Download what is bi-polar disorder? - Alaska Youth and Family Network

ALASKA YOUTH AND FAMILY NETWORK
P.O. Box 23-3142
Anchorage, Alaska 99523-3142
located in the Gateway Learning Center at 9th Avenue & Karluk
Telephone (907) 770-4979
fax (907) 770-4997
http://www.ayfn.org
WHAT IS BI-POLAR DISORDER?
HOW DO I GET HELP?
TABLE OF CONTENTS
What is bipolar disorder?
page
Do children really become mentally ill?
1
What is Bipolar Disorder?
1
When did Bipolar in children become a diagnosed mental illness?
2
Is it common?
3
Is there a general time when symptoms of Bipolar Disorder begin?
3
Who has it?
3
Is Bipolar disorder inherited?
3
Is intelligence a factor?
4
How can I tell if someone has Bipolar Disorder?
4
Do children and adolescents react in the same way as adults?
6
Is bipolar disorder in children the same thing as bipolar disorder in adults?
7
Is it uncommon for the first sign to be a period of depression?
7
What are the symptoms in childhood and how early can they begin?
7
If the child is fidgety and inattentive and hyperactive, isn't the correct
diagnosis attention-deficit disorder with hyperactivity (ADHD)? Or, if
the child is oppositional, wouldn't oppositional-defiant disorder (ODD)
be the correct diagnosis?
7
Why are we suddenly hearing so much about early-onset bipolar disorder?
8
Are there medical problems that can cause these symptoms?
8
What are the signs of childhood and adolescent problems?
8
How are children diagnosed?
8
If a child hears voices or sees things, does that mean he or she is
schizophrenic?
9
How long will bipolar disorder last?
10
Is there a risk of suicide?
10
How is Bipolar disorder different from other diagnoses?
10
The issue of Medication
What are the treatments for early-onset bipolar disorder?
13
Should antidepressants be used?
14
Can a child take antidepressants for the depressive periods after he or
she is stabilized on a mood stabilizer?
14
Should I consider medication?
14
What are these research studies?
15
So why read the research studies?
15
What is “evidence-based research” and why do I need to know it?
15
What if I really don’t understand the study or don’t know if it
related to me/my child?
16
What do I do first if I suspect a bipolar disorder?
16
What information should we bring to the first session with a doctor?
16
What question should I ask about medications?
17
What are the different types of medications?
17
What should I try to remember about all these medications?
24
Is there one type that is better than any other?
25
Are there problem combinations of medications?
25
Are there some guidelines for medication use with a bipolar disorder?
26
What dosage is the best?
26
How long should a person take these medications?
26
How do I deal with the necessary blood tests?
27
What are the major or typical medications?
27
What about the problem of weight gain with these mood stabilizers?
31
How long should we try one medication?
31
Side effects of medications
32
Is there a better schedule for medications?
32
What is a maintenance dose?
33
What about herbal supplements?
33
What about alcohol and street drugs?
33
What about the long-term side effects of the antipsychotic medications?
33
What are the side effects of Lithium?
34
Is there an alternative to Lithium?
35
Are there potential medical problems from taking these medications?
35
Aren’t anti-depressants prescribed along with the mood stabilizers?
36
What are the risks for older teens and pregnancy?
37
What happens after a pregnancy or abortion?
37
Isn’t weight gain a side effect and how can it be avoided?
37
Self-care
Is medication the only thing that will help control the moods?
38
What are the important tools stress management?
38
How do I track the moods or stress level?
39
What can be done when stress is unavoidable?
40
After a while, won’t I need to quit worrying about having mood changes?
41
Do I really need to learn stress management?
42
Are there other risk factors?
44
What about support groups?
44
What are self-help groups
45
Behavioral Health Services and other resources
What are the different types of behavioral health professionals?
46
What kind of professional is right for a child with bi-polar disorder?
49
What question do I ask of a potential provider of services?
49
How do I know when the counselor is “right” for me?
50
What are client’s rights
50
What is involved in an evaluation?
51
What should you do to prepare to see a mental health professional?
52
What happens at the end of an evaluation
52
What is a continuum of care?
52
What about hospitalization or residential treatment?
53
What are some of the different types of therapy or treatment?
54
What should you do to prepare for a visit with a mental health professional?
55
What if medications are prescribed?
55
What if alcohol and drugs are involved?
56
What is involved in adolescent substance abuse treatment?
57
Will insurance cover the treatment my child needs?
58
What if I don’t have enough insurance?
60
What resources are available in Alaska?
60
Making some sense of the organization of services in Alaska
60
What are useful Alaskan web-sites?
61
What national web based resources are available?
62
The Best Navigational Tool to have- The Resource Book
63
Education
What is IDEA and Section 504?
64
When is Section 504 used instead of IDEA?
64
Why have a child certified under the IDEA instead of under Section 504?
65
How does a student get IDEA services?
65
What should be tested for the IEP for a child with bipolar disorder?
66
What is the testing to determine executive function deficits?
67
What should the parent/student do to prepare for the IEP meeting?
68
What is a Resource Binder for the IEP meeting?
68
What should be discussed during the IEP meeting?
69
What is the “least restrictive environment”?
70
How often is the IEP reviewed?
71
What if the student does not improve after the IEP?
71
What if there are discipline problems at school?
72
What is the FBA and BIP of the IEP?
73
What about residential treatment centers?
74
What if the school is just unwilling or incapable of helping the student?
74
What about homeschooling?
75
Model answers to difficult education/school questions
76
What are examples of accommodations under Section 504?
81
What could an IEP look like for a student with bipolar disorder?
83
So, how can AYFN help me and my child?
86
The Bi-Polar Disorder Handbook was developed with funding from:
What is bipolar disorder?
Do children really become mentally ill?
The 1999 MECA Study (Methodology for Epidemiology of Mental Disorders in Children
and Adolescents) estimated that almost 21 percent of U.S. children ages 9 to 17 had a
diagnosable mental or addictive disorder that caused at least some impairment. A total of
4 million or 11% of children suffer from a psychiatric disorder that limits their ability to
function.
Of the children who have serious emotional problems at any point in time, only 1 in 5 of
these children is receiving appropriate treatment. When you suspect an emotional problem, seek a comprehensive evaluation by a mental health professional specifically trained
to work with children and adolescents. It is easy to overlook the seriousness of childhood
mental disorders. In children and youth, these disorders may present symptoms that are
different from or less clear-cut than the same disorders in adults. Younger children, especially, and sometimes older children as well, may not talk about what is bothering them.
For this reason, it is important to have a doctor, another mental health professional, or a
psychiatric team examine the child.
Generally, it is better to refer to children having severe emotional or behavioral disturbances rather than “mentally ill”. Many children who have behavioral disturbance have a
brain disorder and misuse drugs and alcohol. If the focus is on behaviors then the treatment and skill development can focus positively on the changes rather than what is
wrong.
What is Bipolar Disorder?
Bipolar disorder is a serious emotional/behavioral disturbance that has repeated periods
of depression, mania, and/or mixed symptom states. These moments or periods can last
for a few hours or a few months. This time is called an “episode” and can cause unusual
and extreme shifts in mood, energy, and behavior that interfere significantly with normal,
healthy functioning.
A manic episode is a distinct period of abnormally and persistently elevated, expansive,
and/or irritable mood. This period represents a significant change from the child’s usual
attitude or way of behaving and must last for at least 1 week. During this period the child
must have at least three (four if the mood is only irritable) of the following symptoms:
grandiosity, decreased sleep, pressured speech, flight of ideas or racing thoughts, distractibility, increased goal-directed activity, hypersexuality or psychomotor agitation, and
excessive involvement in pleasurable activities that have painful or unwanted consequences. The symptoms cannot have been brought on by the direct effects of a substance (e.g., alcohol or drug abuse, antidepressant medications) or to a general medical
condition.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 1 of 88
A hypomania episode has similar symptoms as a manic episode but differs in the severity
and duration criteria. The symptoms must be present for at least 4 days and must produce an unequivocal change in the child's functioning that is observable by others.
A depressive episode must either have a depressed mood or a lost of interest or pleasure
in daily activities consistently for at least a two week period. This depression in children
may be an unusual and irritable mood most of the day and nearly every day. It would
also include most of the following; significant change in appetite or change in body weight
not due to growth, insomnia, fatigue or loss of energy, physical agitation, feeling of
worthlessness or excessive/inappropriate guilt, indecisiveness or inability to think or concentrate, and. Recurrent thoughts of death, dying or committing suicide.
