View Full Version : Diagnostic guidelines for Bipolar


MGDAD
12-04-09, 02:32 PM
http://www.bpkids.org/site/DocServer/treatment_guidelines.pdf?docID=441

The link above is a document that has the treatment guidlines for Bipolar. However, they talk a lot about differentiating the symptoms of ADHD from Bipolar. Based on my experience, this is a common issue for some children.

One of the main themes of this document, is that the mood dissorder needs to be treated before any other comorbid dissorder. That is, you treat bipolar before treating the ADHD.

While it does not actually say that stimulants can worsen bipolar symptoms, it has this strange statement.


Because the symptoms of ADHD may worsen and
complicate the treatment of BPD, until further research
with larger samples becomes available, it was recommended
to carefully use the stimulants if clinically
indicated and only after the child’s bipolar symptomatology
has been controlled with a mood stabilizer.


It is almost like they replace the words "use of stimulants" with "symptoms of ADHD" in the first part of the sentance. Because, as it is written, the statement makes no sense.

This might be because they mention research by Biederman a lot. He is currently being investigated regarding his research and ties to pharmacuetical companies.

Yes, I am on a bit of a crusade lately, to tell people to be more carefull with stimulants. My daughter is now off stimulants, after taking them for 6 years. She eventually, became so high anxiety, and throwing rages daily, that I found a new doctor, who had us quit the stimulants. She now has no more rages, more focus than ever, and is taking an anticonvulsant Trileptal.

I still believe stimulants are excellent medication for most with ADHD, just that for some, they are a very bad medication. I also believe, that other issues should be treated before ADHD, and most doctors dont do that. As my current doctor says. A - you treat mood issues, B - you treat Anxiety, and C - you treat focus.

Trooper Keith
12-04-09, 04:15 PM
Any practitioner worth their salt will treat bipolar before ADHD - one has much worse treatment outcomes and is much more dangerous than the other. Not that ADHD isn't a serious disorder, but bipolar disorder simply outranks it in order of importance.

ditzydreamer
12-05-09, 03:31 PM
I am on a similar crusade.

But many professionals don't even recognize bipolar in children yet. Professionals are far more likely to diagnose ADHD than bipolar in children. Parents are viewed as exaggerating or misinterpreting their children's emotions as rage rather than simple "tantrums". At least, that is how I'm feeling at the moment. We have to jump through hoops just to be seen by a child psychiatrist...unless of course we could afford a private psychiatrist.

My daughter has had mania/rage as far back as I can remember. In the last 2 years, it has included suicidal ideation/threats. She is 9. It hurts me so much to see her in such pain for no apparent external reason! We have a family history of affective disorders, so I don't understand why we are not taken more seriously...

Our family doctor agrees, but all she can do is refer us to the mental health system, which is somewhat of a joke.

She is now on a waitlist to be seen by a counselor...then if the counselor thinks she needs more, she will be referred to a psychiatrist. I understand the need to reserve psychiatry for those who really need it, but my daughter has already been through anger-management type counseling, youth groups that focus on anger controlling skills, etc and a counselor who gave her a "worry box"...(she already had two, but hey maybe it will work this time)... and considering our family doctor's request and support for psychiatric consult, I just don't get why we have to go through these filters. My interest isn't convincing anyone that she needs medication. My focus is talking with someone who is at least willibg to listen to me and my perspective as her mother, mental health student, and patient of psychiatry.

I was told by the referring agency(?), the next time my daughter shows suicidal ideation to take her to the hospital. I am really hesitant as I think this will only humiliate her and make it worse. She already feels like something is wrong with her, that she's not 'normal' and I think anyone who knows these kids also knows they don't deal well with embarrassment. Besides, she would probably be calmed down by the time we got there! Then what...more talk therapy?? Plan what she can do next time to calm herself down?? I just think this will make her feel worse, because she already knows this stuff and can't act on it in the midst of a rage.

