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1、Early Onset Bipolar Disorderand the Pediatric Behavior Rating Scale (PBRS)Childrens Mental Health5,000,000 (the number of children and adolescents in the U.S. suffer from a serious mental disorder resulting in significant functional impairments at home, at school, and with peers.)80% (Americas youth
2、 with mental health needs who fail to be identified and to receive treatment and services.)6-8 years from onset to treatment for mood disordersCONSEQUENCES (of untreated mental disorders include suicide, addictions, school failure, and criminal involvement).Information obtained from National Allianc
3、e on Mental Illness web site Aug. 2007Society benefits when Mental Health is addressed earlyDIAGNOSIS DU JOUR?1980S ADHD1990S DEPRESSION2000S EOBPDRATES OF DIAGNOSIS4,000% increase in rate of EOBPD diagnoses in the past 10 years (Frontline, 2021)At present, over 1 million American children have an E
4、OBPD diagnosis, and the number is steadily increasing (Frontline, 2021)PROBLEMS IDENTIFYING BPD IN CHILDRENEOBPD is not in DSM IV.EOPBD looks like other disorders.EOBPD has high rates of comorbidity.PROBLEM 1: EOBPD isnt in DSM IVBIPOLAR DISORDERSBipolar l DisorderMania and major depressionBipolar l
5、l DisorderHypomania & major depressionCyclothymic DisorderHypomania & depression/dysthymia EOBPD vs. Adult BPD(Birmaher et al, 2021; Danielyan et al, 2007; Kowatch et al, 2005)EOBPDAdult BPDMixed Mood Episodes are typicalDiscrete Mood Episodes are typicalUltra-Rapid Cycling is commonLonger cyclesSym
6、ptomatic most of the timePeriods of no symptoms between cyclesPROBLEM 1: EOBPD isnt in DSM IVBipolar Disorder-Not Otherwise SpecifiedRapid alternation between manic and depressive symptoms that do not meet the duration criteria for manic, hypomanic, or major depressionHypomanic without depressionInf
7、requent episodesPROBLEM 2: EOBPD mimics other disordersDisruptive Behavior DisordersADHD60-93% meet diagnostic criteria for ADHD (Biederman, et. al, 2003)Mania versus hyperactivityMore anger, irritability, aggressive temper tantrumsPresence of elation, grandiosity, racing thoughts/flight of ideas, d
8、ecreased need for sleep, hypersexuality PROBLEM 2: EOBPD mimics other disordersODD77-88% have ODD (Wozniak et. al, 1995)More intense irritability and severe emotional meltdownsCD42-69% have CD (Biederman, et. al, 2003)Violent and aggressive behavior lacks intent, planning, and premeditationPROBLEM 2
9、: EOBPD mimics other disordersAnxiety Disorders56-75% have anxiety disorder (Wozniak et. al, 1995; Masi, et. al, 2001)Tourettes Disorder, Schizophrenia, Autism Spectrum DisorderWHAT WE KNOW:SYMPTOMS ASSOCIATED with EOBPDInflexibleOppositionalIrritableExplosive ragesErratic sleepDifficult to sootheSe
10、paration anxietyNight terrorsFear of death and annihilationRapid cyclingPrecociousnessSensitivity to stimuliProblems with peersTemperature dysregulationCraving for carbs. and sweetsBedwetting and soilingHypersexualityHallucinationsSuicidal ideationFrequency of EOBPD SymptomsVery Often(90%-97%)Often(
11、60%-80%)Sometimes(20%-35%)Infrequent(Less than 10%)IrritabilityAnxietyHypersexualityHomicidal IdeasMood LabilityRacing ThoughtsPsychosisSuicidal ActsSleep DisorderPressured SpchSuicidal IdeationAnger; RageEuphoria,GrandiositySelf-harmImpulsivityAgitationAggressionFrom: Faedda & Austin, 2006Parenting