A cyclothymic disorder is very similar to bipolar disorder but the symptoms are not as severe but must have been present for at least one year and not absent for more than 2
months at a time. The mania and depression periods are not as extreme. There is less
likelihood of psychosis. The rapid cycling through the periods may be as frequent, however.
A mixed episode is a manic episode and a depressive episode that occurs nearly every
day for a least a full week.
Bipolar Disorder is a mood disorder and is called the “bipolar spectrum” because it can
have different forms.
• bipolar I (exhibiting full-blown mania)
• bipolar II (recurrent hypomania with major depression)
• cyclothymic disorder (recurrent hypomania with "minor" depression)
• depressions in persons with early-onset, low-grade chronic hypomania (hyperthymic personality)
• depressions arising from a cyclothymic temperamental baseline
• depressions complicated by treatment-emergent hypomania/mania; and periodic
depressions responsive to mood stabilizing agents (such as lithium)
The last 4 categories are not currently included in the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) but are grouped as bipolar disorder not otherwise specified (Bipolar NOS).
When did Bipolar in children become a diagnosed mental illness?
Childhood-onset mania generally went unrecognized over the first part of this century.
There are written observations that mania occurred rarely in children and that the onset of
first episodes increased significantly after puberty. By 1990 research separated childhood onset from the type that began more commonly during adolescence. Studies that
reviewed the histories of adults with bipolar disorder have found that approximately one
fifth of adults had recognizable symptoms prior to age 19.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 2 of 88
Is it common?
The incidence appears to increase after onset of puberty and appears fairly rarely before
the age of 6. A 1995 community school survey of older adolescents (14 to 18 years of
age) found the lifetime prevalence rate to be approximately 1% with most having bipolar II
disorder. An additional 5.7% had cyclothymia, a similar but milder illness, or had the bipolar symptoms but had not been diagnosed. Adolescents in the study had experienced a
distinct period of abnormally and persistently elevated, expansive, or irritable mood even
though they never met full criteria for bipolar disorder or cyclothymia. The estimated lifetime prevalence of mania varied from 0.6% to 13.3%. Recent studies have found that
from the time of initial showing of the symptoms, it takes an average of ten years before a
diagnosis is made. The lifetime prevalence in adults is estimated to be 0.8%. The lower
adult prevalence may be a matter of classification, since adults with bipolar symptoms
also have a diagnosis of substance abuse (60%) or chemically dependence (50%).
Is there a general time when symptoms of Bipolar Disorder begin?
Approximately 20% of all bipolar patients have their first episode during adolescence, with
a peak age of onset between 15 and 19 years of age. In over half of the cases the first
symptoms appear in childhood, often between ages eight and fifteen. When the symptoms begin before 18 years of age, it is called childhood or early onset
Who has it?
0verall, bipolar disorder affects both sexes equally. However, in American studies of
early-onset cases, males seem to be more often affected, especially in those with onset
before the age of 13 years. Females are more likely overall to have depressive disorders,
although for children younger than 12 years of age, boys again appear to be at greater
risk. This may indicate a bias related to school behaviors because boys tend to “act out”
or be disruptive in school more than girls. There is no indication that it is found in one
race or culture more than another
Is Bipolar disorder inherited?
If one person in a family has a bipolar disorder diagnosis, there is up to twice the number
of biological relatives in the same family with that diagnosis than in average families. The
number is highest when there are “early-onset” cases or children under 14 years of age
with the diagnosis.
There is also one study that found a mutation in a gene that regulates sensitivity to brain
neurotransmitters such as dopamine causing bipolar disorder in as many as 10 percent of
the people with the psychiatric illness. The mutation in the gene called G protein receptorkinase 3 occurs in a part of the gene called the promoter, which regulates when the
gene is turned on. The University of California, San Diego School of Medicine (USCD)
researchers hypothesize that this mutation causes a person to become hypersensitive to
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 3 of 88
dopamine. This results in the mood extremes that alternate between euphoric peaks and
serious depression seen in people with bipolar disorder.
The UCSD researchers say studies like theirs pinpoint genetic defects that cause bipolar
disorder and can help lead to the development of new drugs directed at specific genes.
This is the first study to pinpoint a precise gene involved in the disease. About a third to a
half of the 1 million people worldwide with bipolar disorder gets little benefit from existing
treatments. One of the major limitations in bipolar treatment is a lack of new molecular
targets for drugs.
Is intelligence a factor?
Studies have generally reported that over 90% of youth with bipolar disorder have normal
IQs. However, bipolar disorder, including rapid cycling, has been reported in patients with
moderate to severe mental retardation, autism, and trisomy 21 (Down’s syndrome).
How can I tell if someone has Bipolar Disorder?
Children and youth often have abrupt swings of mood and energy that occur multiple
times within a day, intense outbursts of temper, poor frustration tolerance, and oppositional defiant behaviors are commonplace in juvenile-onset bipolar disorder. These
youth’s moods go from irritable, easily annoyed, angry mood states to silly, goofy, giddy
elation, and then just as easily descend into low energy periods of intense boredom, depression and social withdrawal, fraught with self-recriminations and suicidal thoughts
Here is a useful quick screening test:
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 4 of 88
1. Has there ever been a period of time when you were not your usual self and...
...you felt so good or so hyper that other people thought you were not your normal
Yes No
self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or arguments?
Yes No
...you felt much more self-confident than usual?
Yes No
...you got much less sleep than usual and found you didn't really miss it?
Yes No
...you were much more talkative or spoke faster than usual?
Yes No
...thoughts raced through your head or you couldn't slow you mind down?
Yes No
...you were so easily distracted by things around you that you had trouble concenYes No
trating or staying on track?
...you had much more energy than usual?
Yes No
...you were much more active or did many more things than usual?
Yes No
...you were much more social or outgoing than usual; for example, you telephoned
Yes No
friends in the middle of the night?
...you were much more interested in sex than usual?
Yes No
...you did things that were unusual for you or that other people might have thought
Yes No
were excessive, foolish, or risky?
...spending money got you or your family into trouble?
Yes No
2. If you checked YES to more than one of the above, have several of these ever happened
during the same period of time?
YES
NO
3. How much of a problem did any of these cause you -- like being unable to work; having
family, money, or legal troubles; getting into arguments or fights?
No Problem
Minor Problem
Moderate Problem
Serious Problem
A Mood Disorder Questionnaire screening score of 7 or more items on #1 yielded good
sensitivity (0.73) and very good specificity (0.90) in a psychiatric outpatient population.
This is called “The Mood Disorder Questionnaire” is a useful screening instrument for bipolar spectrum disorder Am J Psychiatry. 2000 Nov; 157(11):1873-5.
Manic symptoms include:
• Severe changes in mood—either extremely irritable or overly silly and elated
• Overly-inflated self-esteem; grandiosity
• Increased energy
• Decreased need for sleep—ability to go with very little or no sleep for days without tiring
• Increased talking—talks too much, too fast; changes topics too quickly; cannot be interrupted
• Distractibility—attention moves constantly from one thing to the next
• Hypersexuality—increased sexual thoughts, feelings, or behaviors; use of explicit sexual
language
• Increased goal-directed activity or physical agitation
• Disregard of risk—excessive involvement in risky behaviors or activities
Sign of Mania
I feel like I’m on top of the world.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 5 of 88
I feel powerful. I can do anything I want. Nothing can stop me.
I have lots of energy.
I feel restless all the time.
I feel really mad.
I have a lot of sexual energy.
I can’t focus on anything very long.
I sometimes can’t stop talking and I really talk fast.
Friends tell me that I’ve been acting differently. They tell me that I’m starting fights, talking
louder, and getting more often angry. I sometimes can’t stop talking and I really talk fast.
Depressive symptoms include:
• Persistent sad or irritable mood
• Loss of interest in activities once enjoyed
• Significant change in appetite or body weight
• Difficulty sleeping or oversleeping
• Physical agitation or slowing
• Loss of energy
• Feelings of worthlessness or inappropriate guilt
• Difficulty concentrating
• Recurrent thoughts of death or suicide
Signs of Depression
I am really sad most of the time.
I don’t really enjoy doing the things I’ve always enjoyed doing.
I don’t sleep well at night and am very restless.
I am always tired. I find it hard to get out of bed.
I don’t feel like eating much.
I feel like eating all the time.
I have lots of aches and pains that don’t go away.
I have little or no sexual energy.
I find it hard to focus and am very forgetful.
I am mad at everybody and everything.
I feel upset and fearful but can’t figure out why.
I don’t feel like talking to people.
I feel like there isn’t much point to living, nothing good is going to happen to me.
I don’t like myself very much. I feel bad most of the time.
