bipolar disorder in children and adolescents james h. johnson, phd, university of florida *some...

Bipolar Disorder in Children Bipolar Disorder in Children and Adolescentsand Adolescents

James H. Johnson, PhD, James H. Johnson, PhD, University of FloridaUniversity of Florida

*Some material for this presentation provided by NIMH Publication No. 00-4778 (2003)*Some material for this presentation provided by NIMH Publication No. 00-4778 (2003)

Bipolar Disorder: General IntroductionBipolar Disorder: General Introduction

Bipolar disorder is a Bipolar disorder is a biologically basedbiologically based disorder disorder that causes unusual shifts in a person's that causes unusual shifts in a person's moodmood, , energyenergy, and impairs their , and impairs their ability to functionability to function..It causes dramatic It causes dramatic mood swingsmood swings - from overly - from overly "high" "high" and/orand/or irritable mood to sad and hopeless irritable mood to sad and hopeless mood, and then back again.mood, and then back again.In older adolescents and adults there are often In older adolescents and adults there are often periods of normal moodperiods of normal mood in between. in between.These mood related changes are accompanied by These mood related changes are accompanied by severe changes in energy and behavior.severe changes in energy and behavior.The periods of highs and lows are called The periods of highs and lows are called episodesepisodes of of maniamania and and depressiondepression..

Symptoms of Bipolar Disorder: Symptoms of Bipolar Disorder: Mania or Manic EpisodeMania or Manic Episode

Increased energy, activity, and restlessness Increased energy, activity, and restlessness

Excessively "high,“ euphoric mood Excessively "high,“ euphoric mood

Extreme irritability Extreme irritability

Racing thoughts, talking very fast, jumping from Racing thoughts, talking very fast, jumping from one idea to another one idea to another

Distractibility, inability to concentrate Distractibility, inability to concentrate

Decreased need for sleep Decreased need for sleep

Unrealistic beliefs in one's abilities and powers Unrealistic beliefs in one's abilities and powers

Symptoms of Bipolar Disorder: Symptoms of Bipolar Disorder: Manic EpisodeManic Episode

Poor judgment Poor judgment Spending sprees Spending sprees Increased sexual drive Increased sexual drive Abuse of drugs, particularly cocaine, alcohol, and Abuse of drugs, particularly cocaine, alcohol, and sleeping medications sleeping medications Provocative, intrusive, or aggressive behavior Provocative, intrusive, or aggressive behavior Denial that anything is wrong Denial that anything is wrong A manic episode is diagnosed A manic episode is diagnosed if elevated mood if elevated mood occurs with three occurs with three or more of the other symptoms most of the day, nearly every day, or more of the other symptoms most of the day, nearly every day, for 1 week or longer. for 1 week or longer. If the mood is irritableIf the mood is irritable, four additional , four additional symptoms must be present.symptoms must be present.

Symptoms of Bipolar Disorder: Symptoms of Bipolar Disorder: HypomaniaHypomania

A mild to moderate level of mania is called A mild to moderate level of mania is called ““hypomania”hypomania”. .

Hypomania may feel good to the person who Hypomania may feel good to the person who experiences it and may be associated with good experiences it and may be associated with good functioning and enhanced productivity. functioning and enhanced productivity.

Without proper treatment, however, hypomania Without proper treatment, however, hypomania can become more severe in some people or can can become more severe in some people or can switch into depression.switch into depression.

Symptoms of Bipolar Disorder:Symptoms of Bipolar Disorder:Depressive EpisodeDepressive Episode

Sad, anxious, or empty mood Sad, anxious, or empty mood Feelings of hopelessness or pessimism Feelings of hopelessness or pessimism Feelings of guilt, worthlessness, or helplessness Feelings of guilt, worthlessness, or helplessness Loss of interest or pleasure in activities once Loss of interest or pleasure in activities once enjoyed, including sex enjoyed, including sex Decreased energy, a feeling of fatigue or of Decreased energy, a feeling of fatigue or of being "slowed down" being "slowed down" Difficulty concentrating, remembering, making Difficulty concentrating, remembering, making decisions decisions Restlessness or irritability Restlessness or irritability

Symptoms of Bipolar Disorder:Symptoms of Bipolar Disorder:Depressive EpisodeDepressive Episode

Sleeping too much, or can't sleep Sleeping too much, or can't sleep

Change in appetite and/or unintended weight Change in appetite and/or unintended weight loss or gain loss or gain

Chronic pain or other persistent bodily Chronic pain or other persistent bodily symptoms that are not caused by physical symptoms that are not caused by physical illness or injury illness or injury

Thoughts of death or suicide, or suicide attempts Thoughts of death or suicide, or suicide attempts A depressive episode is diagnosed if A depressive episode is diagnosed if five or more five or more of these of these symptoms last most of the day, nearly every day, for a period of 2 symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.weeks or longer.