12、 a bipolar childp. 39.PsychosisTillman et al (2021), 257 EOBPD participants, ages 6-16, funded by NIMHPsychosis was present in 76.3% of subjects38.9% with delusionsGrandiose was most common5.1% with pathological hallucinationsVisual hallucinations were most common32.3% with bothDEVIANCEVOLUNTARY - w
13、e have a tendency to attribute misbehaviorespecially noncompliance and disobedience-to willful disobedience. INVOLUNTARY - we tend to minimize this even when it explains the childs behavior.EOBPD and AROUSAL Children with EOBPD are less able to modulate arousallive in fearare “on alert for dangerare
14、 primed for “fight/flight responseAnd when aroused, aggression is more likely.WHAT KIND OF AGGRESSION IS BEING EXPRESSED?Predatory-controlled (instrumental)Defensive-impulsive, reactive (not for gain)CHARACTERISTICDIAGNOSISAGGRESSION TYPEImpulse ControlADHDAccidents/ InjuriesEmotional InstabilityBip
15、olar, Borderline, IEDReactive, affective attackIrritabilityDepression, DysthymiaActing Out, SuicideAnxiety/Low Frustration ToleranceAnxiety, PTSD, ASDReactive striking outImpaired JudgmentSubstance Abuse, PsychosisInadvertent AggressionStimulation SeekingCD, ODDPredatory AggressionREACTIONARY and CO
16、NFRONTATIONAL approaches serve mainly to provoke and escalate.GOALS OF INTERVENTIONSStabilizeReduce SymptomsOppositionDefianceIrritabilityAggressionImprove Functioning (academic, social)TWO WAYS TO ACHIEVE THESE GOALSMedications (to make the child “available)Psychotherapies (coping & managing)Genera
17、l Rule for InterventionsBehavioral approaches tend to focus on consequences.There are two problems with thisTWO PROBLEMS1. By definition, children and adolescents with deficits in impulse control and self-regulation do not consider consequences before they act.2. Behavioral consequences (especially
18、if they are aversive) introduce provocation, confrontationand escalation.INTERVENTION TARGETSCHILDmedicationssleepself-regulationPARENTSpsychoeducation medication compliance ENVIRONMENT (control the pace)homeschoolDRUG TREATMENTS EOBPDFOUR MAJOR CLASSES of MOOD STABILIZERS LithiumAntiepileptics (Moo
19、d Stabilizers)AntidepressantsAntipsychotics CHARACTERISTICDIAGNOSISAGGRESSION TYPEMEDICATIONImpulse ControlADHDAccidents/ InjuriesSTIMULANTSSSRIANTIPSYCHOTICMOOD STABILIZERSAffective InstabilityBipolar, Borderline, IEDReactive, affective attackANTISPYCHOTICSMOOD STABILIZERSSSRIIrritabilityDepression
20、, DysthymiaActing Out, SuicideSSRIOTHER ANTIDEPRESSANTSAnxiety/Low Frustration ToleranceAnxiety, PTSD, ASDReactive striking outOTHER ANTIDPERESSANTSSSRITENEXCLONODINEImpaired JudgmentSubstance Abuse, PsychosisInadvertent AggressionANTIPSYCHOTICSStimulation SeekingCD, ODDPredatory AggressionMOOD STAB
21、ILIZERNONDRUG INTERVENTIONSTHERE ARE 550 PSYCHOTHERAPIES (NONMEDICAL INTERVENTIONS) FOR TREATING CHILDREN AND ADULTS BEYOND BEHAVIORISMParent Management TrainingCognitive Behavioral TherapyDialectal Behavior TherapyChoice TheoryProblem-Solving SkillsHealth Promoting Environments CHARACT-ERISTICDIAGN
22、OSISAGGRESSION TYPEPSYCHOTHERAPYImpulse ControlADHDAccidents/ InjuriesCBT; DBTPROBLEM-SOLVINGParent TrainingAffective InstabilityBipolar, Borderline, IEDReactive, affective attackCBT; DBTPROBLEM-SOLVINGParent TrainingIrritabilityDepression, DysthymiaActing Out, SuicideCBTAnxiety/Low Frustration Tole
23、ranceAnxiety, PTSD, ASDReactive striking outCBT; DBTPROBLEM-SOLVINGParent TrainingImpaired JudgmentSubstance Abuse, PsychosisInadvertent AggressionCognitive Enhancement TherapyStimulation SeekingCD, ODDPredatory AggressionParent TrainingPSYCHOEDUCATIONThe Bipolar Child (3rd Edition) by Papolos and P
