2002 Annual AACAP Convention

report from the Child & Adolescent Bipolar Foundation

This year's American Academy of Child & Adolescent Psychiatry (AACAP) meeting witnessed a substantial increase from previous years in presentations on early onset bipolar disorder by a variety of research centers. Selected highlights included:

1. Combination Pharmacotherapy in Pediatric Bipolar Disorders-Mood Stabilization

   Dr. Robert Findling presented data on a study of the use of lithium combined with divalproex (Depakote) in adolescents with BD. In this recently completed open-label, prospective, outpatient trial, children and adolescents with bipolar I disorder were treated for up to 20 weeks with combination therapy of lithium and depakote. Substantial symptom reductions were observed. More importantly, approximately half of the subjects who entered the trial achieved syndromal remission. The results of this study lend support to the idea that combination therapy may be a rational form of pharmacotherapy in pediatric bipolarity. It is suggested that treatment start with Lithium or Depakote as monotherapy for a trial of 6 weeks. If at that point the child is considered treatment nonresponsive, a second mood stabilizer may be added.

2. Combination Pharmacotherapy in Pediatric Bipolar Disorders-Treating Comorbid ADHD

   It is widely accepted that ADHD is highly comorbid with BD. In this presentation, Dr. Russell Sheffer and Dr. Robert Kowatch discussed a double-blind trial designed to determine the safety and efficacy of adjunctive Adderall vs. placebo. Subjects were youth ages 7-15 with BD taking Depakote. Results indicate that while significant reductions in mania symptoms are often achieved with Depakote, combination treatments are often needed to additionally address ADHD symptoms Adderall appears both safe and efficacious for co-morbid ADHD, but the mood disorder must be treated first. Of the participants with comorbid ADHD, 92% showed a positive response to adderall. The initial data was not stratified for types of ADHD, but it is suggested that the positive effects are seen on concentration and focus vs. hyperactive behavior. An additional point was made in this presentation that, like ADHD, there may be persistent symptoms of depression, which may respond to a low dose anti-depressant medication.. Again, this treatment should be secondary to treating the BD.

3. Olanzapine Treatment for Adolescent Bipolar Disorder

   Dr. Melissa DelBello presented a study designed to assess the effectiveness, tolerability, and safety of olanzapine (Zyprexa) monotherapy for the treatment of hospitalized adolescents with mania associated with bipolar disorder, type I. In this study, nine manic or mixed-state BD adolescents were treated with 5-20mg of olanzapine during a 4-week open prospective trial. Preliminary results indicate that olanzapine is safe, effective and well tolerated for reducing mania, depressive and psychotic symptoms associated with adolescent BD. 70% of the subjects showed a response and 50% achieved remission, as measured by a score of <12 on the YMRS. It was also noted that comorbid ADHD improved in 89% of the subjects. Side effects noted as follows: sedation (78%), increased appetite (44%), and dizziness (22%). Sedation was associated with nonresponse to treatment, while weight gain (averaging 12 lbs) was associated with a positive response.

4. Omega-3 Fatty Acids in the Treatment of Mood Disorders

   Dr. Janet Wozniak presented a review of the literature, which suggests that this dietary supplement may play an important role in the prevention and treatment of mood disorders, addressing safety, efficacy and dosing. Unfortunately, the current literature is limited to one positive adult bipolar study and one case report addressing adult depression. Dr. Wozniak described her current study in progress, which is focused on the use of Omega-3 fatty acids in the treatment of BD in children and adolescents. Dosing in this study is at 2.6 grams and uses the brand OmegaBrite, the contents of which have been confirmed by MGH labs. The comparison group is being treated with olanzapine and topiramate.

5. Recognition and Treatment of Putative Prodromal Pediatric Bipolar Disorder

   Dr. Kiki Chang discussed the need for prevention of BD in young children. With research advances, several common risk factors have emerged for pediatric bipolar disorder. These include a family history of mood disorders and ADHD in a parent. Dr. Chang presented findings from a recent study designed to evaluate the efficacy of divalproex (Depakote) in children with mood and/or behavior disorders, who have a parent with BD. 25 children with a bipolar parent and who had major depression, dysthymia, ADHD, or cyclothymia were treated with divalproex for 12 weeks. Of the 23 subjects who completed more than 2 weeks of treatment, 18 (78%) were considered responders based on their Clinical Global Impression-Change. Side effects were minimal, except for mild weight gain. The researchers conclude that divalproex may be effective in treating bipolar offspring with mood and behavior disorders. Longitudinal study would be necessary to assess any role of divalproex in the prophylaxis treatment of full-blown BD in these children. This study has important implications for the early recognition and treatment of pediatric BD and raises an interesting area for future research into the efficacy of divalproex as an anti-kindling agent, with possible neuroprotective and neurogenerative effects.

6. Comparison of Two forms of Psychosocial Treatment for Oppositional Defiant Disorder: Outcomes at Four Months Post-Treatment

   Dr. Ross Greene presented data from an exciting study comparing the effectiveness of a Parent Management Training (PMT) approach with his own cognitive-behavioral approach, Collaborative Problem Solving (CPS) for children with oppositional defiant disorder (often part of the picture in unstable children with bipolar disorder). The CPS approach follows Dr. Greene's "Basket Approach" as outlined in his book The Explosive Child. This approach places emphasis on cognitive factors vs. behavior per se in response to increased frustration and increased emotional arousal. Critical elements of Greene's approach include:

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   1. assessing and understanding cognitive skill deficits and adult/child incompatibilities that contribute to ODD behavior
   2. training cognitive skills in the environments they are to be performed (recognizing that these children are often very different in a therapist's office)
   3. the enlistment of caregivers in training.