Mood Swings & Symptoms of Mood Swings & Symptoms of PsychosisPsychosis

Severe episodes of mania or depression can include Severe episodes of mania or depression can include symptoms of symptoms of psychosispsychosis (or psychotic symptoms). (or psychotic symptoms). Common psychotic symptoms are Common psychotic symptoms are hallucinationshallucinations and and delusionsdelusions. . Psychotic symptoms in bipolar disorder tend to reflect Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time (the extreme mood state at the time (are mood are mood congruent.congruent.People with bipolar disorder who have these People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as symptoms are sometimes incorrectly diagnosed as having schizophrenia. having schizophrenia.

Bipolar Disorder and SuicideBipolar Disorder and Suicide

Bipolar disorder can result in an increased Bipolar disorder can result in an increased risk of suicide.risk of suicide.

This increased risk seems to be higher This increased risk seems to be higher earlier in the course of the illness.earlier in the course of the illness.

Recognizing bipolar disorder early and Recognizing bipolar disorder early and learning how best to manage it may learning how best to manage it may decrease the suicidal risk.decrease the suicidal risk.

Suggestions of Suicidal RiskSuggestions of Suicidal Risktalking about feeling suicidal or wanting to die talking about feeling suicidal or wanting to die feeling hopeless - nothing will ever change or get feeling hopeless - nothing will ever change or get better better feeling helpless - nothing I do makes any difference feeling helpless - nothing I do makes any difference feeling like a burden to family and friends feeling like a burden to family and friends alcohol or drug abuse alcohol or drug abuse putting affairs in order or giving away possessions to putting affairs in order or giving away possessions to prepare for one's death prepare for one's death suicide note suicide note putting oneself in situations where there is a danger of putting oneself in situations where there is a danger of being killed being killed

Bipolar Spectrum DisordersBipolar Spectrum Disorders

It may be helpful to think of the various mood It may be helpful to think of the various mood states in bipolar disorder as a states in bipolar disorder as a spectrumspectrum or or continuous range.continuous range.At one end is At one end is severe depressionsevere depression, above which is , above which is moderate depression moderate depression and then and then mild low moodmild low mood..This mild low mood is often short-lived (it is This mild low mood is often short-lived (it is termed "termed "dysthymiadysthymia" " when it is chronic.when it is chronic.Then there is normal or Then there is normal or balanced moodbalanced mood, above , above which which comes hypomania comes hypomania (mild to moderate (mild to moderate mania), and then mania), and then severe maniasevere mania..

BipolarBipolar Spectrum DisordersSpectrum Disorders

Bipolar Disorder: Mixed StatesBipolar Disorder: Mixed States

Symptoms of mania and depression may occur Symptoms of mania and depression may occur together in what is called a together in what is called a mixedmixed state state..

Symptoms of a mixed state often include Symptoms of a mixed state often include agitation, trouble sleeping, significant change in agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking.appetite, psychosis, and suicidal thinking.

This may be accompanied by a sad, hopeless This may be accompanied by a sad, hopeless mood while feeling extremely energized.mood while feeling extremely energized.

Diagnosis of Bipolar Disorder Diagnosis of Bipolar Disorder SubtypesSubtypes

The classic form of the disorder involves The classic form of the disorder involves recurrent recurrent episodes of episodes of bothboth mania and depression mania and depression (Bipolar I).(Bipolar I).In some cases the person never develops severe In some cases the person never develops severe mania, but experiences mania, but experiences milder episodes of milder episodes of hypomaniahypomania that alternate with depression that alternate with depression (Bipolar II).(Bipolar II).When four or more episodes of illness occur within a When four or more episodes of illness occur within a 12-month period, a person is said to have 12-month period, a person is said to have rapid-rapid-cycling bipolar disordercycling bipolar disorder..Some people experience multiple episodes within a Some people experience multiple episodes within a single week, or even within a single daysingle week, or even within a single day..Rapid cycling tends to develop later in the course of Rapid cycling tends to develop later in the course of illness and is more common among women than illness and is more common among women than among men.among men.

Child/Adolescent Bipolar DisorderChild/Adolescent Bipolar DisorderUntil recently, the diagnosis of Bipolar Until recently, the diagnosis of Bipolar Disorder was viewed as only appropriate Disorder was viewed as only appropriate for adults.for adults.Indeed, few clinicians would have even Indeed, few clinicians would have even considered using this diagnostic category considered using this diagnostic category with children.with children.Despite continuing controversy, it is Despite continuing controversy, it is increasingly common to find clinicians increasingly common to find clinicians using this diagnosis with children using this diagnosis with children displaying certain types of symptoms. displaying certain types of symptoms.

