Bipolar Disorder in Children and Adolescents:Bipolar Disorder in Children and Adolescents:Diagnostic Issues and Clinical Case Follow-upDiagnostic Issues and Clinical Case Follow-up

James H. Johnson, PhD, ABPP/James H. Johnson, PhD, ABPP/CAPCAP

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 largely Bipolar disorder is a largely biologically basedbiologically based disorder that causes extreme variations in a disorder that causes extreme variations in a person's person's mood and energymood and energy and impairs their and impairs their ability ability to functionto function..It causes dramatic It causes dramatic mood swingsmood swings - from an overly - from an overly "high" and/or irritable mood to sad and hopeless "high" and/or irritable mood to sad and hopeless mood, and back.mood, and back.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.Mood related changes are accompanied by severe Mood related changes are accompanied by severe variations in energy and behavior.variations 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/Manic EpisodeMania/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 or more of the other symptoms most of the daymost of the day, , nearly every daynearly every day, , for 1 week or longer (?). If the mood is irritablefor 1 week or longer (?). If 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 Hypomania may feel good to the person who experiences it and may be associated who experiences it and may be associated with good functioning and enhanced with good functioning and enhanced productivity. productivity. Without proper treatment, however, Without proper treatment, however, hypomania can become more severe or hypomania can become more severe or can switch into depression.can 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 Thoughts of death or suicide, or suicide attempts. 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, symptoms last most of the day, nearly every daynearly every day, for a , for a period of 2 period of 2 weeks or longer (?)weeks or longer (?)..

Mood Swings & Symptoms of Mood Swings & Symptoms of PsychosisPsychosis

Severe episodes of mania or Severe episodes of mania or depression can include symptoms of depression can include 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 Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state tend to reflect the extreme mood state at the time (at the time (are mood congruent)are mood congruent)

Bipolar SpectrumBipolar Spectrum

It’s helpful to think of various mood states in It’s helpful to think of various mood states in bipolar disorder as a bipolar disorder as a spectrumspectrum or continuous or continuous range.range.At one end is At one end is severe depressionsevere depression, then , then moderate moderate depression depression and then and then mild low moodmild low mood..This mild low mood is often short-lived (it’s This mild low mood is often short-lived (it’s termed "termed "dysthymiadysthymia" " when chronic.when 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 Symptoms of mania and depression may occur together in a occur together in a mixedmixed state state..

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

This may be accompanied by a sad, This may be accompanied by a sad, hopeless mood while also feeling highly hopeless mood while also feeling highly energized.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 both mania and depressionepisodes of both 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 episodes of hypomania that episodes of hypomania that alternate with depressionalternate with depression (Bipolar II).(Bipolar II).When four or more episodes occur within a 12-month When four or more episodes occur within a 12-month period, a person is said to have period, a person is said to have rapid-cycling bipolar rapid-cycling bipolar disorderdisorder..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 illnessillness and is more common among women than 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 seen as only appropriate for Disorder was seen as only appropriate for adults.adults.

Indeed, few clinicians would have Indeed, few clinicians would have considered using this diagnostic category considered using this diagnostic category with children.with children.

Despite continued controversy, it is Despite continued controversy, it is increasingly common to find clinicians increasingly common to find clinicians using this diagnosis with both children and using this diagnosis with both children and adolescents. adolescents.

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 displayeda very young age, often displayed– uncontrollable, seizure-like tantrumsuncontrollable, seizure-like tantrums– rage reactionsrage reactions..These often appear to be without obvious These often appear to be without obvious provocation.provocation.

