Pediatric Bipolar Disorder
Ira Glovinsky, Ph.D.
Prevalence
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Pediatric Bipolar Disorder diagnosis in outpatient
clinics increased 40-fold between 1994-2003:
1. A true increase in prevalence;
2. Rectification of previous under-recognition;
3. Changes in conceptualization of the disorder;
4. Inappropriate application of the diagnosis to
youth with other illnesses.
Should children and adolescents with severe, nonepisodic irritability and symptoms of ADHD be
considered to have a developmental presentation of
mania?
How Pediatric Bipolar Disorder
Evolved
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1. Aretaeus of Cappadocia (Rome 2nd century)- cyclothymia as a form
of mental disease presenting phases of depression alternating with
phases of mania…so that mania is like a variety of melancholia.
2. Through the medieval era mania and depression:
(a) Continued usually to appear together among diseases of the
head;
(b) Were grouped together as the two chronic forms of madness;
(c) Were described as being without fever;
(d) Were presented in adjacent chapters or sections, if not in the
same chapter;
(e) Mania continued to imply primarily excited psychotic states, and
melancholia dejected psychotic states;
(f) The basic clinical description changed little.
How Pediatric Bipolar Disorder
Evolved
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3. Jules Baillarger (1809-1890)- la folie à double forme- the existence of a
distinct and separate disease with both melancholic and manic phases
characterized by regular periods of each.
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4. Jean-Pierre Falret (1794-1870)- la folie circulaire- mania changed to
melancholia and vice versa, with rational intervals of very short duration.
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5. Emil Kraepelin (1921)- “manic-depressive insanity.
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6. Theodor Ziehen (early 1900’s)
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7. Charles Bradley (1945)
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8. John Campbell (1953)
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9. E.J. Anthony and P. Scott (1960)- manic-depression is rare in children under
11 years.
How Pediatric Bipolar Disorder
Evolved
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10. Youngerman and Canino (1978)- studied lithium in youth. Response
to lithium was poor in those without classic manic-depression.
11. Laufer and Denhoff (1957) described “hyperkinesis” in children.
These children were explosive, hyperactive, and distractible, had mood
lability and variations in behavior that was more than how we now
define ADHD.
12. The “diagnostically homeless.” DSM-III broke off the mood lability
symptom from hyperkinesis because it was not felt to be central to
ADHD. Children who had mood lability went into the bipolar
classification.
13. Using adult bipolar criteria to diagnose children.
DSM-IV-TR Criteria for Mania
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Criteria for a Manic Episode
A distinct period of abnormally and
persistently elevated, expansive or irritable
mood, lasting one week (or any duration of
hospitalization is necessary).
DSM-IV-TR and ICD-10 Criteria:
Focus on Episodes
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One specifically makes a diagnosis of
manic episode in DSM-IV, not mania
per se. According to DSM-IV, if one
cannot identify distinct episodes, one
cannot diagnose mania or hypomania,
and by extension, one cannot diagnose
bipolar disorder.
DSM-IV-TR and ICD-10 Criteria:
Focus on Episodes
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‘A’ Criteria- a ‘distinct period’ of abnormal
mood, lasting the requisite number of days
and then returning to a euthymic or
subsyndromal state (At least one identifiable
period when the mood was different from
baseline).
‘B’ Criteria- Concurrent with the change in
mood, the patient must have experienced the
requisite number of ‘B’ criteria.
DSM-IV-TR Criteria for Mania
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During the 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 and grandiosity;
2. decreased need for sleep (e.g., feels rested after only
three 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. increased goal-directed activity (either socially, at work or
school, or sexually) or psychomotor agitation;
7. excessive involvement in pleasurable activities that have a
potential for dangerous consequences.
DSM-IV-TR Criteria for Mania
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The symptoms do not meet criteria for a Mixed Episode;
The mood disturbance is sufficiently severe to cause marked
impairment in occupational functioning or in social activities or
relationships with others, or to necessitate hospitalization to
prevent harm to self and others, or there are psychotic features;
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)
Problems With Using Adult Criteria
to Define Pediatric Bipolar Disorder
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1. “A distinct period….”