Child/Adolescent Bipolar DisorderChild/Adolescent Bipolar DisorderIt is now believed that It is now believed that symptoms symptoms of bipolar of bipolar disorder can emerge in early childhood.disorder can emerge in early childhood.Mothers often report that children, later Mothers often report that children, later diagnosed with early-onset bipolar disorder, diagnosed with early-onset bipolar disorder, were extremely were extremely difficult to soothe difficult to soothe and and slept slept erraticallyerratically..They seemed extraordinarily They seemed extraordinarily clingyclingy and, from and, from a very young age, often displayed a very young age, often displayed uncontrollable, seizure-like tantrums uncontrollable, seizure-like tantrums or or rages rages out of proportion to any eventout of proportion to any event..These severe tantrums often appear to be These severe tantrums often appear to be without provocation.without provocation.

Frequency of Child Bipolar DisorderFrequency of Child Bipolar Disorder

Prevalence is largely unknown as there are no well Prevalence is largely unknown as there are no well accepted criteria for the diagnosis of Child Bipolar accepted criteria for the diagnosis of Child Bipolar disorder.disorder.This is because DSM IV criteria are generally This is because DSM IV criteria are generally viewed as inadequate for use with younger viewed as inadequate for use with younger children.children.The best guess is that the disorder occurs at least The best guess is that the disorder occurs at least as often as adult bipolar disorder (e.g., as often as adult bipolar disorder (e.g., about 1%) about 1%) However, many believe that this disorder is However, many believe that this disorder is significantly under diagnosed in children.significantly under diagnosed in children.

Frequency of Child Bipolar DisorderFrequency of Child Bipolar Disorder

It is It is suspectedsuspected that a significant number of that a significant number of children diagnosed with ADHD at an early age children diagnosed with ADHD at an early age actually have early-onset bipolar disorder instead actually have early-onset bipolar disorder instead of (or along with) ADHD. of (or along with) ADHD.

According to the American Academy of Child and According to the American Academy of Child and Adolescent Psychiatry, Adolescent Psychiatry, up to one-third of children up to one-third of children and adolescents with depressive disorders may and adolescents with depressive disorders may actually have early onset of bipolar disorderactually have early onset of bipolar disorder. .

20 to 40 % of adults with Bipolar Disorder report 20 to 40 % of adults with Bipolar Disorder report a childhood onset of symptoms.a childhood onset of symptoms.

Child/Adolescent Bipolar Disorder:Child/Adolescent Bipolar Disorder: Clinical Presentation Clinical Presentation

As with adults, Bipolar disorder in children is As with adults, Bipolar disorder in children is viewed a serious mental disorderviewed a serious mental disorder

Characterized by recurrent episodes of Characterized by recurrent episodes of depressiondepression, , maniamania, and/or , and/or mixed symptom mixed symptom statesstates..

Some evidence suggests that child bipolar Some evidence suggests that child bipolar disorder disorder may be a different and possibly more may be a different and possibly more severe form of the illnesssevere form of the illness than older adolescent than older adolescent and adult-onset bipolar disorder. and adult-onset bipolar disorder.


While older adolescents often have a clinical While older adolescents often have a clinical presentation that is somewhat similar to that presentation that is somewhat similar to that seen with adults.seen with adults.

The clinical presentation of early-onset bipolar The clinical presentation of early-onset bipolar disorder in children can look quite different than disorder in children can look quite different than that seen in older individualsthat seen in older individuals..

Clinicians may fail to diagnose this disorder Clinicians may fail to diagnose this disorder when using DSM IV criteria for the diagnosis of when using DSM IV criteria for the diagnosis of this condition.this condition.


Most cases of child bipolar disorder do Most cases of child bipolar disorder do not present with the sudden or acute not present with the sudden or acute onset often found with adults.onset often found with adults.

Most do not show the improvement Most do not show the improvement between episodes, often found with adult between episodes, often found with adult bipolar disorder.bipolar disorder.

With children the symptom onset may be With children the symptom onset may be more more insidiousinsidious..


With children,With children,– initial symptoms of the disorder can be depressive in initial symptoms of the disorder can be depressive in

nature nature With these being confused with and treated as MDD.With these being confused with and treated as MDD.

– In other cases, ADHD like symptoms appear firstIn other cases, ADHD like symptoms appear firstwith these symptoms being followed later by a full manic with these symptoms being followed later by a full manic episode.episode.

