Archive for the ‘Childhood Bipolar and Mood Disorders’ Category

Most children with rapidly shifting moods and high energy have other mental disorders, not bipolar disorder, according to a NIMH-funded study published online ahead of print in the Journal of Clinical Psychiatry on October 5, 2010.

Background

Though some researchers feel that mania in children is exhibited when a child has rapid swings between emotions (usually anger, elation, and sadness) coupled with extremely high energy levels. But rapid mood swings and high energy are actually common in youth.

Overdiagnosis and misdiagnosis of bipolar disorder in youth seems to explain the increased numbers of children being diagnosed with and treated for bipolar disorder. In choosing proper treatment, it is important to know whether children with rapid mood swings and high energy have an early or mild form of bipolar disorder, or instead have a different mental disorder.

The Longitudinal Assessment of Manic Symptoms (LAMS) Study

• 707 children, ages 6-12, referred for mental health treatment.
• 621 participants were rated as having rapid swings between emotions and high energy levels, described as “elevated symptoms of mania” (ESM-positive).
• Parents of the other 86 children did not report rapid mood swings. These participants were deemed ESM-negative.

Study Results

• At baseline, all but 14 participants had at least one mental disorder, and many had two or more.
• Attention deficit hyperactivity disorder (ADHD) was the most frequent diagnosis, affecting roughly 76 percent in both the ESM-positive and ESM-negative groups. However, only 39 percent were receiving treatment with a stimulant, the most common medication treatment for ADHD, at the start of the study.
• Only 11 percent of those with rapid mood swings and high energy (69 out of 621) and 6 percent of those without these symptoms (5 out of 86) had bipolar disorder, meaning that only this small percentage had ever experienced a manic episode, as defined by the current diagnostic system.
• Of the children with rapid mood swings and high energy, another 12 percent (75 children) had a form of bipolar disorder that includes much shorter manic episodes.

Children with rapid mood swings and high energy:

• Reported more symptoms of depression, anxiety, manic symptoms, and symptoms of ADHD
• Had lower functioning at home, school, or with peers
• Were more likely to have a disruptive behavior disorder (oppositional defiant disorder and/or conduct disorder).

Important Points:

• 75 percent of ESM-positive youth did not meet the diagnostic criteria for any bipolar disorder.
• Thus, Bipolar disorder may not be common among children who experience rapid shifts in emotions and high energy levels.
• Children with rapid mood swings and high energy levels experience significant impairments due to mood and behavior problems.
• The researchers also noted that ESM-positive and ESM-negative youth were prescribed psychotropic medications—including antipsychotics—at similar rates. Further study may provide insight into how serious mental illnesses should be treated in children.

Study Follow up:

The study participants will be re-assessed every 6 months for up to 5 years, allowing the LAMS researchers to determine which children with rapid mood swings and high energy develop bipolar disorder later in life. This research may help identify predictors of the illness.

Findling RL, Youngstrom EA, Fristad MA, Birmaher B, Kowatch RA, Arnold E, Frazier TW, Axelson D, Ryan N, Demeter CA, Gill MK, Fields B, Depew J, Kennedy SM, Marsh L, Rowles BM, Horwitz SM. Characteristics of Children With Elevated Symptoms of Mania: The Longitudinal Assessment of Manic Symptoms (LAMS) Study. J Clin Psychiatr. Epub 2010 Oct 5.

Young men who attempt suicide before age 18 are much more likely as adults to be aggressive toward their girlfriends or wives, including hitting and injuring their partners.

The Study, published online in Psychological Medicine is based on data from 153 males from higher-crime neighborhoods who were assessed yearly from ages 10 to 32, and their romantic partners who participated when the men were ages 18 to 25.

This  new research highlights the need for intervention with suicidal teens: 58 percent of youth in that study group who attempted suicide went on to injure a partner, compared to 23 percent of young men who did not attempt suicide.