I have done a lot of soul-searching and pride-swallowing to accept that I can't change this on my own. I believe in psychiatry, but I am slowly losing faith in our psychiatric community.

Sorry for the rant. Just very frustrated about this issue.

Dizfriz
12-05-09, 06:44 PM
MGDAD

Thanks for posting this. I am pretty familiar with the material as presented but it is a very good review. I printed the assessment section so I could read it in some detail.

ditzydreamer

There is an ongoing struggle to get educators and professionals trained on childhood bipolar. It seems that so many either will not recognize it at all or diagnose every kid with anger or acting out issues as bipolar.

Much of the problems stems from not having good criteria. For general information, here is the April 09 report for the DSM-V workgroup dealing with childhood bipolar.

http://www.bpkids.org/site/DocServer/treatment_guidelines.pdf?docID=441

Treatment Guidelines for Children and Adolescents With Bipolar Disorder: Child Psychiatric Workgroup on Bipolar Disorder


Clinicians who treat children and adolescents with bipolar disorder desperately need current treatment guidelines. These guidelines were developed by expert consensus and a review of the extant literature about the diagnosis and treatment of pediatric bipolar disorders. The four sections of these guidelines include diagnosis, comorbidity, acute treatment, and maintenance treatment. These guidelines are not intended to serve as an absolute standard of medical or psychological care but rather to serve as clinically useful guidelines for evaluation and treatment that can be used in the care of children and adolescents with bipolar disorder. These guidelines are subject to change as our evidence base increases and practice patterns evolve.

Much of the work performed by the Child and Adolescent Disorders Work Group during the past year focuses on preparing for Field Trials. The group has delineated five sets of issues that generate questions for Field Trials. Three of these issues relate to the creation of either relatively new syndromes or relatively novel developmental extensions of existing DSM-IV syndromes. The final two issues relate to the need to increase the focus on development in DSM-V by increasing the focus on developmental manifestations and by considering the addition of novel developmental subtypes. Moreover, these two issues also might be addressed by the addition of dimensional measures.

The particular questions in some areas are still taking shape. However, the details are sufficiently clear to provide initial answers to the questions posed to each Work Group on anticipated future directions. The specific issues are delineated in five categories.

The current document summarizes areas where field trials appear indicated. The document also briefly delineates the populations in which such trials might be based.

A. Non-Suicidal Self Injury: The Child and Adolescent Disorders Work Group continues to work on the proposal that DSM-V should involve a new entity, labeled non-suicidal self injury (NSSI). A few issues have emerged that should be answered before field trials are considered for this entity:


a. Draft criteria for NSSI must be established. b. The relationship between these criteria and suicidal ideation or behavior must be clarified.

c. Measures for assessing the criteria for NSSI as well as suicidal ideation or behavior must be studied in diverse settings and age groups; this work also should consider methods for distinguishing NSSI from suicidal ideation or behavior.

B Pediatric Mood Disorders: Work continues by the Child and Adolescent Disorders Work Group on possible modifications to various mood disorder syndromes.

a. Pediatric bipolar disorder: New criteria for mania and bipolar disorder may emerge from the Mood Disorders Work Group. Applications of these precise criteria to samples of pediatric mood disorder patients are needed. A field trial would require data among individuals of various ages, including school-aged children, adolescents, and adults.

b. Severe irritability: A new entity related to severe irritability is being defined, potentially as a subtype of both oppositional defiant disorder and mood disorders. A field trial would require data among individuals of various ages, including school-aged children, adolescents, and adults. Moreover, the trial would require data both in psychiatric patients and in community-based individuals.

c. Pediatric Major Depressive Disorder: New criteria for major depressive disorder may emerge from the Mood Disorders Work Group. Applications to pediatric samples are needed, as is a consideration of eliminating the “irritability” criterion.