Unlike adults - children in a manic state are Unlike adults - children in a manic state are more likely to be more likely to be irritableirritable and prone to and prone to destructivedestructive outburstsoutbursts than to be elated or than to be elated or euphoric. euphoric.


Children, more often showChildren, more often show– rapid cyclingrapid cycling and and mixed statesmixed states rather than clear rather than clear

manic or clear depressive episodes, andmanic or clear depressive episodes, and– an “an “ongoing and continuous mood disturbance ongoing and continuous mood disturbance that that

is a mix of mania (or hypomania) and depression”.is a mix of mania (or hypomania) and depression”.

The rapid and severe cycling between moods The rapid and severe cycling between moods produces produces chronic irritabilitychronic irritability and few clear and few clear periods of wellness between episodesperiods of wellness between episodes..


Depression and dysphoria Depression and dysphoria are an almost constant part are an almost constant part of pediatric bipolar disorder.of pediatric bipolar disorder.As noted earlier, As noted earlier, hyperactivityhyperactivity is often the first is often the first manifestation of early-onset bipolar disorder.manifestation of early-onset bipolar disorder.When children are initially seen because of bipolar When children are initially seen because of bipolar symptoms, symptoms, – approximately 90% of early-onset, andapproximately 90% of early-onset, and– 30 % of adolescents with bipolar disorder meet criteria for a 30 % of adolescents with bipolar disorder meet criteria for a

diagnosis of ADHD.diagnosis of ADHD.

Comorbid conduct disorder is also quite common.Comorbid conduct disorder is also quite common.

Bipolar Disorder vs. ADHDBipolar Disorder vs. ADHD

Bipolar Disorder Bipolar Disorder (Mania)(Mania)

1.1. More talkative than More talkative than usual, or pressure to usual, or pressure to keep talkingkeep talking

2.2. DistractibilityDistractibility

3.3. Increase in goal Increase in goal directed activity or directed activity or psychomotor agitationpsychomotor agitation

ADHDADHD1.1. Often talks Often talks

excessivelyexcessively

2.2. Is often easily Is often easily distracted by distracted by extraneous stimuliextraneous stimuli

3.3. Is often “on the go” or Is often “on the go” or often acts as if “driven often acts as if “driven by a motor”by a motor”

Differentiation: Elated mood, Grandiosity, Decreased need for sleep, Hypersexuality, and

Irritable mood. Hart (2005)Hart (2005)

Child Bipolar Disorder: ComorbidityChild Bipolar Disorder: Comorbidity

Attention Deficit Hyperactivity Disorder Attention Deficit Hyperactivity Disorder (ADHD)(ADHD)– Between 60 - 80% display symptomsBetween 60 - 80% display symptoms

Oppositional Defiant Disorder (ODD) & Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD)Conduct Disorder (CD)– 70 - 75%70 - 75%

Substance Abuse (adolescents)Substance Abuse (adolescents)– 40 - 50%40 - 50%

Anxiety DisordersAnxiety Disorders– 35- 40%35- 40%

Child Bipolar Disorder: GeneticsChild Bipolar Disorder: Genetics

Bipolar Disorder has a heavy genetic Bipolar Disorder has a heavy genetic loadingloading

In the general population, a conservative In the general population, a conservative estimate of an individual's risk of bipolar estimate of an individual's risk of bipolar disorder is about 1.2 %.disorder is about 1.2 %.

More than two-thirds of those with bipolar More than two-thirds of those with bipolar disorder have at least one close relative disorder have at least one close relative with the disorder with the disorder oror with unipolar major with unipolar major depression depression

Child Bipolar Disorder: GeneticsChild Bipolar Disorder: GeneticsWhen one parent has bipolar disorder, the risk When one parent has bipolar disorder, the risk to each child is about 15 – 30 %to each child is about 15 – 30 %

When both parents have bipolar disorder, the When both parents have bipolar disorder, the risk increases to 50 – 75 %risk increases to 50 – 75 %

The risk to siblings and fraternal twins is 15 – 27 The risk to siblings and fraternal twins is 15 – 27 %%

The risk in identical twins is approximately 70 %The risk in identical twins is approximately 70 %

Note. Despite these figures only about 5% of Note. Despite these figures only about 5% of children with a parent with Bipolar disorder children with a parent with Bipolar disorder would be expected to develop the disorder would be expected to develop the disorder in in childhoodchildhood..

Etiology :What is Inherited?Etiology :What is Inherited?