The study began when the men were kids, and before anyone had data to predict who would become violent. David Kerr of Oregon State University and Deborah Capaldi of the Eugene-based Oregon Social Learning Center, controlled for other problems suicidal youth can have which are also linked to violence to partner, such as aggression, depression, substance use, and family abuse history.

The researchers still found that young men who attempted suicide were more aggressive toward their partners.

The researchers had data from official domestic violence arrest records, women’s own reports of injury, and live observations of the couples.

In the past, domestic violence has been primarily attributed to cold, controlling and calculating individuals.

This study supports a growing body of research indicating that both men and women who are physically aggressive toward a partner have histories of aggressive and impulsive  behavior.

This study is important for prevention and treatment as well:

If a man is told that domestic violence is due to a need to coldness, a need to control, and systematic battering,  he may dismiss his difficulties, since this pattern doesn’t apply to him. If clinicians explain to men that their difficulties are related to the need to control anger and impulsive  reactions while under stress, they may be more aware that they are at risk, and better able to take responsibility for treatment.

Scientists  have used fMRI to help determine whether children have severe irritability and ADHD or a form of bipolar disorder. This technique appears to separate youth with bipolar disorder from those with chronic irritability.

Very irritable children with ADHD share some characteristics with children with bipolar disorder, but also have significant differences

• very irritable children with ADHD don’t have the distinct episodes of mania that one sees in classic bipolar disorder, and they don’t tend to have as much bipolar disorder in their family history
• very irritable children with ADHD and those with bipolar disorder
• both get frustrated more easily than children without these diagnoses
• shared deficits in social cognition: both have difficulty reading facial emotional cues

Data like these suggest that eventually psychiatric diagnosis will be based on brain mechanisms in addition to symptoms

Using MEG technology, some of the brain regions responsible for the difficulty that children with bipolar disorder have regulating their emotions when frustrated have been identified.

• the anterior cingulate, a region that directs attention to important signals in the environment, functions differently in children with bipolar disorder, compared with healthy children, when they are in frustrating situations.
• the anterior cingulate acts in concert with the prefrontal cortex, an area that organizes behavior — and here too the researchers found differences between the responses of patients and healthy children.

A similar study in children with severe irritability and ADHD is being conducted, to see once again if the brain mechanisms involved in frustration differ between this group and children with bipolar disorder.

CLAUDIA M. GOLD
Warning label on new diagnosis
By Claudia M. Gold  |  March 1, 2010, The Globe
 
I SAW 5-year-old Alex with his parents in my pediatric practice (details have been changed to protect privacy) for “explosive behavior and irritability.’’
 
One morning Alex’s father, Ben, called to Alex upstairs and asked if his younger sister could have some of his pancakes. There was a misunderstanding; Ben thought he said “yes’’ but Alex insisted he had said “maybe.’’ Alex came into the kitchen and found his sister eating his pancakes. He immediately began to scream, and threw her plate on the floor.
 
He hit his mother, Carla, who, overwhelmed with rage herself, grabbed him and carried him up the stairs to his room. There he attempted to kick the door down. After about 45 minutes, both Alex and Carla collapsed in tears of exhaustion and frustration. This type of scene occurred in their home several times a day.
 
I met with Ben and Carla alone, and they described Alex as a challenging baby from the start. Carla cried as she spoke of her own abusive father and her difficulty managing her anger. She decided to address these issues in her own therapy. Ben told of stresses in their marriage that they felt had resulted from having such a difficult child. Over time, as these issues were brought to light, Ben and Carla felt better equipped to help Alex contain and manage his frustration. Though the problems are far from resolved, a more positive pattern of interaction was set in place, and Alex’s development is on a healthier track.
 
I thought of this family while reading about the controversy swirling around the proposed new diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: temper dysregulation disorder with dysphoria (negative, unhappy mood). An 11-page justification for the addition of the new diagnosis, written by the Child and Adolescent Disorders Work Group, begins with reference to a 40-fold increase in the diagnosis of pediatric bipolar disorder since the mid-1990s. That statistic is, in my opinion, justification enough.
 
