol. 2000 Fall;10(3):157-64.
3. Rapid, continuous cycling and psychiatric co-morbidity in pediatric bipolar I disorder: Findling RL, Gracious BL,
McNamara NK, Youngstrom EA, Demeter CA, Branicky LA, Calabrese JR: Bipolar Disord. 2001 Aug;3(4):202-10.
4. Childhood mania: insights into diagnostic and treatment issues: Wozniak J, Biederman J: J Assoc Acad Minor Phys.
1997;8(4):78-84. Review.

27. Opinion 2: Prepubertal BP I patients have
multiple mood swings each day, have mixed
episodes with short periods of euphoria
mixed with longer periods of irritability.5,6
5. Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children: Wozniak J,
Biederman J, Kiely K, Ablon JS, Faraone SV, Mundy E, Mennin D: J Am Acad Child Adolesc Psychiatry. 1995
Jul;34(7):867-76.
6. Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent
bipolar disorder phenotype: Geller B, Tillman R, Craney JL, Bolhofner K: Arch Gen Psychiatry. 2004
May;61(5):459-67.

28. Opinion 3: Geller in her classic paper of 2002 7
describes “Children are developmentally
incapable of many manifestations of bipolar
symptoms described in adults e.g., children
do not “max” out on credit cards or have four
marriages” and has discussed age equivalents
of adult mania behaviors.
7. Phenomenology of prepubertal and early adolescent bipolar disorder: examples of elated mood, grandiose
behaviors, decreased need for sleep, racing thoughts and hypersexuality: Geller B, Zimerman B, Williams M, Delbello
MP, Frazier J, Beringer L: J Child Adolesc Psychopharmacol. 2002 Spring;12(1):3-9.

29. Normal Child Child Mania Adult Mania
Child was super A 7-year-old boy was A 40-year-old man
happy on days family repeatedly taken to giggled infectiously
went to Disneyland, the principal for while being placed in
on Christmas clowning and giggling restraints in the
morning, and during in class (when no one emergency room. A
grandparents’ visits. else was) and was 50-year-old man in
Child’s joy was suspended from the emergency room
appropriate to school. He had to was infectiously
context. Child’s leave church with his amusing as he
behavior was not family for similar described multiple
impairing behaviors. A 9-year- hospitalizations,
old girl continually losing jobs, and losing
danced around at family ties.
home stating, “I’m
high,
over the mountain
high” after
suspension from
school.

30. Normal Child Child Mania Adult Mania
A 7-year-old boy played at being A 7-yo boy stole a go-cart An adult man kept his
a fire fighter, directing other because he just wanted to family in increasing debt
fire fighters and rescuing have it, even though he knew due to multiple unrealistic
victims. The child was not stealing was wrong. He did business ventures. A 21 yo
calling the fire station to tell not, however, believe it was man believed he could
them what to do. Play was wrong for him to steal. When commit a homicide and not
during afterschool hours; it was the police arrived, the child be arrested because the
age appropriate and not thought the officers were laws would not pertain to
impairing. there to play with him. An 8 him. An 18 yo woman rang
yo girl opened a paper flower the mayor’s home doorbell
store in her classroom and because she knew they
was annoyed and refused to were engaged. When asked
class work when asked by the if she had ever met the
teacher. An 8 yo girl, failing mayor, she stated it did not
at school, spent her evenings matter
practicing for when she would
be the first female
president. She was also
planning how to train her
husband to be the First
Gentleman. When asked how
she could fail school and still
be president, she said she
just knew it

31. Normal Child Child Mania Adult Mania
Normal Children sleep An 8 yo boy A 25 yo woman
approx 8-10 hours a chronically stayed up worked both day and
night and are tired if until 2 a.m., evening full time jobs,
they sleep fewer hours rearranging furniture seemingly without
than usual or playing games. fatigue. A father
Then he awoke at 6 described his daughter
a.m. for school & was as “she parties” for
energetic during the days in a row, and
day without evident then “sleeps” for days
tiredness, or fatigue. in a row
A 7 yo girl, daily,
knocked on a friend’s
door at 6 a.m. ready
to play.

32. Normal Child Child Mania Adult Mania
A 7 yo child played doctor An 8 yo boy imitated a rock Numerous adults who had
with the same aged friend. A star by gyrating his hips, and four or more marriages not
12 yo boy looked at his rubbing his crotch during a due to death of spouses or
father’s pornographic research interview. A 9 yo who had multiple
magazines boy drew pictures of naked extramarital affairs.
ladies in public, stating these
were drawings of his future
wife. A 14 yo girl passed
notes to boys in class asking
them to f *** her. A 7 yo girl
touched the teacher’s breasts
and propositioned the boys in
the class. Another child
called the “1-900” sex lines,
which the parents discovered
when the phone bill arrived
at the end of the month.

