Early Onset Bipolar DisorderEarly Onset Bipolar Disorderand the and the

Pediatric Behavior Rating Pediatric Behavior Rating ScaleScale™™ (PBRS (PBRS™™))

Children’s Mental HealthChildren’s 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% (America’s youth with mental health needs who fail to be identified and to receive treatment and services.)

6-8 years – from onset to treatment for mood disorders

CONSEQUENCES (of untreated mental disorders include suicide, addictions, school failure, and criminal involvement).

Information obtained from National Alliance on Mental Illness web site Aug. 2007

Society benefits when Mental Health is addressed early

DIAGNOSIS DU JOUR?DIAGNOSIS DU JOUR?1980’S ADHD

1990’S DEPRESSION

2000’S EOBPD

RATES OF DIAGNOSISRATES OF DIAGNOSIS4,000% increase in rate of EOBPD

diagnoses in the past 10 years (Frontline, 2008)

At present, over 1 million American children have an EOBPD diagnosis, and the number is steadily increasing (Frontline, 2008)

PROBLEMS IDENTIFYING PROBLEMS IDENTIFYING BPD IN CHILDRENBPD IN CHILDREN

EOBPD is not in DSM IV.

EOPBD looks like other disorders.

EOBPD has high rates of comorbidity.

PROBLEM 1: EOBPD PROBLEM 1: EOBPD isn’t in DSM IVisn’t in DSM IV

BIPOLAR DISORDERS•Bipolar l Disorder

•Mania and major depression•Bipolar ll Disorder

•Hypomania & major depression•Cyclothymic Disorder

•Hypomania & depression/dysthymia

EOBPD vs. Adult BPDEOBPD vs. Adult BPD

(Birmaher et al, 2008; Danielyan et al, 2007; Kowatch et al, 2005)

EOBPD Adult BPDMixed Mood Episodes are typical

Discrete Mood Episodes are typical

Ultra-Rapid Cycling is common

Longer cycles

Symptomatic most of the time

Periods of no symptoms between cycles

PROBLEM 1: EOBPD PROBLEM 1: EOBPD isn’t in DSM IVisn’t in DSM IV

Bipolar Disorder-Not Otherwise Specified◦Rapid alternation between manic and

depressive symptoms that do not meet the duration criteria for manic, hypomanic, or major depression

◦Hypomanic without depression◦Infrequent episodes

PROBLEM 2: EOBPD mimics PROBLEM 2: EOBPD mimics other disordersother disorders

Disruptive 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, decreased need for sleep, hypersexuality

PROBLEM 2: EOBPD mimics PROBLEM 2: EOBPD mimics other disordersother disorders

ODD77-88% have ODD (Wozniak et. al, 1995)

More intense irritability and severe emotional meltdowns

CD42-69% have CD (Biederman, et. al, 2003)

Violent and aggressive behavior lacks intent, planning, and premeditation

PROBLEM 2: EOBPD mimics PROBLEM 2: EOBPD mimics other disordersother disorders

Anxiety Disorders56-75% have anxiety disorder (Wozniak et. al, 1995;

Masi, et. al, 2001)

Tourette’s Disorder, Schizophrenia, Autism Spectrum Disorder

WHAT WE KNOW:WHAT WE KNOW:SYMPTOMS ASSOCIATED with SYMPTOMS ASSOCIATED with

EOBPDEOBPD Inflexible Oppositional Irritable Explosive rages Erratic sleep Difficult to soothe Separation anxiety Night terrors Fear of death and

annihilation Rapid cycling

Precociousness Sensitivity to stimuli Problems with peers Temperature

dysregulation Craving for carbs. and

sweets Bedwetting and soiling Hypersexuality Hallucinations Suicidal ideation

Frequency of EOBPD Frequency of EOBPD SymptomsSymptoms

Very Often(90%-97%)

Often(60%-80%)

Sometimes(20%-35%)

Infrequent(Less than

10%)Irritability Anxiety Hypersexuality Homicidal IdeasMood Lability Racing

ThoughtsPsychosis Suicidal Acts

Sleep Disorder Pressured Spch Suicidal IdeationAnger; Rage Euphoria,

GrandiositySelf-harm

ImpulsivityAgitationAggressionFrom: Faedda & Austin, 2006

Parenting a bipolar child p. 39.