A significant question is What is Inherited??A significant question is What is Inherited??The answer is not entirely clear, but …The answer is not entirely clear, but …

– It's believed this condition is caused by an It's believed this condition is caused by an imbalance in imbalance in neurotransmittersneurotransmitters. .

– a a lowlow or or highhigh level of a specific neurotransmitter such level of a specific neurotransmitter such as serotonin, norepinephrine or dopamine is the likely as serotonin, norepinephrine or dopamine is the likely cause. cause.

– Others have suggested that it is an Others have suggested that it is an imbalanceimbalance of these of these substances that may be the problemsubstances that may be the problem

– Here, a specific level of a neurotransmitter may not as Here, a specific level of a neurotransmitter may not as important as its amount in relation to the other important as its amount in relation to the other neurotransmitters.neurotransmitters.

– Still other studies have found evidence that a change in Still other studies have found evidence that a change in the the sensitivity of the receptorssensitivity of the receptors may be the issue. may be the issue.

– It seems likely that the neurotransmitter system is at It seems likely that the neurotransmitter system is at least part of the cause of bipolar disorder, but further least part of the cause of bipolar disorder, but further research is still needed to define its exact roleresearch is still needed to define its exact role..

Etiology of Bipolar DisorderEtiology of Bipolar DisorderEnvironmental FactorsEnvironmental Factors

That more than hereditary is involved in Bipolar That more than hereditary is involved in Bipolar Disorder is indicated by the fact that in studies Disorder is indicated by the fact that in studies involving identical twins, raised in the same home, involving identical twins, raised in the same home, one twin sometimes develops bipolar disorder one twin sometimes develops bipolar disorder while one does not .while one does not .Here it is suggested that environmental factors Here it is suggested that environmental factors may play a role in bipolar disorder.may play a role in bipolar disorder.For some, stresses such as a death in the family, For some, stresses such as a death in the family, divorce, or other traumatic events seem to trigger divorce, or other traumatic events seem to trigger a first episode of mania or depression.a first episode of mania or depression.

Etiology of Bipolar DisorderEtiology of Bipolar DisorderEnvironmental FactorsEnvironmental Factors

PubertyPuberty may trigger the disorder in adolescent may trigger the disorder in adolescent females.females.Stressful life events Stressful life events can lead to the onsetcan lead to the onset– Once the disorder is triggered and progresses, it seems to Once the disorder is triggered and progresses, it seems to

develop a life of its own.develop a life of its own.– Once the cycle begins, a psychological or pathophysiological Once the cycle begins, a psychological or pathophysiological

process takes over and ensures that the disorder will process takes over and ensures that the disorder will continue.continue.

The best explanation for this disorder seems to be The best explanation for this disorder seems to be reflected in the reflected in the "Diathesis-Stress Model.""Diathesis-Stress Model." Genetics PLUS environmental percipients.Genetics PLUS environmental percipients.

Treatment of Child Bipolar DisorderTreatment of Child Bipolar Disorder

Treatment of children and adults with bipolar Treatment of children and adults with bipolar disorder is generally similar to adults with this disorder is generally similar to adults with this disorder.disorder.– Less is known about the effectiveness & safety of Less is known about the effectiveness & safety of

the medications used.the medications used.– Lithium appears to frequently have a strong Lithium appears to frequently have a strong

prophylactic effect against mania, and is sometimes prophylactic effect against mania, and is sometimes used with children.used with children.

– However, in very early onset bipolar disorder, with a However, in very early onset bipolar disorder, with a heavy family loading, children may not respond as heavy family loading, children may not respond as well to lithium as do adults.well to lithium as do adults.


As with adults, As with adults, anti-convulsantsanti-convulsants are often used to are often used to control rapid cycling and aggressive behavior.control rapid cycling and aggressive behavior.– Depakote – an anti-convulsant – used to control Depakote – an anti-convulsant – used to control

rapid cycling.rapid cycling.– Tergetol – an anti-convulsant – has anti-manic and Tergetol – an anti-convulsant – has anti-manic and

anti-aggressive qualities.anti-aggressive qualities.– Other anti-convulsants (Neurontin, Lamictal, Other anti-convulsants (Neurontin, Lamictal,

Topamax)Topamax)

Sometimes these are used in combination with Sometimes these are used in combination with Lithium.Lithium.


As with adults, certain As with adults, certain antipsychotic drugsantipsychotic drugs may may also be used to control symptoms.also be used to control symptoms.

Included here are atypical antipsychotic Included here are atypical antipsychotic medications such as Clozaril®, Zyprexa®, medications such as Clozaril®, Zyprexa®, Risperdal®, and Seroquel®.Risperdal®, and Seroquel®.

