Youth Bipolar I Disorder

Brittany S Saxton

Louisiana State University: School of Social Work

Social Work 7307: Direct Practice with Children and Adolescents

Jennifer Sheridan, LCSW, RPT

November 24th, 2024

Youth Bipolar I Disorder Overview
Overall (Chang, 2009) Manic Episodes (Chang, 2009)
• Bipolar Spectrum Disorders (BPSD) begin in childhood 50-66% of the • It is often mania symptoms that bring in youth for
time diagnosis
• If we know the incidence of BPSD in adults to be 4%, then there are at • High energy
least 1-2 million BPSD children developing • Recklessness
• In a large study (n – 263) children were symptomatic, either major • Impulsivity
depressive or mania, 66% of the time • Sleeplessness
• They averaged a mood shift of 16 times per year and 34.1% • Hyper sexuality
shifted their mood polarity more than 20 times. • Irritability/Anger (Chang, 2009) and even
• The youth average prevalence rate of Bipolar I is 0.6%, and Other aggression in some (Consoli et al., 2009).
Specified Bipolar and Related Disorders (OSBARD) are the most
prevalent BPSD in youth. However, the 5–8 year conversion rate to
Bipolar I is 30-50% (Brickman & Fristad, 2022).

Major Depressive Episodes (Chang, 2009)

• Compared to adults, children spend more time in Major depressive
episodes 32% to 53%, respectively.
• Data also shows children had an increased rate of suicidal ideation (SI)
at 76%. Of these, 31% reported a past suicidal attempt. Children also
have high rates of hospitalization (Brickman & Fristad, 2022).
• 20-49% of children who experience a major depressive episode will
experience a manic episode by adulthood.

Symptoms that may suggest a depressive onset (Chang, 2009)

• Acute psychosis, evident irritability, labile mood, poor or brief
hypomanic reaction to antidepressant treatment
• An atypical depressive episode further suggests the development of a
future manic episode.
Youth Bipolar I Disorder Overview
Clinical Challenges (Chang, 2009)
• Mood episodes are associated with psychotic symptoms 30-70% of the time, making it difficult
to determine if the person is experiencing an acute delusional schizophrenic episode or BPSD.
There is an estimated 50% diagnostic error in the initial evaluation. (Consoli et al., 2007)
• Irritability is a hallmark symptom of both depression and mania in children. This can lead to
episode misdiagnosis.
• Children also frequently experience “mixed episodes” consisting of both mania and
depression, complicating diagnosis further.
• There are often comorbid behavioral disorders, Attention Deficit Hyperactive Disorder (ADHD),
substance abuse, anxiety, and obesity(Consoli et al., 2009)(Goldstein et al., 2020).

Differential Diagnosis (Goldstein et al., 2020)

• ADHD, Disruptive Mood Dysregulation Disorder (DMDD), Other disruptive behavior disorders,
Major Depressive Disorder (MDD)
• Can have BPSD and DMDD.
• Episodic changes in the severity of attention, irritability, and energy problems are more indicative of a
mood disorder.
• Irritability is often present in anxiety disorders and trauma symptoms
Bipolar I Disorder Diagnostic Criteria
B – Three (or more) significant, unusual (for the individual)
A - Distinct period of symptoms (four if the mood is only irritable) also present
Grandiosity/inflated self-esteem
abnormally/persistently elevated, Decreased need for sleep
expansive or irritable mood and More talkative/pressure to keep talking
increased activity or energy, at least Flight of Ideas/reported racing thoughts
Reported/observed Distractibility
one week – present nearly every day Increased goal-directed activity OR psychomotor agitation
for most of the day. Increased involvement in higher-risk behaviors

Manic
Episode*
C – Mood disturbance causes marked
impairment in functioning D – The episode is not attributed to a *Must
fulfill A-
(Hospitalization to prevent self-harm, substance or other medical condition D in a
harm to others, and/or associated single
episode
with psychotic features.