   CPS focuses on "collaborative" parent/child problem solving. CPS has been shown to contribute to a reduction in meltdowns, the teaching of cognitive skills (including emotional regulation and working memory), and the development of linguistic skills, or a "feelings" vocabulary.

   Results of this study show that while both psychosocial approaches produced significant improvements in parent and therapist ratings of ODD behaviors, the gains achieved by CPS were significantly superior to those achieved by PMT at three post-treatment assessments.

   Dr. Greene went on to discuss the recent implementation of CPS at the Child Assessment Unit at Cambridge Hospital in response to a national call to reduce physical and chemical restraints, seclusion events and physical holds in inpatient programs. Unit staff was trained in CPS and was able to dramatically reduce seclusion events and restraints. The use of CPS on the unit was also correlated with improved staff morale. The data from this study suggest that CPS is effective with a wide range of child psychiatric disorders and settings.

7. The Clinical Features of Bipolar Depression in ADHD Children

   Dr. Janet Wozniak discussed the complex clinical problem of distinguishing between bipolar and unipolar depression in children. Results of this study indicate that bipolar depression differs from unipolar depression in that it is:

   1. more likely to present at an earlier age
   2. more likely to present with severe impairment
   3. more likely to present with severe, prolonged, explosive, and violent irritability
   4. more likely to present with high levels of comorbidity with severe ODD, CD and multiple anxiety disorders.
   5. More likely to present with suicidality.

   Results of this study indicate that bipolar depression does show distinctive clinical aspects that can help determine appropriate treatment options. A thorough understanding of these differences by clinicians may decrease the use of inappropriate treatment. Wozniak said that SSRIs can help children with bipolar depression, if they are treated with a mood stabilizer first.

8. Patterns of Comorbidity and Dysfunction in Clinically Referred Preschoolers with Bipolar Disorder

   Dr. Timothy Wilens presented a comparison study of preschoolers (up to age 6) and school age children (age 7-9) referred for BD. This study makes an important contribution to the growing acknowledgement and awareness of the occurrence of BD in preschool age children. In a chart review of 44 preschool children with BD and 77 school age children with BD, the researchers conclude that while preschoolers are significantly younger, their BD is similar to that seen in older children across a number of areas. Preschoolers show similar rates of psychiatric comorbidity and impairment in school, social, and overall functioning. In most of the children, the onset of mania preceded the onset of depression. In the preschool group, the children met criteria for mania at an average age of 2.5, and met criteria for depression at 3.6 years. They were seen in the clinic at the mean age of 5, indicating that these children had already been severely impaired for half of their young lives. The need for a better clinical understanding of pediatric BD is clear and the benefits of early identification, diagnosis and treatment cannot be understated. Follow-up with the children in this study will be needed to evaluate the stability of their diagnosis, treatment response and their long-term outcome. Wilens said that family functioning in both groups of children with BD was relatively normal, and that "it is not family dysfunction driving the psychopathology of the child."

9. Characterizing Child-Onset Bipolar Disorder in Bipolar Adults

   Dr. Eric Mick presented a study designed to test the hypothesis that the earlier onset of BD would correlate with a developmental subtype of BD in adults that includes mixed or dysphoric mania. This occurs in about 30% of adults with BD, said Mick. Child-onset BD in adults was associated with a longer duration, more irritability than euphoria, a mixed presentation, a more chronic or rapid-cycling course and increased comorbidity with childhood disruptive behavior disorders and anxiety disorders and substance use disorders. The fact that this pattern is consistent with the clinical presentation typically seen in children with BD supports the hypothesis that age of onset is correlated with a developmental subtype of BD.

10. Neuroanatomic Magnetic Resonance (MRI) in Pediatric Bipolar Disorder

    In adults with BP, MRI studies consistently find deep white matter and periventricular hyperintensities, which may be evidence of scarring. Dr. Jean Frazier summarized child study findings and presented preliminary analysis of the first 42 of 100 children she has scanned in her ongoing neuroimaging study. All of the children have first or second degree relatives with affective illness, and 62% have a first or second degree relative with BD. The children in her study are very ill, with a YMRS score averaging 31 and GAF of 50. She is finding that in the children with BD (versus normal controls), the thalamus tends to be larger, and total cerebral volune and total hippocampus volume are smaller. Differences in the right inferior lateral ventrical and the amygdala may indicate "some form of damage" that appears to be genetic, and not related to medication use, perinatal or environmental effects, said Frazier. While these findings must be replicated, and it is still too soon to rely on neuroimaging technology (including SPECT scans) to diagnose BD, this is an exciting area of research which may in the future lead to earlier identification and appropriate treatment of pediatric BD. MRI can be helpful in ruling out other conditions; Dr. Frazier told of one case of a girl (9) with psychosis, headaches, and bipolar symptoms, who was nonresponsive to psychiatric medications. Upon MRI scan, she was found to have multiple lesions in her brain and was diagnosed with CNS Lyme Disease.

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