Prevalence of Child Bipolar DisorderPrevalence of Child Bipolar Disorder

Prevalence of Bipolar Disorder in children is Prevalence of Bipolar Disorder in children is largely unknown as there are no well accepted largely unknown as there are no well accepted criteria for the diagnosis of Child Bipolar criteria for the diagnosis of Child Bipolar disorder.disorder.This is because DSM IV criteria are often This is because DSM IV criteria are often viewed as inadequate for use with younger viewed as inadequate for use with younger children, due to a different clinical presentation children, due to a different clinical presentation in childhood.in childhood.The best guess is that the disorder occurs at The best guess is that the disorder occurs at least as often as adult bipolar disorder (e.g., least as often as adult bipolar disorder (e.g., ~1.2 %) ~1.2 %) Many believe that this disorder is significantly Many believe that this disorder is significantly under diagnosed in in younger individualsunder diagnosed in in younger individuals ..

Clinical Presentation of Child Bipolar Clinical Presentation of Child Bipolar DisorderDisorder

It has been suggested that It has been suggested that a significant number a significant number of children diagnosed with ADHD at a very early of children diagnosed with ADHD at a very early age may actually have early-onset bipolar age may actually have early-onset bipolar disorderdisorder instead of (or along with) ADHD. instead 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. .

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

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

As with adults, Bipolar disorder in children As with adults, Bipolar disorder in children is viewed a serious and chronic mental is viewed a serious and chronic mental disorder.disorder.It is characterized by recurrent episodes It is characterized by recurrent episodes of of depressiondepression, , maniamania, and/or , and/or mixed mixed symptom statessymptom states..It has been suggested that child bipolar It has been suggested that child bipolar disorder disorder may be a more severe form of may be a more severe form of the illnessthe illness than older adolescent and than older adolescent and adult-onset bipolar disorder. adult-onset bipolar disorder.

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

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

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

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

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

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

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

With children,With children,– Initial symptoms can be depressive in nature Initial symptoms can be depressive in nature

With these being confused with and treated as MDDWith these being confused with and treated as MDD

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

Unlike adults - Unlike adults - children in a manic state are children in a manic state are more likely to be irritable and prone to more likely to be irritable and prone to destructive outburstsdestructive outbursts than to be elated or than to be elated or euphoric. euphoric.

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

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

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

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

There may be few clear periods of wellness There may be few clear periods of wellness between episodesbetween episodes..

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

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 30 % of adolescents with bipolar disorder meet

criteria for a diagnosis of ADHD.criteria for a diagnosis of ADHD.Comorbid conduct disorder is also common.Comorbid conduct disorder is also 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 30 (adolescents) - 90% (children) Between 30 (adolescents) - 90% (children)

display symptoms 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%

Treatment of Child Bipolar DisorderTreatment of Child Bipolar Disorder

Treatment of children with bipolar disorder is Treatment of children with bipolar disorder is generally similar to adults with this disorder.generally similar to adults with this disorder.– Although, less is known about the effectiveness & Although, less is known about the effectiveness &

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

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

– However, However, in very early onset bipolar disorder, with a 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 adultswell to lithium as do adults..

Treatment of Child Bipolar DisorderTreatment of Child Bipolar DisorderAs with adults, As with adults, anti-convulsantsanti-convulsants are often used to control rapid are often used to control rapid cycling and aggressive behavior.cycling and aggressive behavior.– Depakote – an anti-convulsant – used to control rapid Depakote – an anti-convulsant – used to control rapid

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

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

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

Abilify is another relatively new drug which is being used in the Abilify is another relatively new drug which is being used in the treatment of bipolar disorder in children and adultstreatment of bipolar disorder in children and adults– Developed as an add-on treatment to antidepressants for Developed as an add-on treatment to antidepressants for

Major Depressive Disorder in adults but seems to also have Major Depressive Disorder in adults but seems to also have anti-manic effects.anti-manic effects.

– Not FDA approved for children under 18 but is currently Not FDA approved for children under 18 but is currently being prescribed for children.being prescribed for children.