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2. “Elevated and expansive mood…”
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3. “…of one week duration…”
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4. What does grandiosity in young children look like? Children have fantasies about magic
powers that may seem grandiose.
5. What is the clinical threshold for mania in young children? What is clinical elation versus
the extreme of joyfulness?
6. In very young children there are developmentally normal fluctuations in mood. What is
fluctuation and what is a cycle?
7. Relationship difficulties can cause mood fluctuations.
The Bipolar Controversy
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I. What are we calling bipolar?
A. “Classical” manic-depression is rare- clear episodes of mania
followed by depression and euthymia in well-functioning individuals
who are okay intermorbidly.
B. Children with problems in executive functioning,
hyperactivity, and catastrophic rages comprise the bulk of
children being called bipolar. The have problems:
1. Inhibiting impulses
2. Shifting attention
3. Controlling emotions
4. Initiating activities
5. Planning/ organizing
6. Self-monitoring
C. No one has connected this condition with “classic” manicdepression. Pre-pubertal bipolar children do not change after
adolescence and become “classic.”
What Does Bipolar Disorder in
Childhood Look Like
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1. A chronic course
2. Emotional and behavioral dysregulation with pronounced
irritability.
3. Irritability is a non-specific symptom in psychiatric disorders
in children. The type of irritability observed in pediatric mania is
extremely severe and distinct from other forms of irritability
seen in other childhood disorders.
4. Among Criterion A (abnormal mood) severe irritability was
the predominant abnormal mood rather than euphoria (94%
versus 51%).
5. Episodes last hours rather than days.
6. High rates of comorbid symptomatology.
Why Is It Difficult To Diagnose
Pediatric Bipolar Disorder?
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1. Base-rate problem- At any given time, less than 1% of the
population samples could be expected to have a manic disorder.
20-30% of children who have psychiatric problems are referred
for or receive psychiatric help. Therefore, the typical clinician is
likely to have a low rate of exposure to youths with mania,
which makes it difficult to form a template of the disorder.
2. Cross-sectional and longitudinal variability of
symptoms- Symptoms of mania in childhood are intrinsically
labile and there exists gradients of severity within a given
episode. A manic episode may go unrecognized if the
changeable and labile presentation is not viewed as a salient
characteristic of the disorder. Symptoms are not persistent.
Why Is It Difficult To Diagnose
Pediatric Bipolar Disorder?
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3. Symptom overlap of mania with other disorders.
4. Developmental stage and symptom expressionsa. What does elation look like in a four-year-old?
b. What does grandiosity look like in a four-year-old?
c. What does hyper-sexuality look like in a four-year-old?
d. How do you assess racing speech?
Subtypes of Bipolar Disorder
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I. Leibenluft et al (2003)
A. Narrow Phenotype- those who meet full DSM-IV-TR diagnostic criteria for
mania of hypomania, including duration criteria.
B. Intermediate Phenotype 1- hallmark symptoms of elevated mood and
grandiosity, of short duration, 1-3 days.
C. Intemediate Phenotype 2- episodic irritable mania or hypomania meeting
the duration criteria without elation.
D. Broad Phenotype- Non-episodic symptoms of severe irritablity and hyperarousal without the hallmark features of elated mood or grandiosity.
1. Non-episodic symptoms of severe irritability;
2. Hyper-arousal without hallmark symptoms of elated mood or
grandiosity.
What Do Preschool Age Children
With Bipolar Disorder Look Like?
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Tumuluru, R.V, Weller, E.B., Fristad, M.A., and Weller, R.A. (2003) Mania in Six Preschool
Children. Journal of Child and Adolescent Psychpharmacology.
1. 36 consecutively hospitalized preschool children. 17% of these children had bipolar disorder.