C. Pediatric Trauma-Related Disorders: Work continues by the Child and Adolescent Disorders Work Group on possible modifications to various trauma-related syndromes.

a. Preschool post-traumatic stress disorder (PTSD): New criteria for PTSD in preschoolers will be proposed. Applications of these precise criteria to relevant samples are needed.

b. Child and Adolescent PTSD: New criteria for PTSD in adults may emerge. These will need to be applied to studies in youth. Moreover, developmental manifestations of PTSD also may emerge. These will need to be applied as well. Developmental Trauma Disorder: A proposal for a new disorder has been made. If this proposal is approved, new criteria must be evaluated.

D. Developmental Manifestations: A new proposal for DSM-V concerns the inclusion of a section on “Developmental Manifestations” of other DSM syndromes. When new criteria have been finalized for each DSM-V syndrome, applications of developmental manifestations should quickly be attempted. A few areas appear particularly ripe for such work.

a. As noted above, work on PTSD will need to consider developmental manifestations. b. All of the disruptive behavior disorders should include developmental manifestations.

c. Other categories of disorders that should include considerations of developmental manifestations include the autism-spectrum disorders, mood disorders, anxiety disorders (particularly separation anxiety disorder), personality disorders, and eating disorders.

E. Developmental Subtypes: Work Groups are considering whether the early vs. late-onset conduct disorder designation should be maintained. Beyond this age-related subtype and the consideration of a new age-related subtype of pediatric PTSD, a few other entities may have sufficiently strong data to support consideration of including age-related or developmental subtypes in DSM-V. These comprise: obsessive compulsive disorder (OCD); generalized anxiety disorder (GAD); major depressive disorder; and substance-use disorders.

F. Dimensional Measures: Finally, the group has begun to consider methods for developing symptom-based dimensional measures that can be used for measurement-based care.

This gives a little insight into what may be coming up.

Trying to get help for a bipolar child can be an exercise in frustration especially when working through a medical bureaucracy. Keep on plugging. I firmly feel the best diagnostic tool is parents determined to get appropriate help for their child.

Dizfriz

Trooper Keith
12-05-09, 07:08 PM
But many professionals don't even recognize bipolar in children yet.

The DSM-IV currently does not pay any special consideration to children, which makes it difficult to diagnose unless you're specialized in it. A large portion of children at the hospital where I worked were diagnosed bipolar and I simply saw no evidence of it - it seems that any given practitioner will either diagnose every moody kid with it, or underdiagnose it. I tend to see people leaning more towards the former - rates of bipolar diagnosis in children have drastically increased in the last few years, making it the new "ADHD" with regards to diagnoses in vogue.

Professionals are far more likely to diagnose ADHD than bipolar in children.

I don't know that this is true, but my sample is comprised only of children who have severe disabilities. Almost all children who have a bipolar diagnosis also have ADHD.

Parents are viewed as exaggerating or misinterpreting their children's emotions as rage rather than simple "tantrums". At least, that is how I'm feeling at the moment. We have to jump through hoops just to be seen by a child psychiatrist...unless of course we could afford a private psychiatrist.

What country are you in, out of curiosity? UK, Canada? Juvenile mental health in those countries is a mess to start with.

My daughter has had mania/rage as far back as I can remember.

ADHD can result in rages, as can a plethora of other disorders including garden variety depression. Rages are a child's way of expressing emotions that are too complicated for them to process; emotions like profound depression or frustration. Rages don't necessarily indicate bipolar disorder.

It's very difficult to assess mania in children unless there are psychotic features or other symptoms unique to mania. Irritability and rages can indicate both depression and mania in children. This is one of the reasons why bipolar is so difficult to diagnose in children.

In the last 2 years, it has included suicidal ideation/threats.

This is not indicative of ADHD (but does not rule it out), and is indicative of a severe mood disorder.

She is 9. It hurts me so much to see her in such pain for no apparent external reason! We have a family history of affective disorders, so I don't understand why we are not taken more seriously...