Treatment of Child Bipolar DisorderTreatment of Child Bipolar Disorder

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 seems to be a somewhat There seems to be a somewhat greater likelihood greater likelihood among children with a strong family history of among children with a strong family history of bipolar disorderbipolar disorder..It has been suggested thatIt has been suggested that– if manic symptoms develop or markedly worsen during if manic symptoms develop or markedly worsen during

antidepressant or stimulant use, the diagnosis and antidepressant or stimulant use, the diagnosis and treatment for bipolar disorder should be considered.treatment for bipolar disorder should be 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.Must be aware that Must be aware that bipolar disorder can mimic bipolar disorder can mimic conditions like ADHD and Depressionconditions like ADHD and Depression due to due to symptom overlapsymptom overlap

Additional Treatment ApproachesAdditional Treatment ApproachesTreatments in addition to medication are often Treatments in addition to medication are often necessary to assist children with bipolar disorder necessary to assist children with bipolar disorder and their families.and their families.These interventions may involveThese interventions may involve– Educating the familyEducating 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 therapyFamily and individual approaches to therapy should should be provided as necessary.be provided as necessary.

Case Presentation: ADHD or Bipolar Disorder

Bobby – A 12 year – 8 month old male in the 7th Grade was seen in Clinic during 2002– Brought to the clinic by his guardians (paternal

grandparents)– Always had problems with attention and hyperactivity (from

birth) as well as oppositional and socially inappropriate behavior

– These and other difficulties had worsened during the months preceding the evaluation.

– Diagnosed with ADHD in first grade and has been medicated since then.

– Grandparents and school wonder if there may be some disorder in addition to ADHD that my contribute to his problems.

Developmental/School HistoryMom thought to have used drugs and alcohol during first three months of pregnancyPregnancy with no complicationsReached all milestones on time or earlyLow grade fevers (undetermined causes) from 1 ½ to 4 years.Hospitalized at age 6 for pneumonia.Diagnosed with ADHD at age 6Behavioral difficulties in school but average academic performance in most subjects

Recent Behavioral DifficultiesDuring the six months preceding the evaluation had shown a wide range of behavioral variations including

Increased oppositional behavior and significant depressionRefusal to bathe, brush teeth andHad lost interest in friends and activitiesHad often stayed bed for several days at a time and was easily irritatedMore recently has had difficulty sleeping, sometimes going two to three days without sleeping.

Recent Behavioral DifficultiesGrandparents noted that some of his behaviors seem to have been the result of medication that did not work as expected

Put on hospital homebound school program due to development of tics, secondary to medication change (shouting extreme obscenities at girls – school can’t protect)

Recent Behavioral Difficulties

Had been on multiple medications in multiple doses which had not been effective in controlling his behavior (Examples of Medication).Medications typically seemed to work for a while and then stop working or make him much worseOff-meds grandparents described his behavior as sometimes “silly, elated, giddy, happy, and crazy, as if in another world.”On several occasions has taken off all of his clothes and “run into the streets howling”

Family HistoryMother had been adopted– Little info on her family background– Described as wild, impulsive with multiple

monogamous relationships – never married– Began using tobacco, drugs, and alcohol at 13– Was killed in car accident (when pt was 9)

Little information about biological fatherPaternal GM hospitalized for “Mood Swings”Paternal GF on meds into his 60’s for “activity and attention problems”Paternal Uncle with ADHD.Bobby has lived with Maternal Grandparents most of his life

Behavioral Observations

Had not slept for two days prior to evaluation; did not report being tired

Flat affect through the evaluation

Cooperative throughout the testing but not forthcoming when talking about feelings or responding to personality questionnaires (e.g., leaving out items, refusing to answer some questions)

Test ResultsWASI: FSIQ = 107 (Verbal 102; Performance 109)WIAT: Reading GE = 8 – 3; Math GE = 5 – 8; Spelling GE = 8 – 6 (Note. In 7th Grade)Attention Measures– Conner’s CPT (Confidence Index = 99.9)– TEA-CH Selective Attention (Above Average)’ Attentional