2. All children had irritable mood. (Ages 3-5 years)
3. Five of six cases also had:
(a) a decreased need for sleep;
(b) distractibility
(c) agitation
(d) impaired functioning
4. All had a strong history of affective illness.
5. All six children presented at some point in time with symptoms consistent with attention deficit
hyperactivity disorder. Severe mood lability in the context of hyperactivity and impulsivity
should raise the suspicion of mood disorder.
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6. In all six children mood symptoms were most impairing to the child’s functioning, resulting in
hospitalization
7. All five children treated with lithium showed improvement.
How Do We Assess Bipolar Disorder?
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I. From whom do we obtain information?
A. Parents1. Family and Developmental History
2. Preschool Age Psychiatric Assessment
3. Childhood Age Psychiatric Assessment
4. Behavioral Assessment Questionnaires
(BASC-2)
5. Rothbart Temperament Questionnaires
B. Child1. Self-Rating Scale (BASC-2)
C. Teacher
1. Teacher Rating Scales (BASC-2)
D. Parent-Child
1. Unstructured videotaping of each parent with child scored using the Functional
Emotional Assessment Scale (FEAS)
How Do We Assess Bipolar Disorder?
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II. Other Assessment Tools
1. Symptom Checklist
2. Sensory Profile
3. Behavior Rating Inventory of Executive
Functions (BRIEF)
4. Intellectual Testing/Neuropsychological Testing
5. Developmental Assessment of Non-verbal
Abilities (DANVA)
6. Language Assessment
7. Psychiatric consultation
8. Actigraphy
Symptom Checklist
Sensory Profile
Behavior Rating Inventory of Executive
Functions
What We Are Learning From Our Work:
A Bipolar Signature
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1. Sensory profile shows sensory and modulation challenges in almost
all areas with most hypersensitivity in vestibular processing.
2. Extremely tuned into their environments;
3. Crave sensory input;
4. Go into “active mode” when overloaded. When they are anxious they
seek sensory experiences, including movement in space.
5. As they become more active, craving sensations, sensory overload is
increased, escalating the problem;
6. Self-critical, self-blaming behaviors;
7. “All or nothing” thinking;
8. Counter-phobic defenses.
9. Actigraph patterns show shifts in activity level rather than constant
activity level, serious sleep disturbances, hemi-circadian rhythms
dominate circadian rhythm.
At What Age Are We Diagnosing
Bipolar Disorder in Children?
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Faedda, Glovinsky, Austin, & Baldessarini (2004)
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Measure
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Males (N=54)
Age of 1st Symptom
Age of 1st Treatment
Age of 1st Bipolar Dx
Age of Clinic Assessment
Family History Present
Adopted
Special education
3.2
6.6
9.2
10.1
90.7
16.7
20.4
Females (N=28)
2.2
7.3
10.4
11.5
89.3
21.4
14.3
What Symptoms Do The Children
Present?
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Initial Symptom
Males(N=54)
Females(N=28)
Irritiblity/Moody
Sleep Disturbance
Hyperactivity
Aggressive
Anxiety (All Forms)
Separation Anxiety
Inattention/Racing thoughts
Impulsive
Hypersexual
Pressured Speech
Self Harm
44.4
42.6
38.9
33.3
24.1
9.3
7.4
1.9
0.0
1.9
1.9
75.0
50.0
35.7
17.9
10.7
3.6
0.0
3.6
3.6
0.0
0.0
What Is Missing?
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Greenspan, S.I., and Glovinsky, I.(2002) Bipolar
Patterns in Children.
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1. A unique pattern of sensory processing in which
they evidence sensory oversensitivity to sound and to
touch. These children respond to sensory overload
with increased sensory craving, particularly with
regard to movement, which is usually associated with
high activity and aggressive, agitated or impulsive
behavior. The more overloaded they feel, the more
anxious and agitated they become, which results in
even more sensory overload.
What Is Missing?
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2. An early pattern of interaction, which continues through
childhood, characterized by a lack of fully co-regulated
reciprocal affective exchanges, especially with regard to “down-”
or “up-” regulation to balance states of despondency and
agitation.
