By Dr Tanya Hanstock MAPS, University of New England, Stephen Hirneth MAPS, Newcastle Child and Adolescent Mental Health Service, Catherine Cahill MAPS, University of Sydney and Dr Craig Macneil, Orygen Youth Health

MORBIDITY FOR UNTREATED CLIENTS WITH YBD
  • Suicide attempts
  • Self-harm
  • Substance use
  • Cessation of education and/or employment
  • Negative self esteem
  • Family breakdown
  • Poor peer relations
  • Financial difficulties
  • Legal/criminal issues
  • Trauma

Youth bipolar disorder (YBD) describes young people with bipolar disorder (BD) who are aged between 12 and 25 years. Clinicians who work with young people will invariably encounter YBD, even if it is not immediately apparent. There is an estimated one per cent prevalence of YBD in adolescents which increases to 5.6 per cent if considering sub-threshold symptoms (Lewinsohn, Klein & Seeley, 1995), and peak age of onset of YBD is between 15 and 19 years of age (APA, 2002). The prevalence of YBD in young people may be underestimated as YBD is often misdiagnosed as unipolar depression. Australian researchers have identified an average delay from symptom onset (age 17.5 years) to diagnosis of 12.5 years (Berk et al., 2007).

Despite the recognised average age of onset for BD occurring during youth, the diagnosis remains controversial. Rates of diagnosis of YBD have risen significantly over the past decade, leading some clinicians and researchers to question if normal adolescent issues or other forms of psychological difficulties are being mistaken for BD (Blader & Carlson, 2007; Moreno et al., 2007). However, evidence from numerous prolific and long established YBD research groups  (such as Barbara Geller’s at the University of Washington, Mani Pavuluri’s at the University of Illinois and Ellen Leibenluft’s at the National Institute of Health) strongly supports the diagnosis. Furthermore, there are no neurobiological reasons that BD cannot occur in young people. In the face of this research evidence, although some clinicians do not accept that BD can occur in younger people, there is a general consensus that BD does occur in youth. However, there is ongoing debate regarding the phenomenology and diagnostic boundaries of BD for children and adolescents compared to adults (Carlson et al., 2005).

Identification of youth bipolar disorder

YBD is frequently difficult to identify, as it can be hard to distinguish from other mental health and substance-related disorders that occur in young people. YBD has symptom overlap with attention deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder and even emerging borderline personality disorder. Some clinical indicators of YBD include an extreme and cyclical change in mood, behaviour and functioning, engagement in self-harm and a family history of BD.

Clinical presentation

Clinical assessment

Guidelines advise that the diagnosis of YBD should be made by a clinician with specialist training in child and adolescent mental health (NICE, 2006; Kowatch et al., 2005). The assessment should include an interview and mental state examination with the young person individually, a medical evaluation regarding possible organic causes, and a detailed clinical assessment with the young person as well as parents or carers and other significant adults such as teachers. The assessment should include a history of the presenting problem, developmental and neurodevelopmental history, family history, speech and language development, behaviour problems, substance use, attachment behaviour and any history of abuse. Further neuropsychological and neurological evaluation should be undertaken if indicated. It is useful if families complete a mood diary for at least two weeks prior to the assessment to record mood, energy, sleep and unusual behaviour. Clinical guidelines such as NICE (2006) and Kowatch et al. (2005) provide a comprehensive list of structured interviews as well as diagnostic tools and measures.

ASSESSMENT TOOLS OFTEN USED IN YBD
  • Washington University in St Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS)
  • Child Behaviour Checklists
  • Conners’ Abbreviated Rating Scales
  • Young Mania Rating Scales
  • Parent General Behavioural Inventory
  • Mood diaries

Neuropsychological assessment

The heterogeneity of symptoms, developmental variability in disorder expression and comorbidity in YBD has made it difficult to identify a neurocognitive profile or ‘marker’. However, studies of YBD populations have found wide ranging deficits across neuropsychological domains (Cahill et al., 2007). Regardless of medication status, patients with YBD perform more poorly than healthy controls on tests of verbal fluency, executive functioning, attention and working memory. Such deficits appear to represent trait markers of illness (Pavuluri et al., 2006) but are not differentiated diagnostic indicators.

Treatment of bipolar disorder in young people

As BD is a biopsychosocial disorder, it is imperative that the young person has access to psychological treatment to help the management of mood instability and its consequences. The most researched therapeutic model of psychological treatment for YBD is child and family focused cognitive behavioural therapy (CCBT, FFT and FFCBT; Pavuluri et al., 2004; Miklowitz et al., 2008). This treatment model focuses on reducing expressed emotion, as well as improving communication and problem solving skills within families where a member has BD. Important psychological considerations in treating YBD include developing a therapeutic relationship (which can be challenging with this client population) and utilising a wide variety of psychological strategies (Macneil et al., 2009).

PSYCHOLOGICAL INTERVENTIONS
FOR YBD
  • Collaborative psychoeducation
  • Identifying early warning signs for low, high and mixed moods
  • Helping clients develop a healthy lifestyle and routines
  • Work on comorbid difficulties including:
    • Sleep hygiene
    • Anxiety management
    • Drug and alcohol counselling

Psychologists have an important role in ensuring coordinated care for clients with YBD including firstly, making sure the young person is also linked with a GP and psychiatrist. It is good for  the young person to feel like they are an active and important part of their treating team, and a collaborative approach is often essential. A school counsellor, dietitian and social worker may also be involved in the treatment of the young person. Psychologists need to be aware of the psychopharmacological treatment of YBD and how to help clients with side effects and compliance issues.

It is important for clinicians to balance giving a hopeful message with emphasising that BD can be a relapsing condition, and that the goal of treatment is to learn how to manage it. It is also important to help young people put BD into perspective in their life and to try not to define themselves by it alone.

Conclusions

BD is increasingly being identified in young people. As a result there is an emergent role for psychologists to provide high quality assessment and treatment. Frequently, the issues associated with earlier presentations are extremely amenable to psychological intervention, and early intervention may prevent significant secondary morbidity. Therefore, familiarity with the presentation of YBD, as well as an awareness of optimum treatment choices, leave psychologists well placed to assist in providing positive treatment outcomes for this client population.

The principal author can be contacted at thansto2@une.edu.au

References

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