PsychosisPsychosisTillman et al (2008), 257 EOBPD participants, ages

6-16, funded by NIMHPsychosis was present in 76.3% of subjects

◦38.9% with delusions Grandiose was most common

◦5.1% with pathological hallucinations Visual hallucinations were most common

◦32.3% with both

DEVIANCEDEVIANCEVOLUNTARY - we have a tendency

to attribute misbehavior—especially noncompliance and disobedience--to willful disobedience.

INVOLUNTARY - we tend to minimize this even when it explains the child’s behavior.

EOBPD and AROUSAL EOBPD and AROUSAL

Children with EOBPD are less able to modulate arousal live in fear are “on alert” for danger are primed for “fight/flight” response

And when aroused, aggression is more likely.

WHAT KIND OF WHAT KIND OF AGGRESSION IS BEING AGGRESSION IS BEING

EXPRESSED?EXPRESSED?

Predatory-controlled (instrumental)

Defensive-impulsive, reactive (not for gain)

CHARACTERISTIC DIAGNOSIS AGGRESSION TYPE

Impulse Control ADHD Accidents/ Injuries

Emotional Instability Bipolar, Borderline, IED

Reactive, affective attack

Irritability Depression, Dysthymia

Acting Out, Suicide

Anxiety/Low Frustration Tolerance

Anxiety, PTSD, ASD Reactive striking out

Impaired Judgment Substance Abuse, Psychosis

Inadvertent Aggression

Stimulation Seeking CD, ODD Predatory Aggression

REACTIONARY and CONFRONTATIONAL REACTIONARY and CONFRONTATIONAL approaches serve mainly to provoke and approaches serve mainly to provoke and

escalate.escalate.

GOALS OF GOALS OF INTERVENTIONSINTERVENTIONS

StabilizeReduce Symptoms

OppositionDefianceIrritabilityAggression

Improve Functioning (academic, social)

TWO WAYS TO ACHIEVE TWO WAYS TO ACHIEVE THESE GOALSTHESE GOALS

Medications (to make the child “available”)

Psychotherapies (coping & managing)

General Rule for InterventionsGeneral Rule for InterventionsBehavioral approaches tend to focus on

consequences.

There are two problems with this…

TWO PROBLEMSTWO PROBLEMS

1. By definition, children and adolescents with deficits in impulse control and self- regulation do not consider consequences before they act.

2. Behavioral consequences (especially if they are aversive) introduce provocation, confrontation…and escalation.

INTERVENTION TARGETSINTERVENTION TARGETSCHILD

medicationssleepself-regulation

PARENTSpsychoeducation medication compliance

ENVIRONMENT (control the pace)homeschool

DRUG TREATMENTS EOBPDDRUG TREATMENTS EOBPD

FOUR MAJOR CLASSES of MOOD STABILIZERS

LithiumAntiepileptics (Mood Stabilizers)AntidepressantsAntipsychotics

CHARACTERISTIC DIAGNOSIS AGGRESSION TYPE

MEDICATION

Impulse Control ADHD Accidents/ Injuries

STIMULANTSSSRI

ANTIPSYCHOTICMOOD STABILIZERS

Affective Instability

Bipolar, Borderline, IED

Reactive, affective attack

ANTISPYCHOTICSMOOD STABILIZERS

SSRI

Irritability Depression, Dysthymia

Acting Out, Suicide

SSRIOTHER

ANTIDEPRESSANTSAnxiety/Low Frustration Tolerance

Anxiety, PTSD, ASD

Reactive striking out

OTHER ANTIDPERESSANTS

SSRITENEX

CLONODINEImpaired Judgment Substance Abuse,

PsychosisInadvertent Aggression

ANTIPSYCHOTICS

Stimulation Seeking

CD, ODD Predatory Aggression

MOOD STABILIZER

NONDRUG INTERVENTIONSNONDRUG INTERVENTIONSTHERE ARE 550 PSYCHOTHERAPIES (NONMEDICAL INTERVENTIONS) FOR TREATING CHILDREN AND ADULTS