Such drugs Such drugs have been shown to sometimes have been shown to sometimes function as mood stabilizers in cases were drugs function as mood stabilizers in cases were drugs like lithium and anticonvulsants may not worklike lithium and anticonvulsants may not work

They are used to deal with acute mania, and/or They are used to deal with acute mania, and/or to treat psychotic depression.to treat psychotic depression.

Issues in the Pharmacological Issues in the Pharmacological Treatment of Child Bipolar DisorderTreatment of Child Bipolar Disorder

Bipolar youth often require multiple medications Bipolar youth often require multiple medications for for mood stabilizationmood stabilization, treatment of , treatment of attention attention problemsproblems, , depressiondepression, and sometimes , and sometimes psychotic psychotic symptoms.symptoms.

There can, however, be risks with drug treatmentsThere can, however, be risks with drug treatments

Problems can arise in cases of misdiagnosis.Problems can arise in cases of misdiagnosis.

Sometimes children with undiagnosed bipolar Sometimes children with undiagnosed bipolar disorder are mistakenly treated for MDD with disorder are mistakenly treated for MDD with antidepressants.antidepressants.

Issues in the Pharmacological Issues in the Pharmacological Treatment of Child Bipolar DisorderTreatment of Child Bipolar Disorder

Treating such children with antidepressants (in Treating such children with antidepressants (in the absence of a mood stabilizer) can actually the absence of a mood stabilizer) can actually precipitate or exacerbate manic symptoms.precipitate or exacerbate manic symptoms.

In children with ADHD symptoms, treatment In children with ADHD symptoms, treatment with stimulant drugs (in the absence of a mood with stimulant drugs (in the absence of a mood stabilizer) can result in manic symptoms and/or stabilizer) can result in manic symptoms and/or worsen symptoms. worsen symptoms.

Issues in Pharmacological Issues in Pharmacological Treatment of Child Bipolar DisorderTreatment of Child Bipolar Disorder

It is difficult to determine which children will It is difficult to determine which children will become manic or experience a worsening of become manic or experience a worsening of symptomssymptomsThere is a greater likelihood among children There is a greater likelihood among children with a strong family history of bipolar disorder.with a strong family history of bipolar disorder.It has been suggested thatIt has been suggested that– if manic symptoms develop or markedly worsen if manic symptoms develop or markedly worsen

during antidepressant or stimulant use, the diagnosis during antidepressant or stimulant use, the diagnosis and treatment for bipolar disorder should be and treatment for bipolar disorder should be considered.considered.

Proper diagnosis of Child Bipolar Disorder is Proper diagnosis of Child Bipolar Disorder is necessary to avoid these problems.necessary to avoid these problems.

Additional Treatment ApproachesAdditional Treatment ApproachesAs with adults, treatments in addition to medication As with adults, treatments in addition to medication are often necessary to assist children with bipolar are often necessary to assist children with bipolar disorder and their families.disorder and their families.These interventions may involveThese interventions may involve– Educating the family Educating the family about the nature of childhood about the nature of childhood

bipolar disorder and involving the family in treatment.bipolar disorder and involving the family in treatment.– Insuring that children receive Insuring that children receive the the special educational special educational

servicesservices necessary to prevent them from falling necessary to prevent them from falling behind academicallybehind academically

– Appropriate classroom accommodations to help Appropriate classroom accommodations to help them function effectively in the academic them function effectively in the academic environment.environment.

– Family and individual approaches to therapy Family and individual approaches to therapy should should be provided as necessary.be provided as necessary.

Examples of Educational Examples of Educational AccommodationsAccommodations

Provide student with a safe place and person Provide student with a safe place and person to go to when feeling overwhelmed or stressedto go to when feeling overwhelmed or stressedShortened day (permit late start as needed)Shortened day (permit late start as needed)Prior notice of transitions Prior notice of transitions Consistent scheduleConsistent scheduleScheduling the student’s most challenging Scheduling the student’s most challenging tasks at a time of day when the child is best tasks at a time of day when the child is best able to performable to performModified or shortened assignmentsModified or shortened assignmentsAdjust for medication needs, dispensing, as Adjust for medication needs, dispensing, as well as plans for addressing side effects (e.g., well as plans for addressing side effects (e.g., sedation)sedation)

Hart (2005)Hart (2005)

THE ENDTHE END

Childhood SchizophreniaChildhood SchizophreniaLite*Lite*

James H. Johnson, PhD, ABPPJames H. Johnson, PhD, ABPPUniversity of FloridaUniversity of Florida

*Some material for this presentation provided by NIMH Publication No. 00-5124,(2003)*Some material for this presentation provided by NIMH Publication No. 00-5124,(2003)