A new diagnosis could be a first step off of the path child psychiatry is now on. Use of antipsychotics, powerful drugs with serious side effects, for 2- to 5-year-olds has doubled in the past several years. While medication can be an important part of treatment for older children, a different way to think about “explosive’’ behavior that does not necessarily involve medication is urgently needed.
 
Problems with the new diagnosis abound. There is no guarantee that clinicians will be any less likely to prescribe antipsychotics for this disorder than for bipolar disorder. Though the intention is to view this disorder as biologically based, the authors of the justification report acknowledge that evidence for the biological basis of any psychiatric disorder is “very preliminary.’’ Insurance companies may not cover treatments other than medication.
 
Allen Frances, chair of the DSM-IV Task Force and a harsh critic of DSM-V, refers to the diagnosis as “a misguided medicalization of temper outbursts.’’
 
He worries that the diagnosis would be very common in the general population and promote a large expansion in the use of antipsychotic medication. I agree that this is a risk. Aggression and temper tantrums are a healthy normal part of development. It would be wrong to label children exhibiting these behaviors with a disorder.
 
But families like Alex’s are suffering. It is important to find a way within the DSM system to describe their experience without use of the bipolar label. The criteria for the diagnosis must clearly reflect the intensity, frequency, and disruptive nature of the problem.
 
I hope that this new diagnosis will open up discussion about the meaning of these children’s behavior. Use of the word “dysregulation’’ is an important first step. Extensive research at the interface of developmental psychology and neuroscience has demonstrated that young children learn to regulate emotions in the setting of relationships with their caregivers.
 
A child may be born with a genetic vulnerability for emotional dysregulation. Responsive parenting, however, may alter the actual expression of these genes, and even change the chemistry and structure of the brain.
 
Emotional “dysregulation’’ is an accurate description of Alex’s behavior. DSM-V is primarily a descriptive document that does not address cause. However, if clinicians treating this new disorder think about emotional regulation as a quality that is learned in relationships, it may open up a path to considering meaningful alternative interventions.
 
Dr. Claudia M. Gold is a pediatrician in Great Barrington.

Childhood Bipolar Disorder is not Bipolar? DSM-V and the new Temper Dysregulation Disorder with Dysphoria

Written by Nestor Lopez-Duran PhD on Wednesday, February 10.2010 from childpsych.org

Today the American Psychiatric Association released a draft of the major changes that are expected in the new version of the Diagnostic and Statistical Manual of Mental Disorder – 5th Edition (DSM-V). While most people in the field will be underwhelmed by the relatively minor changes,  there are a few areas where the DSM-V will likely make some drastic changes.  Today most of the news coverage was focused on the proposed changes to the Autism diagnosis, which has raised some heated debate in the autism community. However, there is another major change that has received little, if any, attention: the clarification that a syndrome that in recent years has been labeled childhood bipolar disorder is actually NOT bipolar disorder. Instead, a new disorder category was created: Temper Dysregulation Disorder with Dysphoria (TDD).

Let me start by explaining that the creation of TDD does NOT deny the existence of classic bipolar disorder in childhood. That is, although extremely rare, bipolar disorder can occur in children and adolescents, and it looks very much like adult bipolar.  Instead, TDD was created to capture a valid syndrome with characteristics and outcomes that are different than those of bipolar disorder. The available scientific data supports the position that the TDD syndrome is NOT simply the manifestation of bipolar disorder in childhood. This means that thousands of children that have been diagnosed with childhood bipolar disorder may not have bipolar and instead have a completely different syndrome now called Temper Dysregulation Disorder with Dysphoria.

So what is TDD?

Here is the proposed criteria for TDD:

A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.

1.  The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.

2.  The reaction is grossly out of proportion in intensity or duration to the situation or provocation.

3.  The responses are inconsistent with developmental level.

B. Frequency: The temper outbursts occur, on average, three or more times per week.

C. Mood between temper outbursts:

1.  Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).