BEYOND BEHAVIORISMBEYOND BEHAVIORISM

Parent Management TrainingCognitive Behavioral TherapyDialectal Behavior TherapyChoice TheoryProblem-Solving SkillsHealth Promoting Environments

CHARACT-ERISTIC

DIAGNOSIS AGGRESSION TYPE PSYCHOTHERAPY

Impulse Control

ADHD Accidents/ Injuries CBT; DBTPROBLEM-SOLVING

Parent Training

Affective Instability

Bipolar, Borderline, IED

Reactive, affective attack

CBT; DBTPROBLEM-SOLVING

Parent Training

Irritability

Depression, Dysthymia

Acting Out, Suicide CBT

Anxiety/Low

Frustration

Tolerance

Anxiety, PTSD, ASD Reactive striking out CBT; DBTPROBLEM-SOLVING

Parent Training

Impaired Judgment

Substance Abuse, Psychosis

Inadvertent Aggression

Cognitive Enhancement Therapy

Stimulation Seeking

CD, ODD Predatory Aggression Parent Training

PSYCHOEDUCATIONPSYCHOEDUCATION•The Bipolar Child (3rd Edition) by Papolos and Papolos (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 (2008)•www.bpchildren.com•www.bipolarhelpcenter.com•www.bipolarkids.org•www.cabf.org•www.jbrf.org/juv_bipolar/faq.html

80 - 90%

10 - 15%

1 - 5%

Three-Tier Model of Behavioral Intervention/Support

Tier III: Intensive, Individual Interventions

Tier II: Targeted Group Interventions

Tier I: Universal Interventions/Supports

80 - 90%

10-15%

1-5%

Tier III: Individual InterventionsTier III: Individual Interventions

Goal: To develop and implement interventions for student behaviors that can not be addressed or remedied via Tier I or Tier II interventions.

FUNCTIONAL ASSESSMENTFUNCTIONAL ASSESSMENT

Modified from: Santilli, Nancy, Dodson, W.E., Walton, A.V. (1991)

INTERVENTIONS FOR SIMPLEINTERVENTIONS FOR SIMPLE Monopharmacy Mildly intrusive therapy individual therapygroup therapyparent training

Regular classroom placement Favorable RTI

INTERVENTIONS FOR COMPROMISEDINTERVENTIONS FOR COMPROMISED

Polypharmacy (aggression, irritability, co-morbidity)

Intensive child and family therapiesindividual therapygroup therapyfamily therapy/parent training

May require Spec. Ed. (EH, SED, OHI) Variable RTI

INTERVENTIONS FOR COMPLEXINTERVENTIONS FOR COMPLEX Polypharmacy Intensive Interventions

individual therapyintensive parent trainingalternative educational placements

Acute hospitalizationSelf-contained to RTCLaw Enforcement

Very poor prognosis

Predictors of OutcomePredictors of OutcomeWorse outcomes are associated with:

◦Younger age of onset◦Long duration of mood symptoms◦Low socioeconomic status◦Lifetime psychosis

(Birmaher et al, 2006)

PEDIATRIC BEHAVIOR PEDIATRIC BEHAVIOR RATING SCALERATING SCALE

WHY A NEW RATING SCALE?WHY A NEW RATING SCALE?