Control (Low Average); Sustained Attention (Significantly Impaired on 4 or 5 tests)

– Conner’s: Clinically significant elevations on:– DSM IV Hyperactive/impulsive, DSM IV inattention, DSM

IV Total, ADHD index, Social Problems, Oppositional, Restless-Impulsive, and Emotional Lability (High ranging profie)

Test Results (Cont)

Personality Inventory for Children

Clinically significant elevations on multiple scales:– Psychosis– Withdrawal– Hyperactivity– Social Skills Deficits– Depression– Delinquency (Behavioral Problems)– Anxiety

PIC PROFILE

Child Test Measures

Administered child anxiety and depression scales as well as the Roberts Apperception Test and the Incomplete Sentence Schedule

Due to patients response set and lack of motivation and involvement, this data is of questionable validity

DIAGNOSIS ?

DIAGNOSES

ADHD, Combined type (314.01)– Long standing history of hyperactive-

impulsive, and inattentive behavior – Poorly Controlled with Medication

– Highly significant elevations of Conner’s Parent Report Measure

– Significant Confidence Index on CPT– Impairments in Sustained Attention on Tea-Ch

Diagnoses

Major Depressive Disorder (296.2)Grandparents report of symptoms of depression, including:– Highly significant elevations on Personality

Inventory for Children– Irritable mood– Anhedonia– Decreased energy– Difficulty sleeping– Problems concentrating

DiagnosesBipolar Disorder R/O (296)Question? Should this be the superordinate diagnosis?– Grandparents describe the patient’s behavior off of medication as “Crazy,

wild, hyperactive” and note that he becomes “silly, elated, and giddy, as if in another world”.

– Has taken clothes off and run into the street howling on multiple occasions; this behavior has occurred as far back as 6 years of age and as recently as the past year when medications stop working.

– Patient has a history of depression, decreased need for sleep, irritable mood, and severely disinhibited behavior.

– This is combined with a paternal grandmother who was hospitalization for “mood swings”, a paternal grandfather who was medicated into his 60’ for attention problems and activity level.

– Taken together it is believed that he should be further evaluated for bipolar disorder.

– While a definitive diagnosis is difficult at this time because core psychopathology has been clouded over time by multiple doses and combinations of numerous prescription and over-the-counter medications, it appears that this disorder may well account for his erratic and highly impairing and behavior

Six Year Follow-up

Patient seen for reevaluation this past year

As an adult (18) wanted an evaluation to reconsider the “diagnosis” of bipolar disorder.

Was accompanied to the evaluation by his Grandfather and his 25 year old fiancé, with whom he lives.

Clinical Status Update

Significant change in treatment since last evaluation, although still under the care of a psychiatristChanged from stimulants and antidepressants + to mood stabilizers +Some positive effects of mood stabilizers over the years were described but they seemed to have not helped with continuing “major attention problems”.

Clinical Status UpdateClinical Status UpdateAt the time of evaluation was prescribed At the time of evaluation was prescribed 2000 mg of Depakote, 400 mg of 2000 mg of Depakote, 400 mg of Seroquel, 300 mg of Wellbutrin and .01 Seroquel, 300 mg of Wellbutrin and .01 mg of synthroid.mg of synthroid.Had gained weight on Seroquel; up to 250 Had gained weight on Seroquel; up to 250 pounds.pounds.Said it make him irritable and that he felt Said it make him irritable and that he felt druggeddruggedQuit taking all meds several months and Quit taking all meds several months and has now dropped to 140 pounds.has now dropped to 140 pounds.

Interview FindingsInterview FindingsReports currently sleeping 7 – 8 hours per Reports currently sleeping 7 – 8 hours per night but reports functioning fine without night but reports functioning fine without any sleep.any sleep.