I think about death a lot. I even think about how I might kill myself.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 6 of 88
Do children and adolescents react in the same way as adult?
When manic, children and adolescents, in contrast to adults, are more likely to be irritable
and prone to destructive outbursts than to be elated or euphoric. When depressed, they
may have many physical complaints such as headaches, muscle aches, stomachaches
or tiredness, frequent absences from school or poor performance in school, talk of or efforts to run away from home, irritability, complaining, unexplained crying, social isolation,
poor communication, and extreme sensitivity to rejection or failure. Other signs of manic
and depressive states may include alcohol or substance use or misuse and difficulty with
relationships
Existing evidence indicates that bipolar disorder beginning in childhood or early adolescence may be a different with possibly more severe form of the illness than older adolescent and adult-onset bipolar disorder. When the illness begins before or soon after puberty, it is often characterized by a continuous, rapid-cycling, irritable, and mixed symptom state that may co-occur with disruptive behavior disorders, particularly attention deficit hyperactivity disorder (ADHD) or conduct disorder, or may have features of these disorders as initial symptoms. In contrast, later adolescent- or adult-onset bipolar disorder
tends to begin suddenly, often with a classic manic episode, and to have a more episodic
pattern with relatively stable periods between episodes. There is also less co-occurring
ADHD or conduct disorder among those with later onset illness.
A child or adolescent who appears to be depressed and exhibits ADHD-like symptoms
that are very severe, with excessive temper outbursts and mood changes, should be
evaluated by a psychiatrist or psychologist with experience in bipolar disorder, particularly
if there is a family history of the illness. This evaluation is especially important since psychostimulant medications, often prescribed for ADHD, may worsen manic symptoms.
There is also limited evidence suggesting that some of the symptoms of ADHD may be a
forerunner of full-blown mania.
Is bipolar disorder in children the same thing as bipolar disorder in adults?
Adults seem to experience abnormally intense moods for weeks or months at a time but
children appear to experience such rapid shifts of mood that they commonly cycle many
times within the day. This cycling pattern is called ultra-ultra rapid or ultradian cycling and
it is most often associated with low arousal states in the mornings (these children find it
almost impossible to get up in the morning) followed by afternoons and evenings of increased energy.
What are the symptoms in childhood and how early can they begin?
Many parents report that their children seemed different from birth or that they noticed
that something was wrong as early as 18 months. Their babies were often extremely diffiAlaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 7 of 88
cult to settle, rarely slept, experienced separation anxiety, and seemed overly responsive
to sensory stimulation. Early-onset bipolar disorder is manic-depression that appears
early, before the age of 12.
In early childhood, the youngster may appear hyperactive, inattentive, fidgety, easily frustrated and prone to terrible temper tantrums (especially if the word "no" appears in the
parental vocabulary). These explosions can go on for prolonged periods of time and the
child can become quite aggressive or even violent. The observation is that the child
rarely shows this side to the outside world.
A child with bipolar disorder may be bossy, overbearing, extremely oppositional, and have
difficulty making transitions. His or her mood can veer from morbid and hopeless to silly,
giddy and goofy within very short periods of time. Some children experience social phobia, while others are extremely charismatic and risk-taking.
A significant number of children who are depressed transition from depression into bipolar
mood states.
If the child is fidgety and inattentive and hyperactive, isn't the correct diagnosis attentiondeficit disorder with hyperactivity (ADHD)? Or, if the child is oppositional, wouldn't oppositional-defiant disorder (ODD) be the correct diagnosis?
Several studies have reported that over 80 percent of children who have early-onset bipolar disorder will meet full criteria for ADHD. It is possible that the disorders are co-morbid-appearing together--or that ADHD-like symptoms are a part of the bipolar picture. Also,
the ADHD symptoms may simply appear first on the continuum of a developing disorder.
Children with bipolar disorder exhibit much more irritability, labile mood, grandiose behavior, and sleep disturbances than do children with ADHD. Sleep disturbances are often accompanied by night terrors, such as nightmares filled with gore and life-threatening content.
Because stimulant medications may exacerbate a bipolar disorder and induce an episode
or negatively influence the cycling pattern of a bipolar disorder, bipolar disorder should be
ruled out first, before a stimulant is prescribed.
So how would a doctor diagnose early-onset bipolar disorder?
The family history is an important clue in the diagnostic process. If the family history reveals mood disorders or alcoholism coming down one or both sides of the family tree, red
flags should appear in the mind of the diagnostician. The illness has a strong genetic
component, although it can skip a generation.
Many parents are told that the diagnosis cannot be made until the child grows into the
upper edges of adolescence--between 16 and 19 years old. The Diagnostic and Statisti-
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 8 of 88
cal Manual of Psychiatry--the DSM-IV--uses the same criteria to diagnose bipolar disorder in children as it does to diagnose the condition in adults, and requires that the manic
and depressive episodes last a certain number of days or weeks. But as we already mentioned, the majority of bipolar children experience a much more chronic, irritable course,
with many shifts of mood in a day, and often they will not meet the duration criteria of the
DSM-IVR. The DSM-IVR needs to be updated to reflect what the illness looks like in
childhood. Clinicians who have experience with early-onset bipolar disorder can and do
understand the difference between adult and early onset bipolar disorder.
Are there medical problems that can cause these symptoms?
Symptoms of bipolar mania can be produced by a variety of different medical conditions,
including: (1) neurological disorders, such as brain tumors and CNS infections, including
human immunodeficiency virus (HIV), multiple sclerosis, temporal lobe seizures, and
Klein-Levin syndrome; (2) systemic conditions, such as hyperthyroidism, uremia, Wilson's
disease, and porphyra; (3) prescribed medications, including antidepressant agents,
sympathomimetics, bromocriptine, stimulants, and steroids; and (4) substance abuse, including
amphetamines,
cocaine,
phencyclidine,
inhalants,
and
methylenedioxymethamphetamine (ecstasy). Youth who have manic symptoms need to have a
thorough physical evaluation. Decisions regarding more extensive laboratory and neuroimaging studies should be made based on the clinical findings of the psychiatric, pediatric,
and neurological examinations.
What are the signs of childhood and adolescent problems?
Signs and symptoms of childhood and adolescent emotional problems may include:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
School problems
Frequent fighting
Trouble sleeping
Feeling sad
Thoughts about suicide or running away
Stealing or lying
Mood swings
Setting fires
Obsessive thoughts or compulsive behaviors
Excessive weight loss or gain
Troubling or disturbing thoughts
Use of drugs or alcohol
Withdraw or isolation
Injuring or killing animals
Dangerous or self destructive behavior
Trouble paying attention
Anxiety or frequent worries
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 9 of 88
Children with mania frequently have symptoms that are erratic rather than persistent.
The changes in mood, level of physical activity or agitation, and mental excitement are
often unpredictable. Irritability, belligerence, and mixed manic-depressive features are
more common than euphoria. The reckless behaviors seen in manic adults are limited to
typical childhood behavior problems, such as school failure, fighting, dangerous play, and
inappropriate sexualized activity. Children with bipolar disorder show an exaggeration of
normal childhood boasting, imaginary play, overactivity, and youthful indiscretions.
Adolescents with mania frequently have more complicated symptoms, including: (1) psychotic symptoms of mood-incongruent hallucinations, paranoia, and marked thought disorder; (2) markedly erratic moods, with mixed manic and depressive features; and (3) severe deterioration in their behavior. Teenagers with bipolar disorder are often underdiagnosed, over-diagnosed with conduct disorder and ADHD or misdiagnosed with
schizophrenia.
The Mania Rating Scale and subscales on the Child Behavior Checklist have been used
to distinguish manic children from those with ADHD.
Manic symptoms in youth frequently do not last long enough to meet the 1-week duration
criteria required by DSM-IVR. This is especially true for children. Therefore, youth are
more likely to have a diagnosis of either bipolar II or cyclothymic disorder, rather than bipolar I disorder. Children and adolescents may also be more likely than adults to present
with rapid-cycling episodes. Geller found that in 26 patients with early-onset bipolar disorder (ages 7 to 18 years), 81% had a rapid-cycling course.
If a child hears voices or sees things, does that mean he or she is schizophrenic?
Absolutely not. Psychotic symptoms such as delusions (fixed, irrational beliefs) and hallucinations (seeing or hearing things not seen or heard by others) can occur during both
manic and depression phases of bipolar disorder. In fact, they are not uncommon. Sometimes the voices and visions give commands and often are threatening. Quite a few children report seeing bugs or snakes or say that they see and hear satanic figures.