Child Schizophrenia: SymptomsChild Schizophrenia: SymptomsChildhood Schizophrenia is a severe Childhood Schizophrenia is a severe neurodevelopmental disorder of childhood neurodevelopmental disorder of childhood that is usually manifest in a range of that is usually manifest in a range of symptoms including:symptoms including:– Disturbed though processesDisturbed though processes– psychotic symptoms (hallucinations, delusions)psychotic symptoms (hallucinations, delusions) – social withdrawalsocial withdrawal – flattened emotionsflattened emotions – loss of social and personal care skillsloss of social and personal care skills – increased risk of suicideincreased risk of suicide

Schizophrenia in children is rare, affecting Schizophrenia in children is rare, affecting only about 1 in 40,000 compared to 1 in 100 only about 1 in 40,000 compared to 1 in 100 in adults. in adults.

Child Schizophrenia: SymptomsChild Schizophrenia: SymptomsChildren with schizophrenia often see or hear things Children with schizophrenia often see or hear things that do not exist. and harbor paranoid and bizarre that do not exist. and harbor paranoid and bizarre beliefs.beliefs.They may think people are plotting against them or They may think people are plotting against them or can read their minds.can read their minds.Other symptoms of the disorder includeOther symptoms of the disorder include– problems paying attention,problems paying attention,– impaired memory and reasoning,impaired memory and reasoning,– speech impairments,speech impairments,– inappropriate or flattened expression of emotion,inappropriate or flattened expression of emotion,– poor social skills, andpoor social skills, and– depressed mood.depressed mood.

Such children may laugh at a sad event, make poor Such children may laugh at a sad event, make poor eye contact, and show little body language or facial eye contact, and show little body language or facial expressionexpression..

Child Schizophrenia: OverviewChild Schizophrenia: OverviewWhile schizophrenia sometimes begins as an While schizophrenia sometimes begins as an acute psychotic episode in young adults, it acute psychotic episode in young adults, it emerges graduallyemerges gradually in children. in children.It is often preceded by developmental It is often preceded by developmental disturbances, such as lags in motor and disturbances, such as lags in motor and speech/language development.speech/language development.The diagnostic criteria for childhood The diagnostic criteria for childhood schizophrenia are the same as for adults, schizophrenia are the same as for adults, except that except that symptoms appear prior to age 12symptoms appear prior to age 12, , instead of in the late teens or early 20s..instead of in the late teens or early 20s..It is seldom diagnosed before the age of 7.It is seldom diagnosed before the age of 7.

Child Schizophrenia: Differential Child Schizophrenia: Differential DiagnosesDiagnoses

Misdiagnosis of schizophrenia in Misdiagnosis of schizophrenia in children is common.children is common.

It is distinguished from autism by the It is distinguished from autism by the persistence of hallucinations and persistence of hallucinations and delusions for at least 6 months, and a delusions for at least 6 months, and a later age of onset - 7 years or older.later age of onset - 7 years or older.

Autism is usually diagnosed by age Autism is usually diagnosed by age 3.3.


Some children who later develop Some children who later develop schizophrenia may have a history of schizophrenia may have a history of some Pervasive Development some Pervasive Development Disorder symptoms.Disorder symptoms.

In adolescents, schizophrenia is also In adolescents, schizophrenia is also to be distinguished from bipolar to be distinguished from bipolar disorder.disorder.


Sometimes an acute onset manic episode may Sometimes an acute onset manic episode may be mistaken for schizophrenia, as be mistaken for schizophrenia, as hallucinations and delusions may be present hallucinations and delusions may be present (usually mood congruent).(usually mood congruent).Symptoms of schizophrenia characteristically Symptoms of schizophrenia characteristically pervade the child's life, and are not limited to pervade the child's life, and are not limited to specific situations.specific situations.Since impairment in social relationships are Since impairment in social relationships are central, if the child shows a strong interest in central, if the child shows a strong interest in friendships (even if they fail at maintaining friendships (even if they fail at maintaining them) it is unlikely that they have them) it is unlikely that they have schizophrenia.schizophrenia.

Child Schizophrenia: Presumed Child Schizophrenia: Presumed EtiologyEtiology

Evidence suggests that Childhood Schizophrenia is Evidence suggests that Childhood Schizophrenia is a neurodevelopmental disorder likely involving;a neurodevelopmental disorder likely involving;– a genetic predisposition,a genetic predisposition,– a prenatal insult to the developing brain, anda prenatal insult to the developing brain, and– stressful life eventsstressful life events..

