EARLY ONSET BIPOLAR DISORDER:

1. EARLY ONSET BIPOLAR DISORDER: Epidemiology, Educational Implications, and Interventions Shelley Hart shelley_hart@charter.net

2. DIAGNOSIS

3. DSM-IV-TR • Five types of episodes • Four subtypes • Four severity levels • Three course specifiers  American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision. Washington, DC: Author.

4. Manic Episode Symptoms: • Inflated self-esteem or grandiosity • Decreased need for sleep • Pressured speech or more talkative than usual • Flight of ideas or racing thoughts • Distractibility • Psychomotor agitation or increase in goal-directed activity • Hedonistic interests

5. Hypomanic Episode • Similarities with Manic Episode = • Same symptoms • Differences = • Length of time • Impairment not as severe

6. Major Depressive Episode Symptoms: • Depressed mood (in children can be irritable) • Diminished interest in activities • Significant weight loss or gain • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue/loss of energy • Feelings of worthlessness/inappropriate guilt • Diminished ability to think or concentrate/indecisiveness • Suicidal ideation or suicide attempt

7. Mixed Episode Both Manic and Major Depressive Episode criteria are met nearly every day for a least a one week period.

8. Subtypes Bipolar Disorder I = more classic form; clear episodes of depression & mania Bipolar Disorder II = presents with less intense and often unrecognized manic phases Cyclothymia = chronic moods of hypomania & depression, often evolves into a more serious type Bipolar Disorder Not Otherwise Specified (NOS) = largest group of individuals

9. Children vs. Adults (or early vs. late onset ) • Irritability • Depression • Lack of mood reactivity • Rejection sensitivity • Less evident are the “classic” symptoms of mania

10. EPIDEMIOLOGY

11. Prevalence • Estimated between 3-6% • Subsyndromal bipolar disorder • Equal distribution across gender variables • Average age @ onset = 20 years old

12. Course • Initial cycle typically major depressive episode • Recovery • Relapse • Rapid Cycling • Rapid cycling=4 episodes/year • Ultrarapid cycling=5-364 episodes/year • Ultradian cycling=>365 episodes/year

13. Age at Onset • Pediatric, prepubertal, or early adolescent (prior to age 12) • Adolescent (12 - 18 years) • Adult onset (+ 18 years)

14. IMPAIRMENTS

15. Comorbidity • Attention Deficit Hyperactivity Disorder (ADHD) • Between 60-80%

16. Bipolar Disorder (mania) More talkative than usual, or pressure to keep talking Distractibility Increase in goal directed activity or psychomotor agitation ADHD Often talks excessively Is often easily distracted by extraneous stimuli Is often “on the go” or often acts as if “driven by a motor” Criteria Comparison Differentiation= elated mood, grandiosity, decreased need for sleep, hypersexuality, and irritable mood.

17. Comorbidity(cont.) • Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD) • 70-75% • Substance Abuse • 40-50% • Anxiety Disorders • 35-40%

18. Suicidal Behaviors • Prevalence of suicide attempts • 40-45% • Age of first attempt • Multiple attempts • Severity of attempts • Suicidal ideation

19. Cognitive Deficits • Executive Functions • Attention • Memory • Sensory-Motor Integration • Nonverbal Problem-Solving • Academic Deficits • Mathematics

20. Psychosocial Deficits • Relationships • Peers • Family members • Recognition and Regulation of Emotion • Social Problem-Solving • Self-Esteem • Impulse Control

21. TREATMENT APPROACHES

22. DEPRESSION Mood Stabilizers Lamictal Anti-Obsessional Paxil Anti-Depressant Wellbutrin Atypical Antipsychotics Zyprexa MANIA Mood Stabillizers Lithium, Depakote, Depacon, Tegretol Aypical Antipsychotics Zyprexa, Seroquel, Risperdal, Geodon, Abilify Anti-Anxiety Benzodiazepines Klonopin, Ativan Psychopharmacological

23. Therapy • Psychoeducation • Family Interventions • Cognitive-Behavioral Therapy • RAINBOW Program • Interpersonal and Social Rhythm Therapy • Schema-focused Therapy

24. EDUCATIONAL IMPLICATIONS

25. IDEA Classification • Emotional Disturbance (ED) vs. Other Health Impaired (OHI)

26. Considerations • Rapidly changing moods of depression, irritability, grandiosity, pressured speech, racing thoughts, etc. • Need for movement • Poor relationships • Difficulties with concentration and focus • Difficulties with task completion • Impaired judgment and imulsivity • Disorganization • Becoming overwhelmed with stressful situations

27. Possible Accommodations/Modifications • Provide student with a safe place and person to go to when feeling overwhelmed or stressed • Shortened day (permit late start as needed) • Prior notice of transitions • Consistent schedule • Scheduling the student’s most challenging tasks at a time of day when the child is best able to perform • Modified or shortened assignments • Plan for unstructured times of the day • Adjust for medication needs, dispensing, as well as plans for addressing side effects (e.g., sedation)

28. Other Considerations • Educating staff • Communication • Hospitalization

29. RESOURCES BOOKS/BOOKLETS: • Mondimore, F. (1999). Bipolar disorder: A guide for patients and families. City: Johns Hopkins Press. • Geller, B., & DelBello, M. P. (Eds.). (2003). Bipolar disorder in childhood and early adolescence. New York: Guilford Press. • Educating the child with bipolar disorder. Available from: www.bpkids.org • Anderson, M., Kubisak, J.B., Field, R., & Vogelstein, S. (2003). Understanding and educating children and adolescents with bipolar disorder: A guide for educators.

30. RESOURCES WEBSITES: • The Child and Adolescent Bipolar Foundation • www.bpkids.org • Depression and Bipolar Support Alliance • www.dbsalliance.org • The Bipolar Child • www.bipolarchild.com • Parents of Bipolar Children • www.bpparent.org • The Gray Center for Social Learning and Understanding • www.thegraycenter.org/Social_Stories.htm • National Institute of Mental Health (NIMH) • www.nimh.org