PEDIATRIC BEHAVIOR RATING SCALE - PAR：兒童行為評(píng)定量表的標(biāo)準(zhǔn)

1、Early Onset Bipolar Disorderand the Pediatric Behavior Rating Scale (PBRS)Childrens Mental Health5,000,000 (the number of children and adolescents in the U.S. suffer from a serious mental disorder resulting in significant functional impairments at home, at school, and with peers.)80% (Americas youth

2、 with mental health needs who fail to be identified and to receive treatment and services.)6-8 years from onset to treatment for mood disordersCONSEQUENCES (of untreated mental disorders include suicide, addictions, school failure, and criminal involvement).Information obtained from National Allianc

3、e on Mental Illness web site Aug. 2007Society benefits when Mental Health is addressed earlyDIAGNOSIS DU JOUR?1980SADHD1990S DEPRESSION2000SEOBPDRATES OF DIAGNOSIS4,000% increase in rate of EOBPD diagnoses in the past 10 years (Frontline, 2021)At present, over 1 million American children have an EOB

4、PD diagnosis, and the number is steadily increasing (Frontline, 2021)PROBLEMS IDENTIFYING BPD IN CHILDRENEOBPD is not in DSM IV.EOPBD looks like other disorders.EOBPD has high rates of comorbidity.PROBLEM 1: EOBPD isnt in DSM IVBIPOLAR DISORDERSBipolar l DisorderMania and major depressionBipolar ll

5、DisorderHypomania & major depressionCyclothymic DisorderHypomania & depression/dysthymia EOBPD vs. Adult BPD(Birmaher et al, 2021; Danielyan et al, 2007; Kowatch et al, 2005)EOBPDAdult BPDMixed Mood Episodes are typicalDiscrete Mood Episodes are typicalUltra-Rapid Cycling is commonLonger cyclesSympt

6、omatic most of the timePeriods of no symptoms between cyclesPROBLEM 1: EOBPD isnt in DSM IVBipolar Disorder-Not Otherwise SpecifiedRapid alternation between manic and depressive symptoms that do not meet the duration criteria for manic, hypomanic, or major depressionHypomanic without depressionInfre

7、quent episodesPROBLEM 2: EOBPD mimics other disordersDisruptive Behavior DisordersADHD60-93% meet diagnostic criteria for ADHD (Biederman, et. al, 2003)Mania versus hyperactivityMore anger, irritability, aggressive temper tantrumsPresence of elation, grandiosity, racing thoughts/flight of ideas, dec

8、reased need for sleep, hypersexualityPROBLEM 2: EOBPD mimics other disordersODD77-88% have ODD (Wozniak et. al, 1995)More intense irritability and severe emotional meltdownsCD42-69% have CD (Biederman, et. al, 2003)Violent and aggressive behavior lacks intent, planning, and premeditationPROBLEM 2: E

9、OBPD mimics other disordersAnxiety Disorders56-75% have anxiety disorder (Wozniak et. al, 1995; Masi, et. al, 2001)Tourettes Disorder, Schizophrenia, Autism Spectrum DisorderWHAT WE KNOW:SYMPTOMS ASSOCIATED with EOBPDInflexibleOppositionalIrritableExplosive ragesErratic sleepDifficult to sootheSepar

10、ation anxietyNight terrorsFear of death and annihilationRapid cyclingPrecociousnessSensitivity to stimuliProblems with peersTemperature dysregulationCraving for carbs. and sweetsBedwetting and soilingHypersexualityHallucinationsSuicidal ideationFrequency of EOBPD SymptomsVery Often(90%-97%)Often(60%

11、-80%)Sometimes(20%-35%)Infrequent(Less than 10%)IrritabilityAnxietyHypersexualityHomicidal IdeasMood LabilityRacing ThoughtsPsychosisSuicidal ActsSleep DisorderPressured SpchSuicidal IdeationAnger; RageEuphoria,GrandiositySelf-harmImpulsivityAgitationAggressionFrom: Faedda & Austin, 2006Parenting a

12、bipolar childp. 39.PsychosisTillman et al (2021), 257 EOBPD participants, ages 6-16, funded by NIMHPsychosis was present in 76.3% of subjects38.9% with delusionsGrandiose was most common5.1% with pathological hallucinationsVisual hallucinations were most common32.3% with bothDEVIANCEVOLUNTARY - we h

13、ave a tendency to attribute misbehaviorespecially noncompliance and disobedience-to willful disobedience. INVOLUNTARY - we tend to minimize this even when it explains the childs behavior.EOBPD and AROUSAL Children with EOBPD are less able to modulate arousallive in fearare “on alert for dangerare pr