Describes major problem with angerDescribes major problem with anger– Frequently extremely irritable – small things Frequently extremely irritable – small things

set him offset him off– When angry he yells, hits, and breaks thingsWhen angry he yells, hits, and breaks things– Numerous physical altercations in and out of Numerous physical altercations in and out of

school over the yearsschool over the years– Got drunk and beat fiancé “really bad”Got drunk and beat fiancé “really bad”

Interview FindingsInterview FindingsAfter previous evaluation he had returned After previous evaluation he had returned to school but had rough timeto school but had rough time– Frequently suspended and expelled for Frequently suspended and expelled for

fighting and arguing with teachersfighting and arguing with teachers– Well known to law enforcement in his Well known to law enforcement in his

hometown - fighting, drug usehometown - fighting, drug use– Feels he can’t go back without being hassled Feels he can’t go back without being hassled

by policeby police– Quit high school after middle of 11Quit high school after middle of 11 thth grade grade

Interview FindingsInterview FindingsDescribes frequent mood changesDescribes frequent mood changes– Reports that a couple of times a month will be Reports that a couple of times a month will be

giddy and laughinggiddy and laughing for 2 – 3 days at a time for 2 – 3 days at a time– Mood is way beyond just being happy; people Mood is way beyond just being happy; people

notice and comment on his exaggerated notice and comment on his exaggerated mood.mood.

– Describes having Describes having extreme racing thoughts extreme racing thoughts which “he can’t keep up with” and creates which “he can’t keep up with” and creates problems in concentratingproblems in concentrating

– Describes Describes problems with hyperactivityproblems with hyperactivity, , impulsivity and inattentionimpulsivity and inattention

Interview FindingsInterview FindingsGrandfather describes him as Grandfather describes him as significantly significantly depressed.depressed.Patient also describes himself as “sometimes sad”.Patient also describes himself as “sometimes sad”.Grandfather says he is Grandfather says he is just like his mother just like his mother “overly “overly happy, manic and then depressed.”happy, manic and then depressed.”Pt describes himself as Pt describes himself as self-medicating almost daily self-medicating almost daily with marijuanawith marijuana to help himself “calm down” to help himself “calm down”Currently has a drug possession charges pending.Currently has a drug possession charges pending.Grandfather concerned over failure to meet with Grandfather concerned over failure to meet with probation officer for drug testing and having legal probation officer for drug testing and having legal difficulties.difficulties. Patient seemingly not concernedPatient seemingly not concerned..

Interview FindingsInterview FindingsDiscussed living apart from Grandfather Discussed living apart from Grandfather with fiancé.with fiancé.

Describes good relationship with fiancé Describes good relationship with fiancé

Both unemployedBoth unemployed– Got mom’s inheritance when he turned 18Got mom’s inheritance when he turned 18– Stated that he had enough money to last a Stated that he had enough money to last a

couple of years without workingcouple of years without working– Later wants to get GED and learn Later wants to get GED and learn

computers.computers.

Interview FindingsInterview Findings““Confidential discussion” regarding inheritanceConfidential discussion” regarding inheritance

Patient had agreed with grandfather on a Patient had agreed with grandfather on a budget of $2,800 per month to live on.budget of $2,800 per month to live on.

Unknown to grandfather - first 6 months after Unknown to grandfather - first 6 months after getting inheritance spent over $100,000.getting inheritance spent over $100,000.– Two new carsTwo new cars

(both for patient – the second car to drive when he was (both for patient – the second car to drive when he was tired of driving the first)tired of driving the first)

– ClothesClothes

– Jewelry Jewelry

– Unconcerned about how long money will last!Unconcerned about how long money will last!