Have you considered taking her to the hospital when you feel she might become dangerous to herself? There is a difference, of course, between a frustrated child saying "I'm going to kill myself!" and a child making a plan to actually do so. A lot of times "I'm going to kill myself!" is a child's way of expressing that they are so frustrated that they don't know what to do - they express the most damaging potential option as a way to get you to realize just how frustrated they are.

Our family doctor agrees, but all she can do is refer us to the mental health system, which is somewhat of a joke.

It seems that this is true in the Commonwealths. It might be seen as one of the "cons" to universal health care that our political right keeps touting.

She is now on a waitlist to be seen by a counselor...then if the counselor thinks she needs more, she will be referred to a psychiatrist.

Well at least the ball is rolling.

I understand the need to reserve psychiatry for those who really need it,

That's not the real reason here - it's that psychiatry costs a lot of money and if a cheaper solution can present itself, then that's better. </cynic> Also, there are a limited number of doctors and a lot of children. Better to weed out the less profound ones early on.

I just don't get why we have to go through these filters.

Only so many doctors to treat a lot of children. Also those doctors are expensive.

I was told by the referring agency(?), the next time my daughter shows suicidal ideation to take her to the hospital. I am really hesitant as I think this will only humiliate her and make it worse.

Yeah pretty much this is what I was hinting at above. If you take her to the hospital she'll be triaged for immediate inpatient care, which will get the ball rolling with regards to psychiatric treatment much faster. Hospitalization is a great way to "skip the line" to medication because there isn't enough time to try counseling and such on an inpatient - the goal is to stabilize them and clear the bed for the next person.

She already feels like something is wrong with her, that she's not 'normal' and I think anyone who knows these kids also knows they don't deal well with embarrassment.

Being hospitalized can be humiliating, but the benefits might outweigh the losses. From the sound of it, she's going to be involved in the mental health system for the rest of her life. Might as well start things early so she can get used to the idea.

Besides, she would probably be calmed down by the time we got there!

Maybe, maybe not. The problem is that often times these "rages" burn children out quickly, especially if left unchecked, and they enter tension reduction before you can get them to care - and the tension reduction stage of crisis (characterized by emotional and physical exhaustion) doesn't look impressive to a triage nurse.

Then what...more talk therapy?? Plan what she can do next time to calm herself down?? I just think this will make her feel worse, because she already knows this stuff and can't act on it in the midst of a rage.

Coping skills take a long time to learn but once they're internalized they can be very valuable. Proper crisis intervention encourages children to utilize their coping skills.

I have done a lot of soul-searching and pride-swallowing to accept that I can't change this on my own. I believe in psychiatry, but I am slowly losing faith in our psychiatric community.

My understanding is that psychiatric care in the Commonwealths is poor compared to the United States.

Sorry for the rant. Just very frustrated about this issue.

It can be very frustrating. If you ever need to talk, I'm here for you.

JenE
12-05-09, 10:33 PM
I broached the idea of bipolar for my son at our last psychiatrist visit. As a policy, their office doesn't diagnose children with bipolar since there are no official diagnostic tools for it. She said, even if they did, it wouldn't change anything because they treat the symptoms and not the diagnosis so they wouldn't approach him any differently. Made sense to me.

Dizfriz
12-06-09, 06:59 AM
I broached the idea of bipolar for my son at our last psychiatrist visit. As a policy, their office doesn't diagnose children with bipolar since there are no official diagnostic tools for it. She said, even if they did, it wouldn't change anything because they treat the symptoms and not the diagnosis so they wouldn't approach him any differently. Made sense to me.

I have never worked with a child psychiatrist who would put a diagnosis of bipolar disorder on a young child if at all possible. As you say, they would treat for the symptoms and not the diagnosis.

Dizfriz

Vickie
12-07-09, 01:35 PM
Our psychiatrist also does not really give a formal bipolar diagnosis to kids, but treats the symptoms as needed without the label.