Understanding Bipolar Disorder in Children

School is often the site where mental health disorders are observed when comparing behaviors with other children. Assessing the emotional, academic, and health needs of a student with a bipolar disorder is a critical step in designing effective interventions and school accommodations. Without appropriate medical, psychological, pharmaceutical, and academic interventions, a child is at risk for uncontrolled mania, depression, substance abuse, or suicide. The school nurse is part of the multidisciplinary team and plays a key role in facilitating case management to potentially reverse this possible negative trajectory.

Successful case management provides children with bipolar disorder the opportunity to reach their academic potential. i INTRODUCTION Bipolar disorder (formerly called manic-depressive illness) is an illness of the brain that causes extreme cycles in a person’s mood, energy level, thinking, and behavior. The disorder was first described by French scientist Jules Baillarger in 1854 as “dual-form mental illness. ” Later in the 19th century, German psychiatrist Emil Kraepelin coined the term “manic-depressive psychosis.

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By the 1980s, the term bipolar disorder replaced manic-depressive illness as the name psychiatrists use to describe this condition. Bipolar disorder is usually characterized by episodes of mania and depression, as well as a combination of the two at the same time called a mixed state. It is often first diagnosed during adolescence or in young adulthood; however, some people show symptoms of the illness in early childhood. Bipolar disorder in children and adolescents is not an easy or certain diagnosis. This diagnosis is usually made by a mental health clinician who has evaluated and treated many, many children.

It requires that the clinician take a detailed medical and psychiatric history and perform a thorough evaluation. Many parents are challenged by a child who has extreme changes in mood, energy, thinking, and behavior. Careful evaluation will find that some of these children are suffering from a mental disorder. Yet, only a very few of those will have bipolar disorder. While systematic data on the frequency of bipolar disorder among children are only now being collected, recent studies by the National Institute of Mental Health indicate that, overall, children have a lower rate of bipolar disorder than adults.

However, the rate increases with age, reaching approximately 1 percent (1 in 100) by adolescence. In adults, the rate of people who have some form of the disorder during their lifetime is approximately 4. 4 percent (1 in 20). Even though this illness affects a significant number of children and adolescents, most of the research into the disorder has been conducted in adults. While the number of children and adolescents who are diagnosed with bipolar disorder is increasing, research into bipolar disorder in children and adolescents is limited.

New research is now being conducted with children and adolescents to enhance early recognition, to help doctors accurately diagnose the disorder in children, and to evaluate age-specific therapies. The purpose of this report is to help teachers and parents to better recognize the signs of bipolar disorder and to give those children a better chance at being successful in school, in collage and in the work field. 1 Living Daily Life: Helping Your Teen at Home and School Getting the best possible treatment for your adolescent with depression or bipolar disorder is your top priority.

After that hurdle has been crossed, however, you may soon realize that there are still many challenges left to overcome. Depression and bipolar disorder affect every aspect of your teen’s functioning at home and school. As a parent, there are steps you can take to help things go more smoothly in these key areas of daily life. By reducing stress this way, you may also help speed your teen’s recovery and reduce the chances of a relapse or recurrence. Adolescence is by definition a time of transition from childhood to adulthood.

It’s a period when children naturally start to pull away from their parents and begin to forge independent lives and identities. For both you and your teen, this transition involves major changes in roles and expectations. At times, the changes can be exhilarating, and at other times, they can be rather frightening. For parents of a teen with depression and bipolar disorder, the anxiety may be magnified. However, the push-pull of autonomy versus dependence is something that all parents of adolescents go through. It’s a natural phase in the evolution of your role as a parent.

While your relationship with your teen will change, that doesn’t mean it becomes any less significant. In fact, your teen may need the security of your love and support more than ever now. The way you communicate with your adolescent and structure your family life can have a major impact on how your teen functions at home which can influence how your teen functions in other situations. The time and energy you devote to your other children, your significant other, and yourself can help keep the teen’s issues in perspective, a good thing for all of you.

And the way you address school issues and advocate for your teenager’s educational needs can have a decisive impact on his or her success in school. All the while, you’ll be slowly but surely working toward one of the most difficult but ultimately gratifying tasks for any parent letting go. As the parents of an adolescent with depression or bipolar disorder, you may have to take things a bit more gradually than other parents, but the ultimate goal of helping your child move toward a healthy, productive, independent life as a young adult is still the same.

What can the school do to help my child with bipolar disorder? Teachers often are the first to notice the symptoms of bipolar disorder, and can provide parents, guardians, and doctors with information that may help diagnose and treat the disorder. They also can play an important role in implementing a successful treatment program by using instructional and behavioral strategies in the classroom. Public schools are required to evaluate all students suspected of having a disability and to provide a free appropriate public education (FAPE) to students whose disabilities affect their ability to learn.