33. Normal Child Child Mania Adult Mania
Normal subjects did not Unlike Manic adults, Adults conceptually
give affirmative response children gave concrete understand “racing”
to inquiries about racing answers to describe their thoughts and can describe
thoughts “racing thoughts.” them using the word
Examples are: A girl racing
pointed to the middle of
her forehead and stated
“I need a stoplight up
there.” Other children
noted the following: “It’s
like an energizer bunny in
my head.” “Too much
stuff is flying around up
there.” “I don’t know
what to think first.” “My
thoughts broke the speed
limit.”

34.  Opinion #4: Dr.
Leibenluft’s NIH
lab has given a
demarcation
between various
phenotypic
expressions of
Mania/Hypomani
a
8: Defining clinical phenotypes of
juvenile mania: Leibenluft E,
Charney DS, Towbin KE, Bhangoo
RK, Pine DS: Am J Psychiatry.
2003 Mar;160(3):430-7. Review.

35.  The co-occurrence of additional
disorders complicates both the
accurate diagnosis of BPD and it’s
treatment
 The presence of comorbidity
compounds disability, complicates
RX, and worsens the prognosis
 If comorbidity is not
acknowledged, misattribution of
impairing symptoms could lead to
inappropriate therapeutic
interventions, unnecessary
exposure to neuroleptics,
worsening of symptoms, and
misuse of mental health resources
9. Comorbidity in pediatric bipolar disorder: Joshi G,
Wilens T: Child Adolesc Psychiatr Clin N Am. 2009
Apr;18(2):291-319, vii-viii. Review.

36.  ADHD is comorbid with BPD : 60-90%
 ADHD comorbidity more often associated with
early onset BPD
 Recognition of this comorbidity is very important
because
- Medications with Manicogenic potential
- Atypical response
- Less than expected antimanic response to
thymoleptic agents
- If the symptoms of inattentiveness,
distractibility, talkativeness, and impulsivity are
not recognized as comorbid ADHD, they may be
inappropriately treated as residual symptoms of
mania

37.  Symptoms which are not mania specific : occur in both categories
- Irritable mood
- Accelerated speech
- Distractibility
- Increased energy
 Criteria which provide best discrimination
- Elated mood
- Grandiosity
- Flight of ideas/Racing
- Decreased need for sleep
 Of the poor judgment criteria (total poor judgment,
hypersexuality, daredevil acts, silliness, uninhibited people
seeking) only hypersexuality provides good discrimination
between ADHD & PEA-BP
* = Pediatiric and Early Adolescent
10. DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-
deficit hyperactive and normal controls: Geller B, Zimerman B, Williams M, Delbello MP, Bolhofner K, Craney JL,
Frazier J, Beringer L, Nickelsburg MJ: J Child Adolesc Psychopharmacol. 2002 Spring;12(1):11-25.

38.  There are no FDA approved medications for
children younger than 10 years
 Several antipsychotics are approved 10-17
 Lithium is approved for 12 and above
 Contrast to 19 meds for ADHD

39.  Need for NIMH or Private foundation to fund
research
 Studies without a placebo arm are wanted
by Parents, when considering entering their
children in clinical trials12
 Practical randomized, open comparative
trials of two active agents could be
performed at a single site or several sites,
and not involve the expense of traditional
Multi-site RCT’s13
12. Parental attitudes towards early intervention in children at high risk for affective disorders: Post RM, Leverich GS,
Fergus E, Miller R, Luckenbaugh D: J Affect Disord. 2002 Jul;70(2):117-24.
13. Childhood-onset Bipolar Disorder: The Perfect Storm :Robert. M Post: Psychiatric Annals (Editorial): October 2009

40. AACAP Practice Parameters for BD
 Include screening questions for BD during
psychiatric evaluation
 Use “unmodified” DSM-IV-TR criteria for
diagnosis
 If + make sure you screen for all the
comorbidities viz. substance, suicidality and
medical problems
 Be cautious in diagnosing in pre-schoolers
(refer/second opinion)

41. “If uncertainties make you anxious, don’t think about being a child psychiatrist”
Dr. Elizabeth McCullough