Early-onset bipolar disorder is frequently misdiagnosed (rates of 50% or more) as schizophrenia, especially when symptoms first appear during adolescence. Adolescents with
mania more often have "schizophrenic-like" symptoms (i.e., hallucinations and delusions),
and are more likely to be diagnosed as having schizophrenia or schizoaffective disorder
than patients with adult-onset bipolar disorder.
How long will bipolar disorder last?
Bipolar disorder does not disappear with age. The majority of adults who are not treated
in hospitals or by mental health centers will have usually 10 or more episodes in a lifetime. Episodes tend to come more frequently over time, until the cycle length stabilizes
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 10 of 88
after the fourth or fifth episode. Medication can stabilize the cycles within a few months.
Some teens and adults can adapt their life without medication with careful self-care and
stress management.
In a 5-year naturalistic prospective follow-up study of 54 adolescents with bipolar disorder, two adolescent who received treatment never achieved complete remission (no more
episodes). Of the remaining adolescents, 44% had a relapsing course (either major depression or mania), and 21% had two or more further episodes during the five years. Recovery from the first episode took longer for patients with depression (median time to recovery, 26 weeks) than for either mania or mixed episodes (median time, 9 and 11
weeks, respectively).
Compared with adults, adolescents with bipolar disorder may have symptoms longer and
be less responsive to treatment because adolescents with bipolar disorder frequently
have either mixed features, psychotic symptoms, and/or behavior/substance abuse problems. The most typical medication, lithium, is not recommended when these type of
symptoms or behaviors are present. However, the few available studies suggest that
childhood onset bipolar disorder is similar to that of adult onset; with only approximately
one half of patients showing significant functional impairment years after the first symptoms. If the child can continue to function normally at school and with friends, the likelihood of improvement is quite high.
Is there a risk of suicide?
Adolescents with bipolar disorder are at increased risk for completed suicides. Approximately 20% of the adolescents who sought treatment made at least one medically significant suicide attempt. In the adult literature, a large review of studies examining depressive and manic depressive disorders found that 19% of patients completed suicides. Patients who are male or who are in the depressed phase of their illness are at the highest
risk. You can read more research at http://jbrf.org/juv_bipolar/readings.html
How is Bipolar disorder different other diagnoses?
ADHD is characterized by a lack of concentration and attention, impulsiveness and hyperactivity which begins at a very young age, most often before age 6. 50% to 80% of
these children still have problems in the areas of attention, concentration and behavior in
adolescence and adult life.
The impulsivity, hyperactivity and irritability of ADHD or the antisocial and provocative behaviors of conduct disorder may all be confused with the mania of the bipolar disorder.
Many of the symptoms overlap, including aggression, school failure, psychomotor agitation, restless sleep, distractibility, and sexually inappropriate behaviors. Although historically, mania was undoubtedly under-diagnosed in youth felt to be behaviorally disordered,
the increased recognition of the phenomenon may now be leading to over-diagnosis, especially in preadolescents. Adding to this confusion is the fact that many youth with bipolar disorder also may have ADHD and/or conduct disorder.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 11 of 88
Both ADHD and conduct disorder are chronic persistent disorders of impulse control and
behavioral regulation, and they represent stable patterns of functioning. ADHD begins before age 7 and may evolve into conduct disorder during late childhood or early adolescence. Bipolar disorder is usually episodic, with onset usually after age 12. It is a disorder of affect regulation characterized by abnormal mood and mental excitement usually
presenting as a marked change in a youth's baseline function.
Bipolar disorder is a mood disorder with abnormal emotional and mental excitement,
sometimes with ADHD like symptoms such as irritable hyperactivity and attention and
concentration problems. This typical picture however is rarely seen before age 12. Children with bipolar disorder show interest in new stimuli, more than one usually sees in
children with ADHD. If they are creatively gifted, children with bipolar disorder are often
able to stay involved in fantasy or construction play without outside stimulus. Children
with ADHD too can stay focused but they are typically distracted by an outside attraction
like a television or video-game.
Diagnostic problems come about when a bipolar disorder starts with a history of an
ADHD-like behavior. A sudden worsening of symptoms like agitation and hyper-activity
together with new symptoms of mania may be the basis for a differential diagnosis. For
example: a young person with a history of ADHD may show some improvement in early
adolescence and then suddenly show irritability and unstable moods with rapid talking,
hyper-activity, impulsiveness, and uninhibited social behavior etc. Such a picture is more
likely to be a first manic phase rather than a new ADHD episode. One difficulty is that in
the early stages of bipolar disorder, the hyperactivity and attention problems can be much
more evident than the mood disorder.
Current estimates are that 25% of those with ADHD might be bipolar. In both groups
children are emotionally inadequate and their scores on hyperactivity scales are roughly
similar. However, in the case of children with bipolar disorder, there is more depression,
more psychosis, less social competence and more extreme emotional instability. They
are aggressive more often and the course of the disease is rather episodic. Even though
children with ADHD may sporadically become depressed, the depression never reaches
the depth of depression seen in children who later develop bipolar disorder. Moreover,
there is little family history of mood disorders in children with ADHD.
In the Delong & Aldershof study, 66% of 59 children with bipolar disorder (aged 3.1 - 20)
improved on Lithium, compared to 0% of 19 children with ADHD (aged 5.3 -15.3), 1987
The opposite is true too. Children with bipolar disorder do not improve on standard ADHD
therapy, stimulant medication. If a hyperactive child does not improve with the standard
ADHD medication, it is reasonable to begin to ask about the possibility of a bipolar disorder.
Unipolar illness or depression typically begins after age 25 years. The frequency of depressed episodes is higher for people with bipolar disorders. The episodes tend to have
a more abrupt onset and often display a seasonal pattern. In unipolar depression and
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 12 of 88
childhood depression, a subtle but persistent pattern of low-level depression of several
months to 2 years is not uncommon. Bipolar illness, by contrast, has an earlier age of
onset than unipolar illness, often with significant depressions during childhood or adolescence proceeding periods of expansive mood. Indication of a diagnosis of bipolar disorder may be disregarded because of the normal high emotional turbulence of adolescence; a growing body of psychiatric research suggests that the ultimate outcome of preteen major depression will be a bipolar disorder. This should give pause to those discounting the possibility of a bipolar disorder.
Mania may cause high risk behavior, hurting others, like that in conduct disorder, which
also often starts in adolescence. One of the major differences is the behavioral style.
The motives of a youth with conduct disorder are more callous, more asocial or antisocial.
Moreover, psychotic like symptoms and thoughts disorders are not present in conduct
disorder, while they sometimes are in bipolar disorder. Youth with conduct disorder also
do not show abrupt mood swings that are not beneficial to their goals of self-satisfaction.
One of the major differences between schizophrenia and bipolar disorder is that cognitive functioning remains normal through the bipolar disorder mood swings but is greatly
disrupted with teens with schizophrenia.
About 20% of bipolar I patients suffer from generalized anxiety disorder. Panic attacks
resistant to or intolerant of antidepressant therapies deserve close examination for an underlying bipolar illness.
Youth with Posttraumatic Stress Disorder (PTSD) have significant histories of trauma,
including childhood maltreatment not routinely found in youth with bipolar disorders.
Youth with PTSD often have mood instability, hyper vigilance, irritability, dissociative
symptoms, and sleep disturbances. These symptoms may be confused with mania/mixed
episodes. Youth can have both disorders, concurrently.
A youth with Borderline Personality Disorder has mood instability, poor impulse control
and erratic behaviors of a youth with a bipolar disorder. The traits of a personality disorder are comprehensive and persistent but the symptoms of bipolar disorder represent a
marked change in the youth’s basic demeanor and global functioning. Youth with bipolar
disorder may have chronic symptoms of irritability, cyclothymia, and/or dysthymia, and at
risk of being misdiagnosed as having borderline personality if the abrupt changes are
overlooked.
Schizoaffective disorder requires a period of illness in which the person has both a significant mood disorder (either major depression, mania, or a mixed episode) and psychotic symptoms fulfilling the requirements for schizophrenia. During the same period of
illness, there also must be at least a 2-week period where hallucinations and delusions
persist in the absence of predominant mood symptoms. Finally, the mood symptoms
must be present for a substantial portion of the overall illness. Schizoaffective disorder
has not been well defined in youth though Eggers in 1989 found that 28% of patients with
early-onset schizophrenia had schizoaffective psychoses at follow-up. Other follow-up
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 13 of 88
studies of psychotic youth have found that the diagnosis of schizoaffective disorder was
made infrequently, was associated with the most severe impairment and was somewhat
unreliable.
The Issue of Medication
What are the treatments for early-onset bipolar disorder?