Families also can request an evaluation to determine if their child qualifies for educational services. 2 However, parents and guardians must give written permission before a school can provide testing or services to a child. Testing and services are confidential and are provided through the public school system at no cost to the family. Students whose bipolar disorder impairs their ability to learn may qualify for special education and related services under the Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973.

Both laws provide assistance to students with disabilities to meet their unique learning and behavioral needs, including accommodations and modifications in the classroom and diagnostic and counseling services. Children with bipolar disorder may be eligible for special education under IDEA in two disability categories: Other Health Impairment and Emotional Disturbance. Children who do not meet IDEA’s stringent requirements may still be eligible for accommodations and services under Section 504 of the Rehabilitation Act of 1973.

Because children with bipolar disorder may have coexisting conditions, such as ADHD, anxiety, and learning disabilities, they may qualify for educational services for these conditions as well. Increasing numbers of children with bipolar disorder attend private therapeutic schools, which have an educational and mental health focus. Because public schools may lack the resources or trained staff to teach students with bipolar disorder, some school districts are paying their private school tuition as a way to provide free appropriate public education.

A list of educational resources can be found in Appendix III. The American Academy of Child and Adolescent Psychiatry also has online education resources to help parents find services for children with special needs. To access a fact sheet about services in school for children with special needs. How can you work together with your child’s teachers? Teachers are your most important allies at school. They’re the ones who spend an hour or more per day five days a week, with your child. And they’re the ones who control the learning environment, for better or worse.

When children are in elementary school, it’s easy to get to know their teachers and perhaps volunteer at the school or help chaperone a field trip, if your schedule permits. As students get older, however, they may have a different teacher for each subject. Your teenage children may also seem considerably less enthusiastic about running into you in the hall at school. Don’t let this discourage you, however, No matter how they act, kids of all ages really want their parents involved, just be sensitive to your child’s growing need for independence, especially in front of his or her friends.

Make the extra effort to get acquainted with all your teen’s teachers. After meeting teachers, stay in touch throughout the year. If a problem develops, give the teacher the benefit of the doubt. Most teachers really want to do a good job for every student. Like parents, however, they may sometimes find it difficult to deal with a student whose behavior and learning ability are affected by a mood disorder or medication side effects. Approach the teacher with an attitude that says, “We’re all in this together,” and you’re much more likely to get a positive response. On the other hand, if you start out with an accusatory tone, the teacher’s defenses will go up, and you’re more likely to end up in an antagonistic posture. Don’t forget to also let the teacher know when things are going right. An occasional thank you note or small token of appreciation can help cement a strong alliance. You can also establish yourself as an asset to the school by participating in fund-raising efforts or volunteering in the office. Educators are only human; they respond to encouragement and support like anyone else.

The more you can do to build a positive working relationship with school personnel, the more effective you’ll be when it comes time to request services for your student. Occasionally, you may run across a teacher who remains unresponsive to your teen’s needs, no matter what your approach. In such cases, it’s perfectly appropriate to go to the principal with a complaint. Once again, though, try to avoid sounding accusatory when you state the problem. Instead, approach the principal with the attitude that this is a problem you can team up to solve together.

That may be all it takes to enlist the teacher’s cooperation. If all else fails, though, request a different placement for your student. Your teen has enough challenges in school without also having to cope with a teacher who is unwilling or unable to adapt to individual needs. School & the Child with Bipolar Disorder Does bipolar disorder affect a child’s ability to learn? Having bipolar disorder does not affect your child’s intelligence. It can, however, affect his or her ability to learn.

Bipolar disorder also has been shown to cause cognitive problems, such as impaired concentration, memory, and thinking. For example, this illness tends to interfere with sleep, which in turn can affect alertness and school attendance. Learning also can be compromised by time spent away from the classroom for disciplinary actions, since children with emotional and behavioral disorders are much more likely than other students to be suspended or expelled from school. How does bipolar disorder affect my child’s ability to form friendships?

Children with bipolar disorder often have difficulty with social (peer) relationships, which can cause conflict at home and at school. Poor social skills and problems perceiving emotions of others, coupled with moody, irritable, impulsive, and sometimes aggressive behavior, may cause children with bipolar disorder to act in ways that others think are mean, rude, thoughtless, or weird. Also, children with bipolar disorder are more frequently the targets of bullies or are bullies themselves. Treatment for bipolar disorder can have positive effects on behavior that lead to improved relationships.