(American Psychiatric Association [APA],

2013)
Bipolar I Diagnostic Criteria
Major Depressive Episode
A – Five or more
symptoms present
simultaneously for
at least a two-week
period.
One of these B – Symptoms cause C – Not attributed to
symptoms is either clinically significant a substance or other Fulfills criteria A-C
depressed mood or distress or medical condition
loss of interest or impairment
pleasure.
There is a change in Important Notes (APA, 2013)
the previous level of • Children – irritability, and
functioning. failure to meet weight
milestones
• Nearly every day
Depressed mood (either by self-report or observation) • Restless/slowed observable by
A reported or observed marked decrease in interest or pleasure in all or almost all activities others
A 5% or more weight change in a month, increased or decreased appetite • Caution – Pathologizing normal
Insomnia or hypersomnia behavior
Psychomotor agitation or retardation
Fatigue/loss of energy
Feelings of worthlessness/Inappropriate guilt
Indecisiveness/inability to concentrate or to think
Suicidal Ideation/attempts, thoughts of death and dying

(APA,
2013)
Bipolar I Disorder in Youth
• Hypo-Manic Episode (APA, 2013)
• Fulfills criteria A-F
• A – Same as Manic
• B – Same as Manic
• C – an uncharacteristic change in an individual’s functioning
• D – The change is noticeable by others
• E - Mood disturbance does not cause marked impairment
• F – The episode is not attributed to a substance or other medical condition

• Important Notes (APA, 2013)

• Antidepressants
• Hospitalization
• Hypomanic VS Manic (lifetime occurrence)
• Diagnosis of BPI
 Bipolar I Disorder DSM 5 Coding
Current or most Current or most Current or most Current or most
recent episode recent episode recent episode recent episode
manic hypomanic depressed unspecified

Mild F31.11 N/A F31.31 N/A

Moderate F31.12 N/A F31.32 N/A

Severe F31.13 N/A F31.4 N/A

With psychotic F31.2 N/A F31.5 N/A

features
In partial F31.73 F31.71 F31.75 N/A
remission
In full remission F31.74 F31.72 F31.76 N/A