The first line of treatment is to stabilize the child's mood to treat sleep disturbances and
psychotic symptoms, if present. Once the child is stable, a therapy that helps him or her
understand the nature of the illness and how it affects his or her emotions and behaviors
is a critical component of a comprehensive treatment plan.
Mood stabilizers are the mainstay of treatment for a bipolar disorder but many of these
medications have only recently begun to be used in children with the condition, so not a
lot of data about their use in childhood bipolar disorder exists. Many psychiatrists are
simply adapting what they know about the treatment of adults to the pediatric and adolescent population. However, the anticonvulsant mood stabilizers such as Depakote and
Tegretol, etc. have been used to treat young children with epilepsy for quite some time,
so there is a literature about these drugs in the pediatric population.
The mood stabilizers include lithium carbonate (Lithobid, Lithane, Eskalith), divalproex
sodium (Depakote, Depakene), and carbamazapine (Tegretol). Newer agents such as
gabapentin (Neurontin), lamotrigine (Lamictal), and topirimate (Topomax), Oxcarbazepine (Trileptal) and tiagabine (Gabitril) are currently under clinical investigation for
the treatment of bipolar disorder and are being used in children. Lamictal is not recommended for those under the age of 16.
If a child is experiencing psychotic symptoms and/or aggressive behavior, the newer antipsychotic drugs, risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel)
are commonly prescribed. Older antipsychotics such as thioridazine (Mellaril), haloperidol
(Haldol), and molindone (Moban) are old standbys. Clonazepam (Klonopin) and lorezapam (Ativan) are also used to treat anxiety states, induce sleep, and put a break on rapidcycling swings in activity and energy.
Should antidepressants be used?
It's very risky. Several studies have reported high rates of the induction of mania or hypomania and rapid-cycling in children with bipolar disorder who are exposed to antidepressant drugs of all classes. In addition, the child may experience a marked increase in
irritability and aggression. Many parents of children with a bipolar diagnosis report that
their children experienced psychosis and were hospitalized after their treatment with antidepressants. Some children did well for weeks or even for up to three months before a
switch into mania and ultra-rapid mood shifts began.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 14 of 88
Generally, an antidepressant should not be used without first trying to normalize the
youth’s routine. If self-care and therapy does not reduce the symptoms fairly quickly then
a mood stabilizer or an antipsychotic medication should be started. Only after these
medications have reached a therapeutic level should antidepressants be introduced.
Can a child take antidepressants for the depressive periods after he or she is stabilized
on a mood stabilizer?
Maybe. Some children may be able to take an antidepressant for a brief period if it is
combined with a mood stabilizer. More studies need to be done so that treatment recommendations can be made but generally antidepressants alone are not accepted practice.
Should I consider medication?
Psychiatric medications can be an effective part of the treatment for bipolar disorder and
other psychiatric disorders of childhood and adolescence. In the past few years there
have been an increasing number of new and different psychiatric medications used with
children and adolescents.
When the right medicine is prescribed by an experienced psychiatrist (preferably a child
and adolescent psychiatrist) and taken as directed, medication may reduce or eliminate
troubling symptoms and improve daily functioning of children and adolescents with psychiatric disorders.
But the wrong medication can make the behavior worse and medication is not magic so
even with the right medication, there may be no improvement for a few weeks or months.
There is also some controversy about the long-term useful of any neuroleptic medication.
Primarily, the concern and the studies have centered on whether medication at the time
of the first psychotic break is more effective than other treatment without medication or if
medication is taken that it is best if only taken for a few weeks or months. The studies
have been done with people with schizophrenia not children or adults with bipolar disorder: http://psychrights.org/Research/Digest/Chronicity/NeurolepticResearch.htm or look at
the book published in 2001 “Mad in America: Bad Science, Bad Medicine and the Enduring Mistreatment of the Mentally Ill” by Robert Whitaker.
There is special consideration when thinking about medication for children and adolescents. At this age, dysfunctional behavior at school and the isolation from peers has a
devastating effect. The loss of function during those years is very hard to regain, unlike
the loss of a few months or years in the life of an adult. One of the major issues to consider is the impact of loss of peers, social relations and the difficulty to catch up in school,
both academically and socially if medication is not used to stabilize the child or youth.
There are research studies underway to find out which medications are most helpful for
specific disorders and problems.
What are these research studies?
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 15 of 88
There are three general types of research: literature review, clinical practice, and control
studies. Literature review means that someone reads all the studies and books on a
topic and then writes a summary of the trends. They usually end the review by making
conclusions or recommendations. An example is a study that reviewed the history of the
number of persons with bipolar disorder, concluded that it was probably underreported
and then recommended a change in the DSM IV to have more accurate diagnosis. Clinical practice and experience involves following the progress of certain individuals and
comparing how they change. Often there is a comparison of people in different cities or
similar person taking different medications. The point of the research is that it just describes what happens. Control studies involve matching people or their circumstance
as something is done or not done that the researcher believes will be of help such as taking one medication or none or a placebo (a pill with no medication ingredients) and comparing how the individual changes over time. Control studies try to control everything except the one thing they are testing to see if that thing (treatment style, medicine, environment or whatever) helps the people in that group more than the people in the group who
don’t get that “thing”.
So why read the research studies?
The studies give you a good idea what is in question or controversial in the diagnosis or
treatment r possible prevention of this disorder. Some easy to read summaries are on
the web-site http://www.medscape.com . In the “search” box, type in “bipolar in children”,
check either MEDLINE or MEDSCAPE and a whole list of studies will appear. The title is
usually fairly well descriptive so just read through a few articles.
What is “evidence-based research” and why do I need to know it?.
You need to be an informed consumer of mental health services just as you need to know
something about cars before you go buy one. Pretty and comfortable is not enough, it
needs to work. Mental health or behavioral health services need to be helpful. Control
studies or controlled clinical practice is used to develop agreed upon ways to treat a disorder. It is called evidence based because the technique has scientific research showing
that it does work. Evidence-based practices should be constantly re-evaluated to see
how they support consumers' goals of independence and recovery. Bipolar disorder diagnosis and treatment does have a practice guideline.
It can be read at
http://www.guideline.gov/summary/summary.aspx?doc_id=3302.
What if I really don’t understand the study or don’t know if it related to me/my child?
Here’s an example: http://www.medscape.com/viewarticle/457402 This is a study about
how when quetiapine (Seroquel) was added to either lithium or divalproex (Depakote) to
test if patients had less aggression with no increase in depression. The combination resulted in no increase in aggression or depression in 46% of the people compared to 25%
of the people who only took the placebo and lithium or Depakote (divalproex). So, the
conclusion is that the combination of medication (mood stabilizer and anti-psychotic) is
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 16 of 88
likely to be better for people with a bipolar diagnosis who are aggressive than if they took
only a mood stabilizer like lithium or Depakote.
Even if you only have a vague idea what the study is really saying, it is a good way to begin a conversation with the doctor or therapist. Doctors and therapists read the same articles to determine which medications or treatments are most effective for a particular
child. They should be able to explain how this applies or does not apply to your child.
You can also contact an advocate, like Alaska Youth and Family Network (AYFN)
http://www.ayfn.org for help in figuring out the questions to ask or the answers you received.
What do I do first if I suspect a bipolar disorder?
First, it is essential to have a diagnosis and that the diagnosis of bipolar disorder is correct. There are a number of other problems that can “look like” bipolar and bipolar is often misdiagnosed as other problems, such as, ADHD, depression, aggressiveness and
Oppositional Defiance Disorder. Usually, the diagnosis is made by a psychiatrist or a
team of a psychiatrist and other mental health professionals.
What information should we bring to the first session with a doctor?
For a psychiatrist to do a comprehensive diagnostic evaluation of a child or adolescent, it
is best to have information about:
1. Any biological relative who had similar symptoms like bi-polar or manic depression, as
it used to be called.
2. Description of the length and timing of the manic and depression episodes. A monthly
calendar is useful to chart each day. If the moods will change during the day, use daily
charts. Remember that mania is not just being exited and silly it involved thoughts that
are racing from one topic to another, grandiose thoughts and generally a person that is at
least on double speed and intensity, including the level of irritation when upset in some
way.
3. Examples of behavior patterns when “manic” and when “depressed”
4. Examples of behavior patterns that contradict #3.
5. Description of eating, drinking and sleeping patterns.
6. Description of past response to medications and any side effects.
Beginning on page 46 there is a whole series of questions about the different type of behavioral health professionals, how to choose one of them and what to do for the first session
What questions should I ask about medications?