24、apolos (2006)Understanding the Mind of Your Bipolar Child by Lombardo (2006)The Bipolar Disorder Survival Guide by Miklowitz (2002)The Bipolar Teen by Miklowitz and George (2021) 80 - 90% 10 - 15% 1 - 5%Three-Tier Model of Behavioral Intervention/SupportTier III: Intensive, Individual InterventionsT
25、ier II: Targeted Group InterventionsTier I: Universal Interventions/Supports80 - 90%10-15%1-5%Tier III: Individual InterventionsGoal: To develop and implement interventions for student behaviors that can not be addressed or remedied via Tier I or Tier II interventions.FUNCTIONAL ASSESSMENTModified f
26、rom: Santilli, Nancy, Dodson, W.E., Walton, A.V. (1991) INTERVENTIONS FOR SIMPLEMonopharmacyMildly intrusive therapyindividual therapygroup therapyparent trainingRegular classroom placementFavorable RTIINTERVENTIONS FOR COMPROMISEDPolypharmacy (aggression, irritability, co-morbidity)Intensive child
27、and family therapiesindividual therapygroup therapyfamily therapy/parent trainingMay require Spec. Ed. (EH, SED, OHI)Variable RTI INTERVENTIONS FOR COMPLEXPolypharmacyIntensive Interventionsindividual therapyintensive parent trainingalternative educational placementsAcute hospitalizationSelf-contain
28、ed to RTCLaw EnforcementVery poor prognosis Predictors of OutcomeWorse outcomes are associated with:Younger age of onsetLong duration of mood symptomsLow socioeconomic statusLifetime psychosis(Birmaher et al, 2006)PEDIATRIC BEHAVIOR RATING SCALEWHY A NEW RATING SCALE? Existing scales came out normal
29、 Item analysis told us why The need for differential diagnosisOTHER SCALES Young Mania Rating ScaleParent Version (P-YMRS; 11 items) General Behavior Inventory (GBI; 73 items; age 11; self-report accuracy) Child Mania Rating Scale (CMRS; mania only) Conners Abbreviated Symptom Questionnaire (ASQ; 10
30、 mania items from the Conners Parent Rating Scales CPRS) Omnibus rating scales (e.g., Clinical Assessment of Behavior CAB, Achenbach System of Empirically Based Assessment ASEBA, Behavior Assessment System for Children BASC)PURPOSEFor children and adolescents ages 3-18 yearsPrimary function: To assi
31、st in the identification of emotional dysregulation and related disorders, specifically early onset bipolar disorder (EOBPD)Secondary function: To aid in differential diagnosis, leading to differential interventionsFEATURES Sufficient items to identify core features of EOBPD, such as:Mood swingsIrri
32、tabilityGrandiosityEasily provokedExplosive outbursts Syndromal differentiation (e.g., ADHD vs. EOBPD) Identifies areas of concern rather than providing diagnosesPBRS APPLICATIONS ClinicalDistinguish between EOBPD and its mimicsSymptom identification and profile analysisAreas of concern EducationalC
33、larify diagnosis using IDEAMore complete symptom profile (intervention) ResearchDefining the disorder in childrenHandling comorbidityIntervention efficacy COMPONENTS Parent FormPBRS Parent Item Booklet (102 items)PBRS Parent Response BookletPBRS Parent Score Summary/Profile Form Teacher FormPBRS Tea
34、cher Item Booklet (95 items)PBRS Teacher Response BookletPBRS Teacher Score Summary/Profile FormSCORES PRODUCED Inconsistency ScoreCan I trust the responses? Critical ItemsNo matter what, these are clinically important Symptom ScalesEach is important, as is the profile Total Bipolar IndexComposite o
