Most Children with Rapidly Shifting Moods Don’t Have Bipolar Disorder

Relatively few children with rapidly shifting moods and high energy have bipolar disorder, though such symptoms are commonly associated with the disorder. Instead, most of these children have other types of mental disorders, according to an NIMH-funded study published online ahead of print in the Journal of Clinical Psychiatry on October 5, 2010.

Background

Some parents who take their child to a mental health clinic for assessment report that the child has rapid swings between emotions (usually anger, elation, and sadness) coupled with extremely high energy levels. Some researchers suggest that this is how mania—an important component of bipolar disorder—appears in children. How mania and bipolar disorder are defined in children is important because rapid mood swings and high energy are common among youth.

Furthermore, many experts believe that overdiagnosis and misdiagnosis of bipolar disorder in youth may play a role in the increasing 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.

In the Longitudinal Assessment of Manic Symptoms (LAMS) study, Robert Findling, M.D., of Case Western Reserve University, and colleagues assessed 707 children, ages 6-12, who were referred for mental health treatment. Of the participants, 621 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.

Results of the Study

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.

Compared to children without rapid mood swings and high energy, those with these symptoms:

• 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).

Significance

Given that 75 percent of ESM-positive youth did not meet the diagnostic criteria for any bipolar disorder, the researchers suggest that bipolar disorder may not be common among children who experience rapid swings between emotions and high energy levels. Nevertheless, children with these symptoms 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.

What’s Next

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. Such research may inform efforts to identify early markers or predictors of the illness as well as possible protective factors.

Reference

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.

Source: NIMH

Live Discussion: Dr. Demitri Papolos on Fear of Harm with JBRF Director Alissa Bronsteen

The Juvenile Bipolar Research Foundation (JBRF) sends along this note about a free event this Sunday night via the Internet:

Research supported by the Juvenile Bipolar Research Foundation has moved the conversation about bipolar disorder from abstract behaviors to a biological hypothesis. We now have a road map that could guide us to effective and predictable treatment.

Dr. Demitri Papolos, and JBRF Director Alissa Bronsteen will discuss the Fear of Harm subtype of bipolar disorder and future research priorities on:

The Coffee Klatch: a BlogTalkRadio show on this Sunday, November 21st at 9PM, Eastern

Since this is through your computer, not your radio, no matter where you live, you can hear it. Simply go to:

www.blogtalkradio.com/profile.aspx?userurl=the-coffee-klatch -
http://cts.vresp.com/c/?JuvenileBipolarResea/c657d47b21/2753b3da81/bcbd2c8ca5/userurl=the-coffee-klatch
.
There will be time at the end for questions.

The call-in number for questions is (646) 595-2881.

Insanity defense raised for youth accused of Landstown plot

Kathy Adams reports that the defense attorney for a former student accused of a Columbine-style plot against a high school will plead that the young man was insane due to Bipolar Disorder and PTSD due to a history of child abuse and bullying:

Philip C. Bay, the former student accused of a plot against Landstown High School, began “the countdown to terror” on April 16, 2007, the day of the Virginia Tech massacre, Commonwealth’s Attorney Harvey Bryant told jurors as Bay’s trial got underway Monday afternoon.

Bryant called Bay “the mastermind, the bomb-maker and the recruiter for this suicide mission,” and said Landstown notebooks, calendars and photos will help prove Bay set out to kill at least 30 people.

He read journal entries he said were Bay’s, including this: “I will be armed to the teeth with guns, knives and everything else. I will kill, kill, kill. You have my word.”

An attorney helping defend Bay, Eric Korslund, said the defense will argue he was insane at the time of the crimes. He suffered from untreated bipolar disorder and post-traumatic stress disorder from being bullied and abused as a child, he said.

[...]

Bay’s attorney, James Broccoletti, said during jury selection that Bay’s mental condition was the central issue.

“The defense is that Philip Bay was legally insane at the time of the acts alleged in the indictment,” Broccoletti told potential jurors. “That means that because of a mental disease or defect, he did not understand the nature, the character or the consequences of his actions or could not understand right from wrong.”

Bay was 17 when he was charged in 2009 in connection with what authorities called a plot against the school. He faces 11 counts of manufacturing or possessing an explosive device with intent to cause harm; possessing a weapon of terrorism with intent to terrorize; two counts of possessing a sawed-off shotgun; soliciting or recruiting for an act of terrorism; and committing, conspiring or aiding in the commission of an act of terrorism.

Read more on Hampton Roads.

Bipolar Disorder can, in severe forms, be accompanied by psychotic thinking. But if planning took place over time measured in weeks or longer, I think the defense has its work cut out for it if it plans to claim that at no point was the young man sane and fully aware that what he was planning to do was wrong.

I’d really be curious to read any psychiatric or psychological evaluation of the defendant conducted at the time of his arrest.

More information on the use of the insanity defense in Virginia can be found here.  He may wind up being incarcerated for longer than he might for a straight prison sentence, depending….

Adult Outcomes of Childhood Dysregulation: A 14-year Follow-up Study

A study  by Denis G. Sukhodolsky, Ph.D. and his colleagues looked at whether dysregulation in childhood predicts problems in adulthood.   Their data suggest that anxiety and disruptive behavior in youth predicts problems in adulthood.  Here is the abstract of the research report:

Objective
Using a general population sample, the adult outcomes of children who presented with severe problems with self-regulation defined as being concurrently rated highly on attention problems, aggressive behavior, and anxious-depression on the Child Behavior Checklist–Dysregulation Profile (CBCL-DP) were examined.

Method
Two thousand seventy-six children from 13 birth cohorts 4 to 16 years of age were drawn from Dutch birth registries in 1983. CBCLs were completed by parents at baseline when children from the different cohorts were 4 to 16 years of age and sampled every 2 years for the next 14 years. At year 14 the CBCL and DSM interview data were collected. Logistic regression was used to compare and contrast outcomes for children with and without dysregulation, as measured by the latent-class–defined CBCL-DP. Sex and age were covaried and concurrent DSM diagnoses were included in regression models.

Results
Presence of childhood CBCL-DP at wave 1 was associated with increased rates of adult anxiety disorders, mood disorders, disruptive behavior disorders, and drug abuse 14 years later. After controlling for co-occurring disorders in adulthood, associations with anxiety and disruptive behavior disorders with the CBCL-DP remained, whereas the others were not significant.

Conclusions
A child reported to be in the CBCL-DP class is at increased risk for problems with regulating affect, behavior, and cognition in adulthood.

Journal of the American Academy of Child & Adolescent Psychiatry (49:11,  1105-1116.  (November 2010)

Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents

The American Academy of Child and Adolescent Psychiatry (AACAP) has just announced the release of a new Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.

The guide goes far beyond just describing medications, however, and provides a lot of other useful information for parents. You can download your free copy at http://www.aacap.org/galleries/default-file/aacap_bipolar_medication_guide.pdf.

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