Pediatric Bipolar Disorder: Neuropsychological and Educational Issues

1. Pediatric Bipolar Disorder:Neuropsychological and Educational Issues By Shelly Johns

2. Pediatric Bipolar Disorder • Pediatric Bipolar Disorder seems to diagnosed more often in children and adolescents. • video.smi

3. Symptoms of Bipolar Disorder • There are no medical tests to diagnose Bipolar Disorder, but the diagnosis must be made by a psychiatrist • The diagnosis is usually based on the psychiatrist’s observations and the observations and reports of the child and family. (Psychological testing also helps with diagnosis.) • Children can be diagnosed with Bipolar I, Bipolar II disorder, or Bipolar Disorder NOS.

4. Symptoms of Bipolar Disorder • Doctors diagnose according to the criteria found in the DSM-IV (APA, 2000 and Papolos & Papolos, 2002). • This criteria is based on adult symptoms. • The symptoms in children and adolescents manifest somewhat differently then in adults • Treatment usually involves medication and counseling. • Research indicates a possible connection between symptoms and neurological/biological factors. Although there are separate categories for Bipolar Disorder, common symptoms will be presented.

5. Symptoms of DepressionAccording to the DSM-IV-TR (APA, 2000) Depressed, irritable mood or significant decreased interest in pleasurable activates (such as, in playing) present for at least two weeks. • Loss of weight, increase in appetite, or decrease in appetite • Too much sleep, can’t stay or fall asleep • Appearing to have slow movements or restless movements. • Feeling worthless, or experience inappropriate guilt • Little – no energy • Problems concentrating and making decisions • Thoughts of death, thoughts of suicide, or a suicide attempt

6. Manic Symptoms • For at least one week, “…abnormally and persistently elevated, expansive, or irritable mood…” (APA,2000) • Grandiose thoughts and feelings about oneself (possibly delusions) • Significant decrease in need for sleep • Extremely and unusually talkative or appearing as if one cannot stop talking • Racing thoughts or ideas appearing to not connect • Significant “increase in goal-directed activities” (APA, 2000) or appearing extremely restless • Significant increase with involvement in “pleasurable activities” that could have risky or dangerous consequences. • Hallucinations (in severe cases)

7. Rages and extreme temper tantrums Rapid change in mood (over hours or days) Easily set off by environmental or emotional stressors Hard time waking up in the morning Defiant and oppositional behavior Aggressive behaviors Nightmares and/or bed-wetting Hypersexual behaviors Obsessive or compulsive behaviors “Dare-devil Behaviors” Interested in violent or “morbid” topics Manipulative, excessively bossy, or bullying Appearing excessively silly or goofy Symptoms Exhibited by Children with Bipolar Disorder(Papolos & Papolos, 2002 and Child and Adolescent Bipolar Foundation, 2007)

8. Hyperactive, impulsive, easily distracted, disorganized, or frequent day dreaming Learning disabilities or problems with short term memory Low self-esteem Lying Paranoia Craving Carbohydrates Separation or Social Anxiety Symptoms Exhibited by Children with Bipolar Disorder continued… (Papolos & Papolos, 2002 and Child and Adolescent Bipolar Foundation, 2002) Children with Bipolar Disorder may be diagnosed with other disorders such as ADHD, Oppositional Defiant Disorder, Generalized Anxiety Disorder, Tourette’s Disorder, etc.

9. Autonomic Nervous System Limbic System “receives, regulates, and assembles highly organized information derived from sensations, momentary events, memories of events, and emotions associated with those events” also plays a part in “sexual desire,” hunger, thirst, fear, and fight or flight Amygdala and fear responses Septum and rage Pediatric Bipolar Disorder and the Brain(Papolos & Papolos, 2006, p. 209, BPChildren.com).

10. Pediatric Bipolar Disorder and the Brain Continued(Papolos & Papolos, 2006, p. 216). • when the “neuronal activity” in the limbic system has been disrupted, it could cause children to have problems “registering emotional meaning” and to become “over alert to stimuli” • The disturbance in the limbic system may cause children to exhibit “extremes of atttentional focus (hypervigilance), emotional arousal, and an overreactive startle response” • These children could overreact to stressors from the environment, and may be more likely to exhibit anxiety and panic • It is not uncommon for individual’s with Bipolar Disorder, both adults and children, to suffer from symptoms of anxiety

11. Frontal Lobe smaller (concentration, emotional expression, creativity, inhibition) Hippocampus smaller (“processing and distributing information”) Decrease in N-acetylaspartate in the Hippocampus (emotion regulation and memory) Pediatric Bipolar Disorder and the Brain(BPChildren.com)

12. Norepinephrine and alertness Problems with attention, focus, and being easily distracted, may be related to norepinenphrine Serotonin Serotonin appears to be found in areas of the brain related to arousal Issues related to sleep have been found to be related to serotonin. Dopamine Fluctuations in dopamine can affect “self-esteem; may contribute to abnormal mood states, such as elation and melancholia; and may result in marked variations in activity/hyperactivity and pressured speech seen in mania and hypomania” Pediatric Bipolar Disorder and the Brain Continued(Papolos & Papolos, 2006, p. 226).