14、imed for “fight/flight responseAnd when aroused, aggression is more likely.WHAT KIND OF AGGRESSION IS BEING EXPRESSED?Predatory-controlled (instrumental)Defensive-impulsive, reactive (not for gain)CHARACTERISTICDIAGNOSISAGGRESSION TYPEImpulse ControlADHDAccidents/ InjuriesEmotional InstabilityBipola

15、r, Borderline, IEDReactive, affective attackIrritabilityDepression, DysthymiaActing Out, SuicideAnxiety/Low Frustration ToleranceAnxiety, PTSD, ASDReactive striking outImpaired JudgmentSubstance Abuse, PsychosisInadvertent AggressionStimulation SeekingCD, ODDPredatory AggressionREACTIONARY and CONFR

16、ONTATIONAL approaches serve mainly to provoke and escalate.GOALS OF INTERVENTIONSStabilizeReduce SymptomsOppositionDefianceIrritabilityAggressionImprove Functioning (academic, social)TWO WAYS TO ACHIEVE THESE GOALSMedications (to make the child “available)Psychotherapies (coping & managing)General R

17、ule for InterventionsBehavioral approaches tend to focus on consequences.There are two problems with thisTWO PROBLEMS1. By definition, children and adolescents with deficits in impulse control and self-regulation do not consider consequences before they act.2. Behavioral consequences (especially if

18、they are aversive) introduce provocation, confrontationand escalation.INTERVENTION TARGETSCHILDmedicationssleepself-regulationPARENTSpsychoeducation medication complianceENVIRONMENT (control the pace)homeschoolDRUG TREATMENTS EOBPDFOUR MAJOR CLASSES of MOOD STABILIZERSLithiumAntiepileptics (Mood Sta

19、bilizers)AntidepressantsAntipsychoticsCHARACTERISTICDIAGNOSISAGGRESSION TYPEMEDICATIONImpulse ControlADHDAccidents/ InjuriesSTIMULANTSSSRIANTIPSYCHOTICMOOD STABILIZERSAffective InstabilityBipolar, Borderline, IEDReactive, affective attackANTISPYCHOTICSMOOD STABILIZERSSSRIIrritabilityDepression, Dyst

20、hymiaActing Out, SuicideSSRIOTHER ANTIDEPRESSANTSAnxiety/Low Frustration ToleranceAnxiety, PTSD, ASDReactive striking outOTHER ANTIDPERESSANTSSSRITENEXCLONODINEImpaired JudgmentSubstance Abuse, PsychosisInadvertent AggressionANTIPSYCHOTICSStimulation SeekingCD, ODDPredatory AggressionMOOD STABILIZER

21、NONDRUG INTERVENTIONSTHERE ARE 550 PSYCHOTHERAPIES (NONMEDICAL INTERVENTIONS) FOR TREATING CHILDREN AND ADULTS BEYOND BEHAVIORISMParent Management TrainingCognitive Behavioral TherapyDialectal Behavior TherapyChoice TheoryProblem-Solving SkillsHealth Promoting Environments CHARACT-ERISTICDIAGNOSISAG

22、GRESSION TYPEPSYCHOTHERAPYImpulse ControlADHDAccidents/ InjuriesCBT; DBTPROBLEM-SOLVINGParent TrainingAffective InstabilityBipolar, Borderline, IEDReactive, affective attackCBT; DBTPROBLEM-SOLVINGParent TrainingIrritabilityDepression, DysthymiaActing Out, SuicideCBTAnxiety/Low Frustration ToleranceA

23、nxiety, PTSD, ASDReactive striking outCBT; DBTPROBLEM-SOLVINGParent TrainingImpaired JudgmentSubstance Abuse, PsychosisInadvertent AggressionCognitive Enhancement TherapyStimulation SeekingCD, ODDPredatory AggressionParent TrainingPSYCHOEDUCATIONThe Bipolar Child (3rd Edition) by Papolos and Papolos

24、 (2006)Understanding the Mind of Your Bipolar Child by Lombardo (2006)The Bipolar Disorder Survival Guide by Miklowitz (2002)The Bipolar Teen by Miklowitz and George (2021) 80 - 90% 10 - 15% 1 - 5%Three-Tier Model of Behavioral Intervention/SupportTier III: Intensive, Individual InterventionsTier II

25、: Targeted Group InterventionsTier I: Universal Interventions/Supports80 - 90%10-15%1-5%Tier III: Individual InterventionsGoal: To develop and implement interventions for student behaviors that can not be addressed or remedied via Tier I or Tier II interventions.FUNCTIONAL ASSESSMENTModified from: S

26、antilli, Nancy, Dodson, W.E., Walton, A.V. (1991) INTERVENTIONS FOR SIMPLEMonopharmacyMildly intrusive therapyindividual therapygroup therapyparent trainingRegular classroom placementFavorable RTIINTERVENTIONS FOR COMPROMISEDPolypharmacy (aggression, irritability, co-morbidity)Intensive child and fa