1. What is the name of the medication? Is it known by other names?
2. What is known about its helpfulness with other children who have a similar condition?
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 17 of 88
3. How will the medication help? How long before I see improvement? When will it
work?
4. What are the side effects which commonly occur with this medication?
5. What are the rare or serious side effects, if any, which can occur?
6. Is this medication addictive? Can it be abused?
7. What is the recommended dosage? How often will the medication be taken?
8. Are there any laboratory tests (e.g. heart tests, blood test, etc.) which need to be
done before my child begins taking the medication? Will any tests need to be done
while taking the medication?
9. Will a child and adolescent psychiatrist be monitoring the response to medication
and make dosage changes if necessary? How often will progress be checked and
by whom?
10. Are there any other medications or foods that should be avoided while taking the
medication?
11. Are there interactions between this medication and other medications (prescription
and/or over-the-counter)?
12. Are there any activities that should be avoided while taking the medication? Are
any precautions recommended for other activities?
13. How long does this medication need to be taken? How will the decision be made to
stop this medication?
14. What do I do if a problem develops (e.g. if my child becomes ill, doses are missed,
or side effects develop)?
15. What is the cost of the medication (generic vs. brand name)?
16. Does the school nurse need to be informed about this medication?
What are the different types of medications?
Here are the medications by types. Later in this section, there will be a description of
each one in more detail. The idea is to know the categories so the psychiatrist can help
you compare the effect of drugs from the same categories.
Mood Stabilizers and Anticonvulsant Medications: Mood stabilizers may be helpful in
treating manic-depressive episodes, excessive mood swings, aggressive behavior, impulse control disorders, severe mood symptoms in schizoaffective disorder and schizophrenia. Lithium (lithium carbonate, Eskalith) is an example of a mood stabilizer. Some
anticonvulsant medications can also help control severe mood changes. Examples include: Valproic Acid (Depakote, Depakene), Carbamazepine (Tegretol), Gabapentin
(Neurontin), and Lamotrigine (Lamictil).
Antipsychotic Medications: Antipsychotic medications can be helpful in controlling psychotic symptoms (delusions, hallucinations) or disorganized thinking. These medications
may also help muscle twitches ("tics") or verbal outbursts as seen in Tourette's Syndrome. They are occasionally used to treat severe anxiety and may help in reducing very
aggressive behavior. Examples of traditional antipsychotic medications include: Aripiprazole (Abillify), Chlorpromazine (Thorazine), Thioridazine (Mellaril), Fluphenazine (Prolixin), Trifluoperazine (Stelazine), Thiothixene (Navane), and Haloperidol (Haldol). Newer
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 18 of 88
antipsychotic medications (also known as atypical or novel) include: Clozapine (Clozaril),
Risperidone (Risperdal), Quetiapine (Seroquel), Olanzapine (Zyprexa), and Ziprasidone
(Zeldox).
Anti-anxiety Medications: Anti-anxiety medications may be helpful in the treatment of
severe anxiety. There are several types of anti-anxiety medications: benzodiazepines;
antihistamines; and atypicals. Examples of benzodiazepines include: Alprazolam (Xanax),
lorazepam (Ativan), Diazepam (Valium),and Clonazepam (Klonopin). Examples of antihistamines include: Diphenhydramine (Benadryl), and Hydroxizine (Vistaril). Examples of
atypical anti-anxiety medications include: Buspirone (BuSpar), and Zolpidem (Ambien).
Antidepressant Medications: Antidepressant medications are used in the treatment of
depression, school phobias, panic attacks, and other anxiety disorders, bedwetting, eating disorders, obsessive-compulsive disorder, personality disorders, posttraumatic stress
disorder and attention deficit hyperactive disorder. There are several types of antidepressant medications (tricyclics, serotonin reuptake inhibitors, monoamine oxidase inhibitors
and atypical). Examples of tricyclic antidepressants (TCA's) include: Amitriptyline (Elavil), Clomipramine (Anafranil), Imipramine (Tofranil), and Nortriptyline (Pamelor). Examples of serotonin reuptake inhibitors (SRI's) include: Fluoxetine (Prozac), Sertraline
(Zoloft), Paroxetine (Paxil), Fluvoxamine (Luvox), Venlafaxine (Effexor), and Citalopram
(Celexa). Examples of monoamine oxidase inhibitors (MAOI's) include: Phenelzine
(Nardil), and Tranylcypromine (Parnate). Examples of atypical antidepressants include:
Bupropion (Wellbutrin), Nefazodone (Serzone), Trazodone (Desyrel), and Mirtazapine
(Remeron).
Stimulant Medications: Stimulant medications are often useful as part of the treatment
for attention deficit hyperactive disorder (ADHD). Examples include: Dextroamphetamine
(Dexedrine, Adderal), Methylphenidate (Ritalin, Concerta), and Pemoline (Cylert),
Sleep Medications: A variety of medications may be used for a short period to help with
sleep problems. Examples include: SRI anti-depressants, Trazodone (Desyrel), Zolpidem
(Ambien), and Diphenhydramine (Benadryl).
Miscellaneous Medications: Other medications are also being used to treat a variety of
symptoms. For example: clonidine (Catapres) may be used to treat the severe impulsiveness in some children with ADHD and guanfacine (Tenex) for "flashbacks" in children
with PTSD.
You can read about these medications at http://bipolar.about.com/bl-medsAZ.htm. Psychiatrist will often use the trade name (brand name) and the generic name (scientific name) interchangeably. To help you identify them, you will find the typical medications prescribed for children and youth followed by two alphabetical listings of the common psychiatric drugs, by trade
name and then by generic name.
Children’s Medications
TRADE NAME
GENERIC NAME
APPROVED AGE
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 19 of 88
Stimulant Medications
Adderall
amphetamine
3 and older
Adderall XR
amphetamine
(extended release)
6 and older
Concerta
methylphenidate
(long acting)
6 and older
Cylert*
pemoline
6 and older
Dexedrine
dextroamphetamine
3 and older
Dextrostat
dextroamphetamine
3 and older
Focalin
dexmethylphenidate
6 and older
Metadate ER
methylphenidate
(extended release)
6 and older
Ritalin
methylphenidate
6 and older
Non-stimulant for ADHD
Strattera
atomoxetine
6 and older
*Because of its potential for serious side effects to the liver, Cylert should not be a first-line drug therapy
for ADHD.