13. Experts are beginning to think that children with Bipolar Disorder have problems related to the frontal lobes, which causes problems with executive functions, such as attending and problem solving Children with Bipolar Disorder may experience difficulty with executive functions, such as disorganization, using the same strategy even if it is not working, difficulty acting on a plan or developing the parts of the plan, difficulty with attention, difficulty with “follow through,” and difficulty with trying something new. Researchers have also found that children and adolescents with Bipolar Disorder also have difficulties with working memory, meaning that they have problems holding information in “short-term memory while manipulating it toward problem solving or sequencing it in a logical order” Bipolar Disorder and Neuropsychological Issues(Papolos & Papolos, 2006, p. 351).

14. Possible Learning Difficulties(Child and Adolescent Bipolar Foundation, 2007 and Juvenile Bipolar Research Foundation, 2002) • Children may have difficulty with: • Memory and recall • Being able to think critically and problem solve • Energy fluctuations • Problems with executive functioning • Side effects of medication (“cognitive dulling,” thirst, hunger, increase in need to urinate, and diarrhea)

15. Try to offer a structured and consistent day. Interact with the students in a calm manner. Ignore minor behavioral problems and praise positive behaviors. Be open to adapting assignments and curriculum when needed. Have some activities prepared for when the student has fluctuations in mood and energy (if manic – provide physical jobs or activities). Learn “conflict management skills” in order to help to calmly solve conflicts. Be open to communicating and working with the child’s parents and outside service providers. Try to keep a sense of humor. Place the child in an area of the class that has less distractions, possibly seating the child by “model students.” Teaching Strategies and suggestions(Child and Adolescent Bipolar Foundation, 2007)

16. Try to offer a structured and consistent day. Interact with the students in a calm manner. Ignore minor behavioral problems and praise positive behaviors. Be open to adapting assignments and curriculum when needed. Have some activities prepared for when the student has fluctuations in mood and energy (if manic – provide physical jobs or activities). Learn “conflict management skills” in order to help to calmly solve conflicts. Be open to communicating and working with the child’s parents and outside service providers. Try to keep a sense of humor. Place the child in an area of the class that has less distractions, possibly seating the child by “model students.” Teaching Strategies and suggestions(Child and Adolescent Bipolar Foundation, 2007)

17. Suggestions for Accommodations(Child and Adolescent Bipolar Foundation, 2007 and Juvenile Bipolar Research Foundation, 2002 • Accommodations for symptoms • Because of difficulty waking in the morning, allow the student to start the day later. • Schedule harder academic courses and/or tests later in day, to improve chances for concentration and success. • Allow the child to take breaks. • Designate one (safe and trusting) staff member and/or place for the student to go to when needing to calm down or when feeling overwhelmed • Establish a private signal between the child and teacher, so that he/she can use it with out drawing attention. • Allow child to have a permanent pass to use to go to his/her designated staff or place.

18. Consider assigning an aid, for direct support and intervention with behaviors. Schedule regular sessions with the school psychologist, social worker, or counselor to work on anger management, coping skills, and tools to use for calming down. Develop a Behavioral Intervention Plan for interventions to use with behavior problems, based on the results of a Functional Behavior Assessment (to discover the causes of behaviors). Due to anxiety, warn the child about transitions and changes in schedule. Possibly allow the student to transition before the other students Due to possible issues with social relationships, have the child participate in a social skills group run by the school psychologist, social worker, or counselor. Provide a student planner, an extra set of books for home, and options for quiet study areas. Post assignments daily on the class web page, or email assignments to the child’s parents. Accommodations Continued…(Child and Adolescent Bipolar Foundation, 2007; Juvenile Bipolar Research Foundation, 2002

19. To help with organization, “color-code” folders and notebooks to match specific text books. Have the child clean out his/her locker weekly, and help him/her to organize it so that morning materials are in one area of the locker and afternoon materials are in another area of the locker. Give the child a prompt at the end of the day (“What do I need to take home to do what I need to do?”) Similarly, a checklist can be created and used daily, to help the child remember what items need to go home. Due to medication side effects, allow the student to have a bottle of water at his/her desk Develop a private signal for the child to use when needing to use the bathroom. Designate a location for the student to take brief naps if experiencing sleepiness due to the medication. If the student appears fatigued, or having problems with “cognitive dulling,” adjust amount of work and extend completion time. Accommodations Continued…(Child and Adolescent Bipolar Foundation, 2007 and Juvenile Bipolar Research Foundation, 2002)

20. References • American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., TR). Washington DC: Author. • BPChildren.com. Brain Abnormalities Associated with Bipolar Disorder. Retrieved November 7, 2006, from http://www.BPChildren.com • Child and Adolescent Bipolar Foundation (2002, October 27). About Pediatric Bipolar Disorder. Retrieved October 20, 2006, from http://www.bpkids.org • Child and Adolescent Bipolar Foundation (2007). Educating the Child with Bipolar Disorder. Retrieved on June 4, 2007, from http://www.bpkids.org • Juvenile Bipolar Research Foundation (2002). The Educational Issues of Students with Bipolar Disorder. Retrieved on October 20, 2006, from www.bpchildrenresearch.org • Papolos, D & Papolos, J. (2006). The Bipolar Child: The Definitive and Reassuring Guide to Childhood’s Most Misunderstood Disorder (3rd edition). New York: Broadway Books.

21. Helpful Resources • www.bpkids.org (Child and Adolescent Bipolar Foundation) • www.bpchildresearch.org (Juvenile Bipolar Research Foundation) • www.bpchildren.com