Unspecified F31.9 F31.9 F31.9 N/A

(APA, 2013)
Bipolar I Diagnostic Coding
• Notes (APA, 2013)
• If the current/most recent episode is hypomanic severity and
psychotic features do not apply – F31.0 not in remission
• If the current/most recent episode is unspecified then no specifiers
apply – F31.9
• If psychotic features present code “with psychotic features”
irrespective of episode severity
• Name of diagnosis to be listed as Bipolar I, current/most
recent episode, severity/with psychotic/remission
• This is followed by any of the specifiers listed that apply to
the current or most recent episode
• With
• anxious distress, mixed features, rapid cycling, melancholic features, atypical
features, mood-congruent or mood-incongruent psychotic features, catatonia
(requires additional code F06.1), peripartum onset, seasonal pattern
• Ex: Bipolar I, Current episode manic, moderate, rapid cycling, atypical
Disorder Youth
Impact • BPSD is often chronic and continuous for
youth (Consoli, 2009) and associated with
• Increased rates of functioning impairment (high levels of
control, conflict, criticism, hostility, and emotional significant impairment and reduced quality of
involvement by family members) and low levels of life (Brickman & Fristad, 2022).
cohesion and expressiveness are all risk factors for youth • BPSD youth are at an increased risk for
BPSD (Brickman & Fristad, 2022).
• Negative family environments are associated with poor
behavioral problems, suicidality, family
prognosis and higher symptom severity for youth conflict, physical and sexual abuse, and poor
(Brickman & Fristad, 2022) functioning (Goldstein et al, 2020).
• Current therapies focus on family response to treatment • Greater comorbidities, environmental
due to their significant impact on prognosis (Goldstein et
al., 2020). stressors, poor psychosocial functioning, low
• Parent diagnosis of BPSD is the biggest risk factor for socioeconomic status, and a family history of
their child’s diagnosis, though a parent history of MDD or psychopathologies all contribute to poorer
Obstinate Defiant Disorder(ODD) was also associated prognoses (Goldstein et al., 2020)
with BPSD (Goldstein et al., 2020).
• A study found that 33.6% of children aged 6-18 of a
• BPSD progression in high-risk youth often
parent with BPSD were also diagnosed with a BPSD. begins with prepubescent non-mood
• If a parent were diagnosed before age 21 and their child symptoms, followed by nonspecific minor
showed suggestive symptoms, then the child’s risk rose mood symptoms around puberty and
to 50%.
•
depressive episodes in adolescence. Finally,
Environmental feedback loops created through BPSD
youth interaction with peers, parents, teachers, siblings, a (hypo)manic episode occurs. This usually
etc., and vice versa contribute to symptom severity, happens several years after the first
longevity, and disorder prognosis (Chang, 2009) depressive episode (Brickman & Fristad,
2022).
 Diagnostic and Treatment
Psychosocial Treatments for Challenges in the Diagnosis
Treatment in Child and Challenges in Bipolar
Bipolar Disorder in Children and Treatment of Pediatric
Adolescent Bipolar Disorders Disorder in Children and
and Adolescents Bipolar Depression
Adolescents
Researchers presented all The researcher discusses the Researchers conducted a Researchers begin with an
known evidence-based challenges associated with literature review of acute outline of the four Bipolar
treatment options for youth recognizing Bipolar and prophylactic treatment Disorder variants included
with BPSDs. They divided depression in youth. They of Bipolar disorder in youth in the DSM 5. They then
them into categories based discuss how Bipolar populations. They focus discuss differential
on empirical support for depressive symptoms their data gathering on diagnosis, and the
their efficacy. They also usually present, in adult pharmacotherapy and challenges associated with
compare the treatments populations and how that compare the efficacy of the this process. They then
core components and differs from youth most popular treatments. discuss disorder onset and
treatment targets. They presentation. They then They found that, for mood prognosis factors. Of note,
then summarize research end their article discussing stabilizers, only Lithium this section discusses new
on treatment moderators the use of antidepressants, had been tested in a research suggesting four
and mediators. Finally, they specifically SSRIs in this double-blind placebo study. mood trajectories of youth
discuss best practices for population. They cite issues They also gave information BPSDs. The authors then
BPSD treatment based on such as triggering a about electroconvulsive discuss treatment options.
age and disorder (hypo)manic episode. Their therapy. The paper They divide these
progression. The authors recommendation is the use concluded by detailing the treatments by the
suggest that manualized of mood stabilizers, issues related to rigorous presenting symptomology.
psychosocial interventions antipsychotics and study and empirically For example, 2 of the
coupled with adjunctive psychotherapy supported treatment categories are Mania and
pharmacotherapy is best (Chang, 2009). options for youth (Consoli Comorbid disorders. They
practice when treating et al., 2007). conclude with a discussion
youth. They also make a about risk calculators. It is
case for preventative their recommendation that
interventions (Brickman & future research focus on
Fristad, 2022) the development and
validation of a BPSD risk
calculator (Goldstein et al.,
2020).
 • Pharmacotherapy is considered the first line of treatment (Consoli