Antidepressant and Antianxiety Medications
Anafranil
clomipramine
10 and older (for OCD)
BuSpar
buspirone
18 and older
Effexor
venlafaxine
18 and older
Luvox (SSRI)
fluvoxamine
8 and older (for OCD)
Paxil (SSRI)
paroxetine
18 and older
Prozac (SSRI)
fluoxetine
18 and older
Serzone (SSRI)
nefazodone
18 and older
Sinequan
doxepin
12 and older
Tofranil
imipramine
6 and older (for bedwetting)
Wellbutrin
bupropion
18 and older
Zoloft (SSRI)
sertraline
6 and older (for OCD)
Antipsychotic Medications
Clozaril (atypical) clozapine
18 and older
Haldol
3 and older
haloperidol
Risperdal (atypirisperidone
cal)
18 and older
Seroquel (atypical)
quetiapine
18 and older
Mellaril
thioridazine
2 and older
Zyprexa (atypical)
olanzapine
18 and older
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 20 of 88
Orap
pimozide
12 and older (for Tourette's syndrome -- Data for age 2 and
older indicate similar safety profile)
Mood Stabilizing Medications
Cibalith-S
lithium citrate
12 and older
Depakote
valproic acid
2 and older (for seizures)
Eskalith
lithium carbonate
12 and older
Lithobid
lithium carbonate
12 and older
Tegretol
carbamazepine
any age (for seizures)
Alphabetical list of medications by trade name
TRADE NAME
GENERIC NAME
Antipsychotic Medications
Abilify
aripiprazole
Clozaril
clozapine
Geodon
ziprasidone
Haldol
haloperidol
Lidone
molindone
Loxitane
loxapine
Mellaril
thioridazine
Moban
molindone
Navane
thiothixene
Orap (for Tourette's syndrome)
pimozide
Permitil
fluphenazine
Prolixin
fluphenazine
Risperdal
risperidone
Serentil
mesoridazine
Seroquel
quetiapine
Stelazine
trifluoperazine
Taractan
chlorprothixene
Thorazine
chlorpromazine
Trilafon
perphenazine
Vesprin
trifluopromazine
Zyprexa
olanzapine
Antimanic Medications
Cibalith-S
lithium citrate
Depakote
valproic acid, divalproex sodium
Eskalith
lithium carbonate
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 21 of 88
Lamictal
lamotrigine
Lithane
lithium carbonate
Lithobid
lithium carbonate
Neurontin
gabapentin
Tegretol
carbamazepine
Topamax
Topiramate
Antidepressant Medications
Adapin
doxepin
Anafranil
clomipramine
Asendin
amoxapine
Aventyl
nortriptyline
Celexa (SSRI)
citalopram
Desyrel
trazodone
Effexor
venlafaxine
Elavil
amitriptyline
Lexapro (SSRI)
escitalopram
Ludiomil
maprotiline
Luvox (SSRI)
fluvoxamine
Marplan (MAOI)
isocarboxazid
Nardil (MAOI)
phenelzine
Norpramin
desipramine
Pamelor
nortriptyline
Parnate (MAOI)
tranylcypromine
Paxil (SSRI)
paroxetine
Pertofrane
desipramine
Prozac (SSRI)
fluoxetine
Remeron
mirtazapine
Serzone
nefazodone
Sinequan
doxepin
Surmontil
trimipramine
Tofranil
imipramine
Vivactil
protriptyline
Wellbutrin
bupropion
Zoloft (SSRI)
sertraline
Antianxiety Medications
(All of these antianxiety medications except BuSpar are benzodiazepines)
Ativan
lorazepam
Azene
clorazepate
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 22 of 88
BuSpar
buspirone
Centrax
prazepam
Librax, Libritabs, Librium
chlordiazepoxide
Klonopin
clonazepam
Paxipam
halazepam
Serax
oxazepam
Tranxene
clorazepate
Valium
diazepam
Xanax
alprazolam
Alphabetical list of medications by generic name
GENERIC NAME
TRADE NAME
Antipsychotic Medications
aripiprazole
Abilify
chlorpromazine
Thorazine
chlorprothixene
Taractan
clozapine
Clozaril
fluphenazine
Permitil, Prolixin
haloperidol
Haldol
loxapine
Loxitane
mesoridazine
Serentil
molindone
Lidone, Moban
olanzapine
Zyprexa
perphenazine
Trilafon
pimozide (for Tourette's syndrome)
Orap
quetiapine
Seroquel
risperidone
Risperdal
thioridazine
Mellaril
thiothixene
Navane
trifluoperazine
Stelazine
trifluopromazine
Vesprin
ziprasidone
Geodon
Antimanic Medications
carbamazepine
Tegretol
divalproex sodium (valproic acid)
Depakote
gabapentin
Neurontin
lamotrigine
Lamictal
lithium carbonate
Eskalith, Lithane,
Lithobid
lithium citrate
Cibalith-S
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 23 of 88
topimarate
Topamax
Antidepressant Medications
amitriptyline
Elavil
amoxapine
Asendin
bupropion
Wellbutrin
citalopram (SSRI)
Celexa
clomipramine
Anafranil
desipramine
Norpramin, Pertofrane
doxepin
Adapin, Sinequan
escitalopram (SSRI)
Lexapro
fluvoxamine (SSRI)
Luvox
fluoxetine (SSRI)
Prozac
imipramine
Tofranil
isocarboxazid (MAOI)
Marplan
maprotiline
Ludiomil
mirtazapine
Remeron
nefazodone
Serzone
nortriptyline
Aventyl, Pamelor
paroxetine (SSRI)
Paxil
phenelzine (MAOI)
Nardil
protriptyline
Vivactil
sertraline (SSRI)
Zoloft
tranylcypromine (MAOI)
Parnate
trazodone
Desyrel
trimipramine
Surmontil
venlafaxine
Effexor
Antianxiety Medications
(All of these antianxiety medications except buspirone are benzodiazepines)
alprazolam
Xanax
buspirone
BuSpar
chlordiazepoxide
Librax, Libritabs, Librium
clonazepam
Klonopin
clorazepate
Azene, Tranxene
diazepam
Valium
halazepam
Paxipam
lorazepam
Ativan
oxazepam
Serax
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 24 of 88
prazepam
Centrax
What should I try to remember about all these medications?
The depression phase of bipolar disorder can be the most serious because of the possibility of suicide risk and the child’s inability to function on a day to day basis. Treatment
with just antidepressant may bring on mania and increase the cycles’ frequency or intensity. When rapid cycling begins or mania is happens when taking one mood stabilizer,
the ideal long-term treatment is add a second mood stabilizer like lithium or Tegretol or an
atypical antipsychotic instead of combining two mood stabilizers and an atypical antipsychotic medication.
If you want to do more reading you can find specific dosage guidelines at:
http://www.psychguides.com/Bipolar_2000.pdf The Expert Consensus Guidelines Series
for the Treatment of Bipolar Disorders 1997. The first 46 pages describe the best practices in medication use. Page 50-96 describes the results to the questions asked in order
to produce the “best practices”. Especially useful are pages 97-104 that are developed
specifically for consumers. You can also read more about medications at
http://bipolar.about.com/library/meds/bl-meds-abilify.htm or place the name of a specific
medication in the blank “search” at the bottom of the page and check “drug info” at
http://www.medscape.com.
Is there one type that is better than any other?
If there is a family history of a good response to one drug, that drug is more likely to be
effective with your children. Conversely, the drug is less likely to be effective if someone
in the family has had an allergic reaction or there is a medical history that would caution
against taking the drug, such as a thyroid problem would suggest not taking lithium.
.Are there some combinations of medications that I should be very careful about?
There is some evidence that using antidepressant medication to treat depression in a
person who has bipolar disorder may bring on manic symptoms. For someone with bipolar disorder, the antidepressant should be taken along with a mood stabilizer.
There is also evidence that using only stimulant medications to treat attention deficit hyperactivity disorder (ADHD) or ADHD-like symptoms in a child with bipolar disorder may
make manic symptoms worse.
Young children and adolescent are not easily diagnosed with bipolar and it is even harder
to determine which person will become manic. There is a greater likelihood that children
and adolescents who have a family history of bipolar disorder will develop manic symptoms after they have symptoms of depression.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 25 of 88
If manic symptoms develop or really get worse after taking antidepressants or stimulants,
a psychiatrist should be consulted immediately. This is a strong indication that a diagnosis and treatment of bipolar disorder should be considered and a different medication or
combination or no medication should be taken. The combination or increase of antidepressants and psychostimulants can lead to rapid cycling or worse cycles, more ups and
down or higher or longer manic periods and lower or longer depressed periods.
Are there some guidelines for medication use with a bipolar disorder?
Yes but remember that guidelines are not set recipes so they don’t dictate exactly what
should be done.
1. When bipolar disorder is diagnosed (no matter if it is in the manic or depressed state),
initial treatment with a mood stabilizer is preferred. Since bipolar depression is the most
frequent mood aberration seen, many psychiatrists prefer to begin with a mood stabilizer
with what appears effective for the depressed states (lithium, olanzapine or Zyprexa,
lamotrigine or Lamictal). If the person is in a hypomanic/manic phase, olanzapine or
Zyprexa, divalproex or Depakote, or lithium are preferred, remembering that lithium is
less effective in patients with mixed manic/depressed symptoms.
2. If depression persists, a second mood stabilizer may be added or the initial mood stabilizer can be combined with a non-Tricyclic antidepressant (TCA). Careful observation for
signs/symptoms of mood switching and mixed states is mandatory.
3. When a mood stabilizer/antidepressant combination is producing the desired effect, the
combination can be continued or an attempt can be made to reduce or eliminate the antidepressant. Experts differ on this issue. Some point out that antidepressants may destabilize the long-term course of bipolar illness, and others emphasize the frequency and severity of bipolar depression and the need to prevent depressive intrusions.
What dosage is the best?
There are guidelines but this is best discussed directly with the psychiatrist. You can
download the dosage recommended at http://www.medscape.com. Go to the “Search”
box at the bottom of the page, type the name of the medication and check “DrugInfo”.
How long should a person take these medications?
There is no clear cut answer. Some medication can be stopped and others need to be
cut back gradually.
Some experts believe that medication is a life-long necessity for
someone with bi-polar disorder. Other experts believe you can taper down the number of
medications and the amount taken. There are no good long-term studies of the effects of
the medication taken by children with bipolar disorder. It is important that children and
teens complete school so you have to find the critical balance between taking the medication. Unfortunately, psychotherapeutic medications do not produce the same effect in
everyone. Some people respond better to one medication than another and some may
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 26 of 88
need larger dosage than others. Inherited traits and self- care skills also influence the
need for medication.