Parents can help foster friendships for their children by letting teachers, school counselors, and coaches know about problems that might develop, arranging one-on-one play dates, and Encou-raging participation in school activities and peer-group programs. 4 Peer-group programs focused on successful social interactions (social skills groups) may be offered by school personnel, psychologists, speech pathologists, occupational therapists, licensed counselors, and social workers. Disorders that Can Accompany Bipolar Disorder

Research shows that two-thirds of children diagnosed with bipolar disorder have at least one additional mental health or learning disorder. Having more than one condition at a time is called having a coexisting (or comorbid) condition. Coexisting conditions can make diagnosing and treating bipolar disorder more difficult and create more challenges for a child to overcome. According to several studies, the most common coexisting conditions with bipolar disorder in children and adolescents are ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD).

In fact, more than half of all children with bipolar disorder also may have ADH Rates of Mental Health Disorders that Can Coexistwith Bipolar Disorder in Childhood and Adolescence| Mental Health Disorder| Rate Coexisting withChildhood BipolarDisorder (%)| Rate Coexisting withAdolescent BipolarDisorder (%)| Attention-Deficit/HyperactivityDisorder (ADHD)| 70-90%| 30-60%| Anxiety Disorders| 20-30%| 30-40%| Conduct Disorders (CD)| 30-40%| 30-60%| Oppositional Defiant Disorder(ODD)| 60-90%| 20-30%|

Substance Abuse| 10%| 40-50%| Learning Disabilities| 30-40%| 30-40%| Can my child take medication for bipolar disorder if there is a coexisting condition? If your child’s doctor determines that your child has one or more coexisting conditions, a treatment plan should be developed to address each coexisting condition as well as the bipolar disorder. Treatment plans for children and adolescents with bipolar disorder and a coexisting condition often include one or more medications as well as psychosocial treatment.

For example, children with bipolar disorder and ADHD can have as good a response to stimulants as do children who only have ADHD. This is especially true if the symptoms of bipolar disorder are controlled first. 24 However, more frequent monitoring for a reaction to the medication or a dependency on the medication is advised when treating children and adolescents with stimulant medications who have coexisting substance use disorders. 5 Working with the School Your child spends more time at school than anywhere else but home.

For teens, school is a place not only to learn about academic matters but also to connect with friends and get involved in extracurricular activities. Those who are successful in this setting acquire the cognitive and social skills they’ll need later for college, work, and adult relationships. Unfortunately, teens with mood disorders are at high risk for poor attendance, academic underachievement, school failure, and dropping out. In the midst of an episode, they can find it very difficult to pay attention, think clearly, solve problems, recall information, sit still, and follow classroom rules.

Once stabilized, it’s quite possible for these teens to thrive in school, but they may still need a little extra assistance from parents and teachers. Among other things, certain medications may cause side effects that detract from learning. These effects include drowsiness, fatigue, lack of mental alertness, memory problems, slurred speech, poor coordination, or physical discomforts, such as nausea or excessive thirst. When confronted with a teen who has special needs, some teachers and administrators are quite adaptable and eager to help.

Others, however, are inflexible and unsympathetic, based on ignorance or prejudice about mental disorders. Your challenge as a parent is to build an effective partnership with the school. Your goal is to support the positive teachers, educate the uninformed ones, and avoid the few who are unable to understand what you child or teen is experiencing. To help your teen make the most of public school, you need to become aware of the educational opportunities that are available to students with disabilities, including those with mental illnesses. The school system is the equal opportunity mental health provider, because if your child meets the eligibility requirements for IDEA(the Individuals with Disabilities Education Act), your income doesn’t matter,” says Tammy Seltzer, a senior staff attorney at the Bazelon Center for Mental Health Law. The schools are charged with providing a free and appropriate public education to all. For families whose income disqualifies them from Medicaid, the schools may be the best source of publicly funded services. 6 Medications used to treat child and adolescent mental disorders Class: Stimulants

Benefits: Treats the core symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) including, impulsivity, hyperactivity and inattention. There is very little documented difference in the effectiveness between the amphetamine and methylphenidate medicines. However, some children respond to one group better than another. Side Effects: Loss of appetite, difficulty falling asleep, irritability and /or moodiness. Some children may develop tics while on the medicine while those with a tic disorder may find that the tics worsen.

Both growth and weight should be monitored, since weight loss can occur, and there is some evidence that stimulants may cause a slowdown in growth. Very rarely they may cause hallucinations or exacerbate manic symptoms These medications can increase blood pressure and pulse slightly. Please tell your doctor if there are any relatives with a history of heart disease at an early age. | MEDICATION NAME| NOTES| Brand Name| Generic Name**| | Ritalin Focalin Methylin Methylin Chewable Methylin Liquid| methylphenidate| These are short acting—generally lasting about 3–4 hours. Concerta Focalin XR Metadate CD Ritalin LA Daytrana Patch| methylphenidate| These are long acting—generally lasting about 8–12 hours. Each one is formulated somewhat differently but there is generally no way to determine which will last the longest for any individual. Daytrana is the newest and uses a patch to deliver methylphenidate through the skin. The patch may cause some skin irritation. | Dexedrine Dextrostat Adderall| amphetamine| These are short acting—generally lasting about 3–6 hours.