2.  The negative mood is observable by others (e.g., parents, teachers, peers).

D. Duration: Criteria A-C have been present for at least 12 months.  Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.

E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.

F.  Chronological age is at least 6 years (or equivalent developmental level).

G. The onset is before age 10 years.

H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the “B” criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.

I.  The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.

The syndrome captured by section A-C (frequent and intense temper outbursts, happening several times per week in the context of negative emotionality) is the core of the symptoms that has been incorrectly interpreted as indicative of childhood bipolar disorder.  Section H is very interesting. It states that this diagnosis is not appropriate if the person has experienced classic mania (e.g., bnormally elevated or expansive mood), as in such a case the diagnosis of bipolar is likely more accurate.

So why did the DSM-V decide that this syndrome is not simply bipolar disorder of childhood?

1. Lack of continuity to bipolar.

If TDD is simply the expression of bipolar disorder during childhood, then children diagnosed with this condition would eventually develop symptoms of classic bipolar disorder as they reach adulthood. The data do not support this hypothesis. That is, children who display the TDD syndrome in childhood (and are often incorrectly diagnosed as bipolar) are not more likely to develop classic bipolar disorder later in life as their peers (see Brotman et al., 2006; Leibenluft et al, 2006; Stringaris et al, 2009).  Instead, these children are more likely to develop depression, not bipolar!

2. Different Biological Markets.

Youth who are diagnosed with classic bipolar differ significantly from those who have a TDD-like syndrome (see Brotman et al, 2010; Guyer et al, 2007; Rich et al, 2008).  If TDD is simply bipolar, then the biomarkers of TDD should be similar to those of bipolar, but this is not the case.

3. Different Demographic Factors.

If TDD is simply bipolar, then the gender distribution of TDD should be similar to that of bipolar. This does not appear to be the case. Specifically, there is no gender differences in the rate of classic bipolar; male and females are equally likely to develop the condition. However, the TDD-like syndrome is disproportionately observed in boys rather than girls.

4. A need for a new category that would impact treatment and research.

In theory, the presence of TDD will educate clinicians, researchers, and the public that this syndrome is not simply a version of bipolar disorder. This would facilitate research on the causes, features, and treatments for this condition. This has major implications for treatment. For example, the standard treatment for bipolar disorder does NOT seem to work in children that have the TDD syndrome (Dickstein et al, 2009). By explicitly stating that TDD is not bipolar, researchers would be less likely to approach the search for treatments from a “bipolar framework”, which would potentially facilitate the discovery of more effective interventions.

I am actually glad about this change as it will have a clear impact on clinical practice and research that will most likely benefit the children affected with this condition.

References:

Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, Egger HL, Angold A, Pine DS, & Leibenluft E (2006). Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biological psychiatry, 60 (9), 991-7 PMID: 17056393

Dickstein DP, Towbin KE, Van Der Veen JW, Rich BA, Brotman MA, Knopf L, Onelio L, Pine DS, Leibenluft E (2009): Randomized double-blind placebo-controlled trial of lithium in youth with severe mood dysregulation. J Child Adolesc Psychopharm 19: 61-73

Guyer AE, McClure EB, Adler AD, Brotman MA, Rich BA, Kimes AS, Pine DS, Ernst M, Leibenluft E (2007): Specificity of face emotion labeling deficits in childhood psychopathology. Journal of Child Psychiatry and Psychology, 48:863-71

Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS (2003): Defining clinical phenotypes of juvenile mania. Am J Psychiatry 160: 430-437

Rich BA, Grimley ME, Schmajuk M, Blair KS, Blair RJR, Leibenluft E (2008): Face emotion labeling deficits in children with bipolar disorder and severe mood dysregulation. Development and Psychopathology 20: 529-546

Stringaris A, Cohen P, Pine DS, Leibenluft E (2009): Adult outcomes of adolescent irritabilty: A 20-year community follow-up. Am J Psychiatry 166: 1048-54