3. An ego organization in which affects or emotions are either
not represented (i.e., remain in a prerepresentational, somatic,
or action mode) or are represented as separate affect states
(i.e., polarized rather than in an integrated form).
We Need to Go Further!
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I. Emotional Dynamics-
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A. Reactivity/Latency
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B. Rise time
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C. Intensity- (Initial/Peak)
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D. Lability (changes from one emotion to another, fluctuations between positive
and negative emotions, changes in discrete emotions, variations in the intensity of
emotion expression.
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E. Persistence
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F. Recovery
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G. Range (Intensity/ Tone)
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We Need to Go Further!
Affective-Social Competence
Expression
Awareness
Identification
Social
Context
Management
And
Regulation
Reception
Experience
A Developmental Pathway to Very
Very Early Bipolar Disorder
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INTERNAL COMPONENTS
EXTERNAL COMPONENTS
Neuro-regulatory
Mechanisms
Behavioral
Traits
Caregiving &
Training
A Developmental Pathway to Very
Very Early Bipolar Disorder
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Neuro-regulatory Mechanisms
(a) ANS/CNS Reactivity
(b) Endocrine activity
(c) Sensory sensitivities
(d) Temperament factors
Behavioral Traits
(a) Irritability
(b) Low frustration tolerance
(c) High reactivity
(d) High Intensity
(e) Polar emotions
(f) Slow emotional recovery
(g) Child feels helpless
Caregiving & Training
(a) Parent matches child’s
emotion expression
(b) Parent & child spiral
out of control
(c) Parent tries to exert more
control
(d) Parent feels helpless
A Developmental Pathway to Very
Very Early Bipolar Disorder
Beliefs &
Cognitions
Regulatory
Style
Caregiving &
Modeling
A Developmental Pathway to
Very Very Early Bipolar Disorder
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Beliefs and Cognitions
1. I must take care of myself;
2. I am powerful;
3. I am a failure;
4. I have to act quickly
5. React first!
Regulatory Style
1. Omnipotent;
2. Controlling;
3. Defiant
4. Oppositional
Caregiving & Training
A Developmental Pathway to Very
Very Early Bipolar Disorder
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INTERNAL COMPONENTS
EXTERNAL COMPONENTS
Regulatory
Style
Interactions
With
Peers
A Developmental Pathway to Very
Very Early Bipolar Disorder
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Regulatory Style
(a) Coercive/Angry/ Helpless
Interactions with peers
(a) Ungratifying
(b) Rejected
(c) Aggressive or Avoiding
Things to Think About
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1. Psychotherapeutic treatment models for treating mood
disorders in children are just beginning to be developed and
are generally modeled on adult models.
2. Early-onset mood disorders derail a child and parent at the
primary functional emotional developmental levels of:
(a) attention and regulation, (b) engagement, (c) two-way coregulated affective chains of communication; (d) behavioral
organization.
3. Medication with children helps about 40% of children. Even
with medication we need a model that addresses core
developmental capacities.
4. Parent and child development is so severely derailed that
we need a model that repairs parent/child relationships at the
earliest levels of development.
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2. Early-onset bipolar disorder derails a
child and parent at the primary
functional emotional developmental
levels of:
(a) attention and regulation, (b)
engagement, (c) two-way co-regulated
affective chains of communication; (d)
behavioral organization
Things to Think About
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5. Intervention must consider:
(a) Neuro-regulatory mechanisms
ANS/CNS reactivity
(b) Sensory Profiles
(c) Temperament Match or Mismatch
(d) Emotional Regulation Dynamics
- Reactivity and Rise Time
- Initial Intensity/Peak Intensity
- Child and parent’s range of emotions
- Lability of emotions
- Recovery from upset states
(e) Level of emotional competence
Psychotherapy with Young Children
Diagnosed with Bipolar Disorder
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1. See mother and child simultaneously.
2. Focus on the dyadic interaction and the “dance” between
parent and child.