Treatment Information et al., 2007). Data has shown that complementary psychosocial
interventions increase treatment efficacy, leading current
guidelines to suggest a combined approach (Brickman & Fristad,
2022).
• For children aged 6 to 17 treatment is similar to • Stimulants for comorbid ADHD have not been found to cause
adult treatment (Consoli et al., 2007). adverse psychological effects for BPSD youth (Goldstein et al.,
2020).
• Some suggest prophylactic treatment to reduce
• Antidepressants caused as many as 44% of children to switch from
relapse (Consoli et al., 2007). a depressed episode to a manic/mixed episode (Chang, 2009).
• Depressive episodes have been found to be more • Youth are more susceptible to the side effects of SSRIs and a
responsive to psychotherapy treatment than manic chart review (n – 87,920) found that children aged 10-14
were most likely to be switched from a MDD to a BPSD
episodes (Chang, 2009). diagnosis after being prescribed an SSRI.
• Adjunctive psychotherapy treatment has shown • BPSD Youth may account for a large portion of the SSRI-SI
even greater improvement in mood symptom association that led to the Black Box warning on SSRIs for
severity and frequency. Data has shown that these suicidality.
interventions have led to greater medication • Psychotherapy (CBT, DBT, Family therapy) for youth with
BPSD has been found to be as effective as SSRIs without the
adherence as well. Parent and individual Pharmacotherapy
side effects (Chang, 2009).
education, skill development, and recovery support Treatment Stages
alongside pharmacotherapy have shown long-term Post-mania
improvements in family and peer relations and • Intensive treatment • 2 years
school performance (Goldstein et al., 2020) pharmacotherapy and • Pharmacotherapy may
psychosocial • !2 to 24 months be lessened or
• A major focus of psychotherapy is the identification interventions maintenance stopped
• May include • Consists of • Psychosocial
of disorder risk factors and early symptoms, as it is hospitalization pharmacotherapy and interventions may
believed that early intervention can disrupt the psychosocial continue
interventions Post
conversion of subclinical symptoms into later discontinuation
BPSDs (Goldstein et al., 2020). Acute Treatment
Symptom
Monitoring
(Goldstein et al., 2020)
 Psychotherapy
Psychotherapy treatment focuses on:
1. Psychoeducation
A. Contributes to an improved family environment which in turn contributes to better short and
long-term treatment outcomes (Brickman & Fristad, 2022)
2. Behavioral/Cognitive Interventions
A. Stress reduction
B. Improving coping techniques
C. Mood recognition techniques (Chang, 2009)
• Specific Treatments include:
• Family Psychoeducation and Skill Building (FP+SB)– three manualized treatments that have shown
efficacy, feasibility, and acceptability through large, rigorous, single-blind, randomized controlled
trials. These treatments all incorporate a progression of three important interventions (Brickman &
Fristad, 2022)
• First, family-focused psychoeducation, followed by cognitive behavioral therapy (CBT) for family
and individuals and ending with communication and problem-solving skill training.
• These treatments all aim to increase positive family interactions while simultaneously reducing
expressed emotion through constructive communication and effective problem-solving.
• Studies focused on FP+SB were the first to show that treatment can delay or prevent youth
progression to a BPSD diagnosis. – these youth were 4x less likely to receive a BPSD diagnosis
at their 1-year follow-up than their control counterparts.
 Psychotherapy
3. Psychoeducational Psychotherapy PEP
1. Family Focused Treatment for Adolescents FFT-A A. Focuses on psychosocial contributors to mood disturbances.
A. Adapted from an adult BPSD treatment B. Utilizes family-based psychoeducation and cognitive behavioral
B. 21 sessions and 3 phases techniques
a) Psychoeducation a) Mood symptoms, identification and monitoring as well as
emotional regulation, coping skills, cognitive restructuring,
b) Communication enhancement training
communication training, problem-solving skills, social skills
c) Problem solving skills training training
C. This treatment has three goals as well b) Especially educates and empowers parents through
a) Develop a common understanding of BPSDs knowledge and resources
b) Reduce family expressed emotion C. Can be in a group or individual format – some studies show that
c) Psychoeducation about symptom management, stress and improvements were maintained for up to 5 years post-treatment
coping techniques, mood charting, and prevention D. Symptom (mood symptom severity, family functioning, emotional
planning. regulation, and coping skills) severity was significantly reduced
D. This treatment is especially effective at treating depressive and maintained at 1 year following treatment and at an 18-month
symptoms. follow-up
E. It was found that family cohesion persisted up to 2 years at 4. Dialectical Behavioral Therapy DBT (Brickman & Fristad,
follow-up. 2022)
F. There are adaptations - FFT-HR (High Risk) for youth with A. Explicit focus on suicidality, sleep and treatment
significant mood disturbances and a family history of BPSDs and
FFT-SUD (Substance use disorder) , which is also conducted in 21 adherence – effective at reducing depressive and
sessions for youth with comorbid SUD. D. suicidal symptoms
B. DBT participants showed an 83% reduction in SI
2. Child and Family Focused Cognitive Behavioral Therapy CFF-CBT compared to 50% for their control counterparts, these
A. Created to be developmentally specific to children with BPSDs. participants also spent 2x more time in a euthymic
B. 12 sessions during the acute phase, alternating individual, family state.
and parent sessions C. Weekly and Biweekly sessions – alternate between
C. Booster sessions are provided as needed during the maintenance individual therapy and family skill building sessions –
phase
longer length than other therapies at 1 year
D. This treatment focuses on affect regulation, cognitive
restructuring, social skills, healthy habits and family support. D. Most appropriate for youth who have recently
E. Participants showed several improvements in manic and experienced an acute mood episode
depressive symptoms as well as sleep disturbance, social and
academic functioning psychosis, and ADHD symptomology which
was maintained 3 years post acute/maintenance treatment.
Pharmacotherapy BPSD Medication
Hierarchy
BPSD with no acute Psychosis