Each one is formulated somewhat differently but there is generally no way to determine which will last the longest for any individual. Adderall is a mixture of different forms of amphetamine (amphetamine salts). | Adderall XR| amphetamine salts| Lasts 8–10 hours| Dexedrine Spansules| amphetamine| Lasts 8–10 hours| 7 Psychotherapy In addition to medication, psychotherapy (“talk” therapy) can be an effective treatment for bipolar disorder. Studies in adults show that it can provide support, education, and guidance to people with bipolar disorder and their families.

Psychotherapy may also help children keep taking their medications to stay healthy and prevent relapse. Children and teens may also benefit from therapies that address problems at school, work, or in the community. Some psychotherapy treatments used for bipolar disorder include: Cognitive behavioral therapy helps young people with bipolar disorder learn to change harmful or negative thought patterns and behaviors. Family-focused therapy includes a child’s family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their child.

This therapy also improves communication and problem-solving. Interpersonal and social rhythm therapy helps children and teens with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes. Psych education teaches young people with bipolar disorder about the illness and its treatment. This treatment helps people recognize signs of relapse so they can seek treatment early, before a full-blown episode occurs. Psych education also may be helpful for family members and caregivers.

Other types of therapies may be tried as well, or used along with those mentioned above. The number, frequency, and type of psychotherapy sessions should be based on your child’s treatment needs. A licensed psychologist, social worker, or counselor typically provides these therapies. This professional often works with your child’s psychiatrist to monitor care. Some may also be licensed to prescribe medications; check the laws in your state. For more information, see the Substance Abuse and Mental Health Services Administration web page on choosing a mental health therapist.

In addition to getting therapy to reduce symptoms of bipolar disorder, children and teens may also benefit from therapies that address problems at school, work, or in the community. Such therapies may target communication skills, problem-solving skills, or skills for school or work. Other programs, such as those provided by social welfare programs or support and advocacy groups, can help as well. Some children with bipolar disorder may also have learning disorders or language problems. Your child’s school may need to make accommodations that reduce the stresses of a school day and provide proper support or interventions. CONCLUSION No one has a bigger stake in ongoing research on the diagnosis, treatment, management, and prevention of mood disorders than you. As the parent or teacher of an adolescent with depression or bipolar disorder, you are directly affected by any new advances that such research might bring. There is an urgency and immediacy to your concern, since the drive to protect and nurture your child is a powerful, primal force. You can draw on that energy to become an agent for change, both in the private life of your adolescent and in the public realm of American society.

To get momentum started in your community, share information and resources with those who have an impact on young people, such as teachers, primary care physicians, sports coaches, youth group leaders, and directors of local social service organizations. Get involved in support and advocacy groups, and volunteer your time and energy in whatever way seems most appropriate for you. Don’t give up. Parenting and schooling children with depression or bipolar disorder can be a long and arduous task. With time and appropriate treatment, however, there’s an excellent chance your adolescent’s mood will stabilize, and his or her symptoms will improve.

As your teen’s prospects brighten, your own life will get easier. There is an end in sight. 9 WORK CITED Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE, Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005 Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RM, Petukhova M, Kessler RC, Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2007.

Wagner M, Marder C, Blackorby J, Cameto R, Newman L, Levine P, DaviesMercier E, The Achievements of Youth With Disabilities During Secondary School. A Report from the National Longitudinal Transition Study-2 (NLTS2). Menlo Park, CA: SRI International, 2003. U. S. Department of Education, Free Appropriate Public Education for Students With Disabilities: Requirements under Section 504 of The Rehabilitation Act of 1973. Washington, DC: U. S. Department of Education, Sept 2007. Available at: http://www. ed. gov/about/offices/list/ocr/docs/edlite-FAPE504. html. U. S.

Department of Health and Human Services, Your Rights Under Section 504 of the Rehabilitation Act. Washington, DC: U. S. Department of Health and Human Services, Office for Civil Rights. Available at: http://www. hhs. gov/ ocr/504. html. Wagner M, Cameto R, The characteristics, experiences, and outcomes of youth with emotional disturbances. NLTS2 Data Brief 3, 2004. Available at: http://www. ncset. org. Kiki Chang, M. D. , Dir. , Pediatric Bipolar Disorders Program, Lucile Packard Children’s Hospital at Stanford February 28, 2008. If Your Adolescent Has Depression of Bipolar Disorder Dwight L. Evans, MD, and Linda Wasmer Andrews 2005 10

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