• Existing scales came out normal

• Item analysis told us why

• The need for differential diagnosis

OTHER SCALESOTHER SCALES• Young Mania Rating Scale–Parent 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 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])

PURPOSEPURPOSE• For children and adolescents ages 3-18 years

• Primary function: To assist 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 interventions

FEATURESFEATURES• Sufficient items to identify core features of EOBPD, such as:

Mood swingsIrritabilityGrandiosityEasily provokedExplosive outbursts

• Syndromal differentiation (e.g., ADHD vs. EOBPD)• Identifies areas of concern rather than providing diagnoses

PBRS APPLICATIONS PBRS APPLICATIONS • Clinical

Distinguish between EOBPD and its mimicsSymptom identification and profile analysisAreas of concern

• EducationalClarify diagnosis using IDEAMore complete symptom profile (intervention)

• ResearchDefining the disorder in childrenHandling comorbidityIntervention efficacy

COMPONENTSCOMPONENTS• Parent Form

PBRS Parent Item Booklet (102 items)PBRS Parent Response BookletPBRS Parent Score Summary/Profile Form

• Teacher FormPBRS Teacher Item Booklet (95 items)PBRS Teacher Response BookletPBRS Teacher Score Summary/Profile Form

SCORES PRODUCEDSCORES PRODUCED• Inconsistency Score

Can I trust the responses?• Critical Items

No matter what, these are clinically important• Symptom Scales

Each is important, as is the profile• Total Bipolar Index

Composite of all 8 symptom scales

CRITICAL ITEMSCRITICAL 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-abuse•Hallucinations•Bizarre beliefs•Expresses violent themes•Suicidal thoughts•Aggression

SYMPTOM SCALESSYMPTOM 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)• Inattention (as in ADHD)• Affect (mood disturbances, cognitive distortion)• Social Interactions (interacting with peers)• Total Bipolar Index

Atypical (ATY) ScaleAtypical (ATY) ScaleBizarre beliefsAuditory hallucinationsDelusionsSelf-harm behaviorsExcessive fears

Irritability (IRR) ScaleIrritability (IRR) ScaleEmotional dysregulationBehavioral/emotional outburstsDemandingness

Grandiosity (GRAND) ScaleGrandiosity (GRAND) ScaleElevated sense of self and moodNot taking responsibility for actionsExaggeratingStealing

Hyperactivity/Impulsivity (HYPER) ScaleHyperactivity/Impulsivity (HYPER) Scale

Classic description of overactivity and impulsivity

Difficulty sitting stillActs without thinking about consequencesAlways on the go

Aggression (AGG) ScaleAggression (AGG) ScaleAggression targeting other people, animals, or

objects

Inattention (INATT) ScaleInattention (INATT) ScaleTraditional scale for inattention and

distractibilityDifficulty focusingDifficulty sustaining attention

Affect (AFF) ScaleAffect (AFF) ScaleMood disturbancesSuicidal ideationCognitive distortions

Social Interactions (SOC) ScaleSocial Interactions (SOC) ScaleAbility to interact with peersAbility to make friendsRelating to othersEngaging in social interactions

TOTAL BIPOLAR INDEXTOTAL 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; T scores >80 suggest EOBPD

• The most effective way to differentiate EOBPD from other diagnoses (especially ADHD)

POPULATIONPOPULATION• Normative sample

Parents n = 541Teachers n = 610

• Clinical sample (clinical groups included BPD, ADHD, CD, ODD, and autism spectrum disorders [ASD])

Parents n = 224Teachers n = 194

RELIABILITYRELIABILITYInternal consistency• Coefficient α for PBRS-P = .60 to .89• Coefficient α for PBRS-T = .75 to .93

• Coefficient α for PBRS-P TBX = .95• Coefficient α for PBRS-T TBX = .97

RELIABILITYRELIABILITY• Parent-teacher interrater reliability

Coefficient α = .77 to .86Coefficient α for TBX = .88

• Parent-parent interrater reliability

Coefficient α = .67 to .86Coefficient α for TBX = .85

VALIDITYVALIDITYConvergent 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

VALIDITYVALIDITYConvergent validity: Domain-specific rating scales•PBRS-P with CMRS = .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 scales•PBRS-T with Conners’ Teacher Rating Scales (CTRS) = .16 (Cognitive Problems/Inattention with Atypical) to .69 (Hyperactivity with Hyperactivity/Impulsivity)

VALIDITYVALIDITYClinical validity•Normative 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).