3. Work on the rhythm, tempo, and pacing of the “dance.”
4. Work on spontaneous back-and-forth verbal and non-verbal
communication.
5. Make sure child understands mother’s communication.
6. Work on “matching” and “balancing” the interaction.
7. Help mother to “down-regulate” as child “up-regulates.”
8. Meet with parents to review taped therapy sessions.
9. Work with mother in adult therapy to help with grief and loss.
10.Work closely with parents and educational professionals in a
“tripartite” model.
Things to Think About
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7. Mood disorders derail a parent’s self-confidence and positive
feelings about being a parent.
a. Parents experience unpredictable traumatic experiences.
They are afraid to take their children outside and to places
typically populated by children and parents.
b. Because there are so few adults who understand the
illness, parents tend to feel alone and isolated.
c. Parents feel rage that they fear will come out when they
are with other family members and friends.
d. Parents feel fearful of their own safety as well as the safety
of the child. They are often needing to use control measures
that evoke feelings of shame and guilt.
Things to Think About
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6. Clinicians often do not recognize the “traumatic effect” of
mood disorders on the parent and siblings. Parents experience
an affective state that is similar to post-traumatic stress. They
are fearful of interactions. We need to work on the basics of
emotional interactions focusing on the “dancing dialogue” and
considering:
(a) the rhythm of the interaction- the way verbalizations and
actions are grouped together, e.g., the movements are smooth
and the back-and-forth interaction is even.
(b) the tempo of the interaction- e.g., fast vs. slow, overstimulating vs. under-stimulating.
(c) contour of the interaction- e.g. bursts of interaction,
sluggishness, attentiveness of parent, spacing, etc.
Why Is Early Intervention
Important?
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1. “Kindling” Effect
2. Severity- Modest episodes become more profound.
3. Frequency- Inter-episode periods become more abbreviated.
4. Autonomy- Cycling initially occurs after a stressor; they
subsequently develop spontaneously.
5. Tolerance- Previously effective therapies may not work.
6. Refractoriness- discontinuation of a previously effective
medication can lead to relapses that no longer respond to the previous
agent.
7. Ultradian fluctuations- Extreme rapidity of cycles can occur at
later stages, but may also be characteristic of the earliest forms.
8. Polypharmacy- Later in the course of the illness affective
episodes may not respond to a single medication.
Severe Mood Dysregulation:
Inclusion Criteria
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Inclusion Criteria
Aged 7-17, with the onset of symptoms before age 12;
Abnormal mood (specifically anger and sadness), preent at
least half the day most days, and of sufficient severity to be
noticeable by people in the child’s environment (e.g.,
parents, teachers, peers).
Hyper-arousal, as defined by at least three of the following
symptoms: insomnia,
agitation,
distractibility,
racing thoughts or flight of ideas,
pressured speech, intrusiveness.
Severe Mood Dysregulation:
Inclusion Criteria
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Compared to his/her peers, the child exhibits markedly increased reactivity to
negative emotional stimuli that is manifest either verbally or behaviorally. For
example, the child responds to frustration with extended temper tantrums
(inappropriate for age and/or precipitating event), verbal rages, and/or
aggression toward people or property. Such events occur, on average, at least
three times a week.
The symptoms above are currently present and have been present for at least
12 months without any symptom-free periods exceeding two months.
The symptoms are severe in at least one setting (i.e., violent outbursts,
assaultiveness at home, school, or with peers). In addition, there are at least
mild symptoms (distractibility, intrusiveness) in a second setting.
Severe Mood Dysregulation:
Exclusion Criteria
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The individual exhibits any of these cardinal bipolar
symptoms:
1. Elevated or expansive mood;
2. Grandiosity or inflated self-esteem;
3. Episodically decreased need for sleep.
The symptoms occur in distinct periods lasting more
than one day.
Meets criteria for substance use disorder in the past
three months;
IQ at or below 70;
The symptoms are due to the direct physiological
effects of a drug of abuse, or to a general medical or
neurological condition.