27、mily therapiesindividual therapygroup therapyfamily therapy/parent trainingMay require Spec. Ed. (EH, SED, OHI)Variable RTI INTERVENTIONS FOR COMPLEXPolypharmacyIntensive Interventionsindividual therapyintensive parent trainingalternative educational placementsAcute hospitalizationSelf-contained to

28、RTCLaw EnforcementVery poor prognosis Predictors of OutcomeWorse outcomes are associated with:Younger age of onsetLong duration of mood symptomsLow socioeconomic statusLifetime psychosis(Birmaher et al, 2006)PEDIATRIC BEHAVIOR RATING SCALEWHY A NEW RATING SCALE? Existing scales came out normal Item

29、analysis told us why The need for differential diagnosisOTHER SCALES Young Mania Rating ScaleParent Version (P-YMRS; 11 items) General Behavior Inventory (GBI; 73 items; age 11; self-report accuracy) Child Mania Rating Scale (CMRS; mania only) Conners Abbreviated Symptom Questionnaire (ASQ; 10 mania

30、 items from the Conners Parent Rating Scales CPRS) Omnibus rating scales (e.g., Clinical Assessment of Behavior CAB, Achenbach System of Empirically Based Assessment ASEBA, Behavior Assessment System for Children BASC)PURPOSEFor children and adolescents ages 3-18 yearsPrimary function: To assist in

31、the identification of emotional dysregulation and related disorders, specifically early onset bipolar disorder (EOBPD)Secondary function: To aid in differential diagnosis, leading to differential interventionsFEATURES Sufficient items to identify core features of EOBPD, such as:Mood swingsIrritabili

32、tyGrandiosityEasily provokedExplosive outbursts Syndromal differentiation (e.g., ADHD vs. EOBPD) Identifies areas of concern rather than providing diagnosesPBRS APPLICATIONS ClinicalDistinguish between EOBPD and its mimicsSymptom identification and profile analysisAreas of concern EducationalClarify

33、 diagnosis using IDEAMore complete symptom profile (intervention) ResearchDefining the disorder in childrenHandling comorbidityIntervention efficacyCOMPONENTS Parent FormPBRS Parent Item Booklet (102 items)PBRS Parent Response BookletPBRS Parent Score Summary/Profile Form Teacher FormPBRS Teacher It

34、em Booklet (95 items)PBRS Teacher Response BookletPBRS Teacher Score Summary/Profile FormSCORES PRODUCED Inconsistency ScoreCan I trust the responses? Critical ItemsNo matter what, these are clinically important Symptom ScalesEach is important, as is the profile Total Bipolar IndexComposite of all 8

35、 symptom scalesCRITICAL ITEMSThese items have special clinical significance and should be given special attention. Any item with a score greater than zero should be investigated further as this suggests a serious problem that must be addressed or ruled out.Self-abuseHallucinationsBizarre beliefsExpr

36、esses violent themesSuicidal thoughtsAggressionSYMPTOM SCALESEight clinical scales and one index Atypical (psychotic symptoms) Irritability (persistent and chronic) Grandiosity (exaggerated sense of self) Hyperactivity/Impulsivity (as in ADHD) Aggression (toward others, animals, objects) Inattention

37、 (as in ADHD) Affect (mood disturbances, cognitive distortion) Social Interactions (interacting with peers) Total Bipolar IndexAtypical (ATY) ScaleBizarre beliefsAuditory hallucinationsDelusionsSelf-harm behaviorsExcessive fearsIrritability (IRR) ScaleEmotional dysregulationBehavioral/emotional outb

38、urstsDemandingnessGrandiosity (GRAND) ScaleElevated sense of self and moodNot taking responsibility for actionsExaggeratingStealingHyperactivity/Impulsivity (HYPER) ScaleClassic description of overactivity and impulsivityDifficulty sitting stillActs without thinking about consequencesAlways on the g

39、oAggression (AGG) ScaleAggression targeting other people, animals, or objectsInattention (INATT) ScaleTraditional scale for inattention and distractibilityDifficulty focusingDifficulty sustaining attentionAffect (AFF) ScaleMood disturbancesSuicidal ideationCognitive distortionsSocial Interactions (S

40、OC) ScaleAbility to interact with peersAbility to make friendsRelating to othersEngaging in social interactionsTOTAL BIPOLAR INDEX TBI is a composite of the 8 scales The most robust PBRS score (like g on IQ tests) T scores 70 are a significant concern for disorders of emotional dysregulation; T scores 80 suggest EOBPD The most effective way to differentiate EOBPD from other diagnoses (especially ADHD)POPULATIONNormative sampleParents n = 541Teachers n = 610 Clinical sample (cli