35、f all 8 symptom scalesCRITICAL ITEMSThese items have special clinical significance and should be given special attention. Any item with a score greater than zero should be investigated further as this suggests a serious problem that must be addressed or ruled out.Self-abuseHallucinationsBizarre beli
36、efsExpresses violent themesSuicidal thoughtsAggressionSYMPTOM SCALESEight clinical scales and one index Atypical (psychotic symptoms) Irritability (persistent and chronic) Grandiosity (exaggerated sense of self) Hyperactivity/Impulsivity (as in ADHD) Aggression (toward others, animals, objects) Inat
37、tention (as in ADHD) Affect (mood disturbances, cognitive distortion) Social Interactions (interacting with peers) Total Bipolar IndexAtypical (ATY) ScaleBizarre beliefsAuditory hallucinationsDelusionsSelf-harm behaviorsExcessive fearsIrritability (IRR) ScaleEmotional dysregulationBehavioral/emotion
38、al outburstsDemandingnessGrandiosity (GRAND) ScaleElevated sense of self and moodNot taking responsibility for actionsExaggeratingStealingHyperactivity/Impulsivity (HYPER) ScaleClassic description of overactivity and impulsivityDifficulty sitting stillActs without thinking about consequencesAlways o
39、n the goAggression (AGG) ScaleAggression targeting other people, animals, or objectsInattention (INATT) ScaleTraditional scale for inattention and distractibilityDifficulty focusingDifficulty sustaining attentionAffect (AFF) ScaleMood disturbancesSuicidal ideationCognitive distortionsSocial Interact
40、ions (SOC) ScaleAbility to interact with peersAbility to make friendsRelating to othersEngaging in social interactionsTOTAL BIPOLAR INDEX TBI is a composite of the 8 scales The most robust PBRS score (like g on IQ tests) T scores 70 are a significant concern for disorders of emotional dysregulation;
41、 T scores 80 suggest EOBPD The most effective way to differentiate EOBPD from other diagnoses (especially ADHD)POPULATIONNormative sampleParents n = 541Teachers n = 610 Clinical sample (clinical groups included BPD, ADHD, CD, ODD, and autism spectrum disorders ASD)Parents n = 224Teachers n = 194RELI
42、ABILITYInternal consistency Coefficient for PBRS-P = .60 to .89 Coefficient for PBRS-T = .75 to .93 Coefficient for PBRS-P TBX = .95 Coefficient for PBRS-T TBX = .97 RELIABILITY Parent-teacher interrater reliabilityCoefficient = .77 to .86Coefficient for TBX = .88 Parent-parent interrater reliabilit
43、yCoefficient = .67 to .86Coefficient for TBX = .85 VALIDITYConvergent validity: Omnibus rating scales for similar behaviors PBRS-P with CAB .50-.80 PBRS-T with CAB .30-.80 PBRS-P with BASC-2 .60-.80 PBRS-T with BASC-2 .70-.80 VALIDITYConvergent validity: Domain-specific rating scalesPBRS-P with CMRS
44、 = .07 (Affect) to .63 (Aggression)PBRS-T with CMRS = -.23 (Affect) to .70 (Hyperactivity/Impulsivity)PBRS-T with Conduct Disorder Scale (CDS) = .52 to.74 on four similar scalesPBRS-T with Conners Teacher Rating Scales (CTRS) = .16 (Cognitive Problems/Inattention with Atypical) to .69 (Hyperactivity
45、 with Hyperactivity/Impulsivity)VALIDITYClinical validityNormative group compared to clinical groups (BPD, ADHD, ODD, CD, ASD) on the 8 scales and the TBX were significant at p .001.The 8 scales and the TBX differentiated the five clinical groups on all scales except Atypical and Inattention (Parent) and Irritability and Inattention (Teacher).