Test FindingsTest FindingsWASIWASI– FSIQ = 98;FSIQ = 98;– VIQ = 97;VIQ = 97;– PIQ = 99PIQ = 99

WIAT IIWIAT II– Word Reading >12.9 GEWord Reading >12.9 GE– Reading Comp 12.6 GEReading Comp 12.6 GE– Math 7.0 (NO) – 7.2 (MR) GE’sMath 7.0 (NO) – 7.2 (MR) GE’s– Written Expression 3.1 GEWritten Expression 3.1 GE(Low Written Expression due to disinterest and (Low Written Expression due to disinterest and

impulsiveness in responding) impulsiveness in responding)

Test FindingsTest FindingsParent Report Measures: Conner’s 3; BASCParent Report Measures: Conner’s 3; BASC– Clinically Significant Elevations on Conner’s ScalesClinically Significant Elevations on Conner’s Scales::

ADHD Inattentive; ADHD Hyperactive/Impulsive; ADHD Inattentive; ADHD Hyperactive/Impulsive; Oppositional Defiant; Aggression; Peer Relations; ADHD Oppositional Defiant; Aggression; Peer Relations; ADHD Index; Global Index; and Executive Function ScaleIndex; Global Index; and Executive Function Scale

– Extreme Elevations on Most ScalesExtreme Elevations on Most Scales

– Clinically Significant Elevations on the BASCClinically Significant Elevations on the BASCClinically Significant elevations on Hyperactivity, Conduct Clinically Significant elevations on Hyperactivity, Conduct Problems, Attention Problems; “At Risk elevations on Problems, Attention Problems; “At Risk elevations on Depression, Atypicality, and WithdrawalDepression, Atypicality, and Withdrawal

Also, significant impairment in Daily Living Skills, and Also, significant impairment in Daily Living Skills, and difficulties in social skills and functional communicationdifficulties in social skills and functional communication

MMPI 2

MMPI FINDINGSClinically significant elevations on scales reflecting– extremely high levels of manic/hypomanic

symptomatology– suspiciousness/distrust– antisocial features– a level of mental confusion that may be reflected in

poor judgment in everyday life.

Content Scales, composed of critical items associated with depression, suggest significant depressive symptomatology

Examples of Critical Items

DIAGNOSIS ?DIAGNOSIS ?

DiagnosesDiagnoses

Attention Deficit Hyperactivity Disorder, Attention Deficit Hyperactivity Disorder, Combined Type (314.01)Combined Type (314.01)

Bipolar Disorder, Not Otherwise Specified Bipolar Disorder, Not Otherwise Specified (296.80)(296.80)

Are both warranted ??Are both warranted ??

RecommendationsRecommendations

Given concerns expressed by the patient and his Given concerns expressed by the patient and his Grandfather regarding his current medication regimen, Grandfather regarding his current medication regimen, along with the fact that pt is not taking his medications, along with the fact that pt is not taking his medications, continued consultation with his psychiatrist is continued consultation with his psychiatrist is important.important.This consultation should include discussion of the This consultation should include discussion of the undesirable side effects that patient has experienced undesirable side effects that patient has experienced from this current medications (weight gain, feeling from this current medications (weight gain, feeling drugged), as well as concerns that his serious drugged), as well as concerns that his serious attention problems continue to impair his functioning.attention problems continue to impair his functioning.Hopefully, an approach can be found to optimally Hopefully, an approach can be found to optimally address his current mood related difficulties as well as address his current mood related difficulties as well as his attention problems and impulse control.his attention problems and impulse control.

RecommendationsRecommendationsIt is highly recommended that the Bobby become It is highly recommended that the Bobby become involved in working with a therapist who can focus involved in working with a therapist who can focus on evidence based treatment to help him deal with on evidence based treatment to help him deal with issues of depression and anger management.issues of depression and anger management.It would also be important for Bobby to work with a It would also be important for Bobby to work with a counselor to assist him in the areas ofcounselor to assist him in the areas of– financial management,financial management,– the development of more adaptive life management the development of more adaptive life management

and general problem solving skills,and general problem solving skills,– assisting him in planning for the completion of the assisting him in planning for the completion of the

GED andGED and– the subsequent development of vocational skills in an the subsequent development of vocational skills in an

area related to his interests.area related to his interests.

The EndThe End