The role of genetics has long been established;The role of genetics has long been established;– the risk of schizophrenia rises from 1 percent with no the risk of schizophrenia rises from 1 percent with no

family history of the illness,family history of the illness,– to 10 percent if a first degree relative has it,to 10 percent if a first degree relative has it,– to 50 percent if an identical twin has it..to 50 percent if an identical twin has it..

Prenatal insults may include viral infections, such Prenatal insults may include viral infections, such as maternal influenza in the second trimester, as maternal influenza in the second trimester, starvation, lack of oxygen at birth, and untreated starvation, lack of oxygen at birth, and untreated blood type incompatibilityblood type incompatibility

Child Schizophrenia: EtiologyChild Schizophrenia: Etiology

Studies find that children with schizophrenia Studies find that children with schizophrenia display many of the same abnormal brain display many of the same abnormal brain features (structural, physiological, and features (structural, physiological, and neuropsychological) that are found in adults.neuropsychological) that are found in adults.

The children seem to have more severe The children seem to have more severe symptoms than adults, with more symptoms than adults, with more pronounced neurological abnormalities.pronounced neurological abnormalities.

Unlike most adult-onset patients, children Unlike most adult-onset patients, children who become psychotic prior to puberty show who become psychotic prior to puberty show conspicuous evidence of progressively conspicuous evidence of progressively abnormal brain development.abnormal brain development.

Child Schizophrenia: NeurologyChild Schizophrenia: Neurology““In the first longitudinal brain imaging In the first longitudinal brain imaging study of adolescents (Giedd, et al 1999; study of adolescents (Giedd, et al 1999; Rapoport, et al, 1999), MRI scans revealed Rapoport, et al, 1999), MRI scans revealed fluid filled cavities in the middle of the fluid filled cavities in the middle of the brain, enlarging abnormally between ages brain, enlarging abnormally between ages 14 and 18, in teens with early-onset 14 and 18, in teens with early-onset schizophrenia, suggesting a shrinkage in schizophrenia, suggesting a shrinkage in brain tissue volume.brain tissue volume.These children lost four times as much These children lost four times as much gray matter, neurons and their branchlike gray matter, neurons and their branchlike extensions, in their frontal lobes as extensions, in their frontal lobes as normally occurs in teens.normally occurs in teens.

Child Schizophrenia: NeurologyChild Schizophrenia: NeurologyThis gray matter loss engulfs the brain in a This gray matter loss engulfs the brain in a progressive wave from back to front over 5 progressive wave from back to front over 5 years, beginning in rear structures involved years, beginning in rear structures involved in attention and perception, eventually in attention and perception, eventually spreading to frontal areas responsible for spreading to frontal areas responsible for organizing, planning, and other "executive" organizing, planning, and other "executive" functions impaired in schizophrenia. (NIMH, functions impaired in schizophrenia. (NIMH, 2000).”2000).”

Child Schizophrenia: TreatmentChild Schizophrenia: Treatment

Early diagnosis and treatment is important in Early diagnosis and treatment is important in dealing with childhood schizophrenia.dealing with childhood schizophrenia.

Children with this disorder must have a complete Children with this disorder must have a complete evaluation in order to develop a comprehensive evaluation in order to develop a comprehensive individual treatment plan to address their individual treatment plan to address their difficulties.difficulties.

A combination of medication and individual A combination of medication and individual therapy, family therapy, and specialized programs therapy, family therapy, and specialized programs (school, activities, etc.) is often necessary.(school, activities, etc.) is often necessary.

Medication can be helpful for many of the Medication can be helpful for many of the symptoms and problems identified.symptoms and problems identified.

Child Schizophrenia: TreatmentChild Schizophrenia: Treatment

Standard antipsychotic drugs appear to be effective Standard antipsychotic drugs appear to be effective for many schizophrenic children and adolescents.for many schizophrenic children and adolescents.And the atypical drug clozapine is helpful for at least And the atypical drug clozapine is helpful for at least half of those who do not respond to other drugs.half of those who do not respond to other drugs.In a few cases psychotic symptoms seem to In a few cases psychotic symptoms seem to disappear entirely.disappear entirely.Unfortunately, children may be more susceptible Unfortunately, children may be more susceptible than adults to the toxic effects of clozapine; about than adults to the toxic effects of clozapine; about one third of them have to stop taking it because of one third of them have to stop taking it because of the side effects. the side effects. Newer antipsychotic drugs that may be safer and Newer antipsychotic drugs that may be safer and just as effective are now being tested.just as effective are now being tested.

The EndThe End

bipolar disorder in children and adolescents james h. johnson, phd, university of florida *some...

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