• 1 Mood Stabilizer OR
• 1 Antipsychotic
Lithium is only recommended for children
over the age of 12. One study found that
After 4-6 weeks and a low response
children who ended Lithium treatment early
had a relapse rate of 92% compared to the • Add another medication
37% rate of those who completed the • 2 mood stabilizers are preferred to 1 mood
treatment (Consoli et al., 2007) stabilizer and 1 antipsychotic
• If psychotic features appear then use 1 mood
A study of electroconvulsive therapy found stabilizer and 1 antipsychotic
that 72% of people suffering with a mood
disorder saw significant improvement or the If there is a partial response
disappearance of their symptoms (Consoli et
al., 2007). • Add another medication, preferably a mood
stabilizer
The procedure is relatively safe. There have
been no recorded adolescent deaths and If there is low response or poor medication
tolerance
side effects (while substantial – e.g., tardive
seizures and prolonged epileptic fits) appear • Refer to Electroconvulsive therapy (only
recommended for adolescents and older)
to be transient (Consoli et al., 2007).
(Consoli et al.,
2007)
Additional Information
• From 2000-2009 Bipolar I diagnosis in children under 18 increased 4000%, though it is unclear
why. (Chang, 2009)
• Even with all the information on youth Bipolar symptomology, impairment, treatment, and
• Mediators and Moderators
prognosis, approximately ½ of BPSD youth remain untreated (Brickman & Fristad, 2022).
• Child age, sex, race – no effect on treatment efficacy
• Maternal Expressed Emotion, High levels of family conflict/Expressed emotion increase dropout and relapse – children of
these families also showed a greater response to FFT-A but, younger samples of PEP/CFF-CBT did not show Expressed
Emotion moderating effects
• Parental Beliefs about treatment
• Parental personality disorders and substance dependency – may predict treatment nonresponse and premature treatment
termination
• Level of participant impairment
• Greater the impairment the greater the improvements
• SI/Suicidality – age?
• Increased interleukin – reduced depressive symptoms post-group CBT
• Comorbidities – Unmedicated ADHD shows a greater reduction of (hypo)manic symptoms (FFT-A) Anxiety/BPSD had a
greater time with depressive symptoms, more severe (hypo)manic symptoms and fewer family conflict improvements.
Depression was found to have mixed results – either increased improvements or did not moderate (CFF-CBT)
• SES – mixed results, low-income families may benefit most from CFF-CBT. MF-PEP studies report no difference in treatment
effectiveness based on income or other family demographics
• This data gives us valuable information – we can match treatments to families based on their individual factors
• Early comprehensive assessment and intervention with low-risk treatments can help delay or prevent disorder
onset while simultaneously providing skills.
 References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Brickman, H. M., & Fristad, M. A. (2022). Psychosocial treatments for bipolar disorder in children
and adolescents. Annual Review of Clinical Psychology, 18, 291–327.
https://doi.org/10.1146/annurev-clinpsy-072220-021237

Chang, K. (2009). Challenges in the diagnosis and treatment of pediatric bipolar depression.
Dialogues in Clinical Neuroscience. 11(1), 73-80.
https://doi.org/10.31887/DCNS.2009.11.1/kchang

Consoli, A., Deniau, E., Huynh, C., Purper, D., & Cohen, D. (2007). Treatment in child and
adolescent bipolar disorders. European Child & Adolescent Psychiatry, 16(3), 187–198.
https://doi.org/10.1007/s00787-006-0587-7

Goldstein, B. I., Birmaher, B., & Youngstrom, E. A. (2020). Diagnostic and treatment challenges in
bipolar disorder in children and adolescents. Psychiatric Times, 37(1), 5–7.