One of the things that distinguish the maintenance treatment of children from that of
adults is that children are growing and their body mass is increasing constantly, as is their
cardiovascular volume. As the volume of their blood increases, a dose that was adequate
in September may not be adequate in January. In other words, the blood levels may be
constantly changing and parents and physicians must take into account these physiological changes. Many reports of relapses occurring despite the consistency of dosing (no
skipped meds) but can be blamed on falling blood levels.
How do I deal with the necessary blood tests?
The problem with checking blood levels is that many children are extremely sensitive and
needle phobic. The very idea of frequent blood tests is a stress to parents and children.
However, there is a product developed in Israel called Emla that is available by prescription. It is an anesthetic that can be administered to a child’s arm about an hour before the
blood draw. One 5 gram tube costs about $15 and is good for one to two blood draws.
There is a five-tube kit that costs approximately $50 and a 30 gram tube is also available.
The kit comes with an occlusive dressing (it helps the cream penetrate better) but the
doctor will give complete directions. Some insurance plans will pay for the prescription,
some won’t. But if Emla helps the child deal with the uncomfortable situation and produces a less fearful reaction, than it’s priceless to the child and the parents who have to
deal with the visit to the lab.
Many parents report that they pay their children for each visit to the lab ($10-$15 seems
to be the going rate), or plan a special treat afterwards to brace them for the experience
and so they associate some pleasant things with it. It is also very important to find
someone who is good at drawing blood (quick, accurate and without inflicting pain) and
stay with that person, no matter where they work!
At first, more frequent blood levels will be required to make sure the level of medication is
high enough to be therapeutic but not too high to do damage. Generally blood level tests
are done monthly.
What are the major or typical medications?
Lithium is considered the gold standard for the treatment of bipolar disorder in adults,
and an estimated 70-80 percent of patients have a positive therapeutic response to it. But
there has long been an idea that rapid-cyclers may not do as well on lithium as they do on
the anticonvulsant drugs--Tegretol or Depakote and so on.
Very importantly, there is newly emerging evidence from the research literature that lithium has a strong and possibly unique effect against suicidal behavior in people with bipolar disorder. And this is not true of the other mood stabilizers as far as we know. According to Ross J. Baldessarini, M.D. of Harvard Medical School "If the antisuicidal side ef-
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 27 of 88
fects are not shared with other mood-altering agents, this may be due to the cerebral serotonin-enhancing properties of lithium, properties that are not known to be associated
with anticonvulsants.”
You should do the following before treatment: Complete medical history, blood tests that
include kidney function studies and thyroid-function studies and urinalysis.
Dosage
in
mg
for
children
under
twelve
years
of
age.
WEIGHT (pounds)
7 A.M. 12 noon 6 P.M. Total Daily Dose
Less than 55
150
150
300
600
55-88
300
300
300
900
88-110
300
300
600
1200
110-132
600
300
600
1500
The range of effective levels: are 0.6 to 1.5 mEq during acute episodes and maintenance
ranges from 0.6 to 0.85 mEq/liter.
Lithium cannot just be stopped suddenly. Lithium treatment is associated with an approximately seven-fold reduction of suicide attempts and fatalities in adult bipolar patients. However, Drs. Ross J. Baldessarini and Leonardo Tondo recently reported statistics from their large Sardinia study and found that discontinuing lithium rapidly after longterm maintenance led to a sharp increase in suicidal risk. The risk increased twenty-fold
in the first twelve months than at later times, but was only half as great following slow discontinuation (fifteen to thirty days versus one to fourteen days). These researchers recommend gradually discontinuing mood-stabilizing medications whenever possible, perhaps over several months. The research suggests that antidepressants should not be
used during this time.
Tegretol (carbamazepine) has acute antimanic effects and also acts to prevent future
episodes of illness in bipolar disorder. Some studies have reported that Tegretol has antiagressive properties, something that might make it particularly useful for children with frequent rage attacks.
You should do the following before treatment: complete medical evaluation, blood tests to
evaluate liver function, blood cell and platelet counts and iron concentration.
Dosage for younger children between the ages of six to twelve might be started on 100
mg daily (or 50 mg two times a day if the liquid is used). The dose is typically increased
weekly by increments of 100 mg with an initial target dose of 500-600 mg/ml. At this point,
the blood level is obtained five to six days after reaching the initial target dose. Further
increases would depend on evidence of clinical response, side effects, and achieving a
therapeutic level.
Adolescents older than twelve usually start treatment with doses of 200 mg twice a day
and the dose is increased weekly by increments of 200 mg. The usual daily maintenance
dose is 800 to 1200 mg.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 28 of 88
Tegretol activates certain enzymes in the liver. This causes Tegretol itself and many others medications to be metabolized faster. The serum Tegretol level may drop somewhat
after the first month of treatment, requiring increased doses based on blood levels. Blood
tests are needed more frequently in the beginning of treatment and every three months or
so afterward.
The generic form of Tegretol, carbamazepine, appears to be less well formulated than the
brand name drug. The tablets tend to fall apart and to be less well absorbed. If a young
woman is on oral contraceptives, Tegretol will reduce the effectiveness of the “pill.”
Do not store Tegretol in the bathroom cabinet or in any humid area because humidity
may cause Tegretol tablets to harden, become less soluble and lose one-third or more of
its effectiveness. They should be stored in moisture-proof containers. The range of the
effective levels is 6 to 12 mg/ml
Depakote is prescribed Depakote (divalproex sodium) but all too often we receive med
charts from parents or emails reporting that the Depakote dosage was 250-500 mg a day
and "it didn’t work." Most children will require far higher doses to achieve therapeutic
blood levels, and while all children will reach different blood levels at different dosages,
it’s important to get the right levels and wait a few weeks before making any judgment
about the effectiveness of the drug.
You should do the following before treatment: medical exam to gauge liver function,
blood cell and platelet counts, and serum iron concentrations.
Children are often started on a test dose of 125 mg and adolescents on 250 mg, and the
doses are gradually increased to obtain a daily target dose of between 1,000-1,200 mg.
Some children will require 1,500-2,000 mg a day to maintain an effective Depakote level.
Like Tegretol, Depakote increases its own breakdown and the levels will need to be examined after a month on the medication to see if the level has dropped.
The range of effective levels is between 80-90 mg/ml but some require levels of 100 to
125 mg/ml to achieve adequate symptom relief.
Topamax (topiramate) is an anticonvulsive drug chemically unrelated to any other anticonvulsant or mood stabilizing medication. It has been reported to control rapid-cycling
and mixed bipolar states in patients who have not responded well to Tegretol or Depakote
but its long-term prevention of cycling has not been established.
What makes this drug of particular interest is that it causes no weight gain. In fact, it may
reduce the intense food cravings that may occur with other commonly used psychiatric
drugs such as Depakote, Risperdal, and Zyprexa. It can also be used as a sedating
agent.
An initial dose of 25 mg is given once or twice a day and increased by 25 to 50 mg every
week. When Topamax is prescribed as an add-on drug with other anticonvulsants, a tar-
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 29 of 88
get dose of 150 to 200 mg is often enough for mood stabilization but some children will
require higher doses, even up to 400 mg a day. When Topamax is used as alone, a target dose of upwards of 200 mg seems to provide mood stabilization.
The blood levels of Topamax can be lowered by Depakote and especially Tegretol, and
Topamax may decrease the effectiveness of birth control pills.
Lamictal (lamotrigine) is an anti-seizure medication that may have a significant place in
the treatment of bipolar disorder. What sets it apart from most the other mood stabilizers
is that it seems to have a significant effect on the depressive symptoms of bipolar disorder. The other mood stabilizers work to act to prevent future episodes of depression and
mania but do not work as well on acute depression. This medication might allow doctors
to treat the depressive symptoms of bipolar disorder without antidepressants which tend
to cause increased cycling or to flip patients into mixed or manic states. However,
Lamictal seems to have weaker antimanic effects, and at higher doses, above 175 mg, it
can be activating.
There are no blood levels to be taken and the side effect profile is mild but Lamictal can
produce an allergic response of a rash. On rare occasions, the rash can be a serious one
that signals a life-threatening condition known as Stevens-Johson Syndrome.
In most cases, the rash is mild, similar to a sunburn and usually clears up after the drug is
stopped (many people can resume the drug later and no rash will occur). But let’s take a
look at some of the newest research concerning Lamictal and serious rash.
A rash is most likely to develop when the dosing schedule starts too high or is increased
too rapidly. It often takes three months to reach the target dose. Other cases of rash occurred when Lamictal was given with Depakote, the Depakote doubles the Lamictal levels. Typically the rash occurs in the first eight weeks of treatment.
Lamictal cannot be given to adolescents younger than 16 and is approved only for children with the severe seizure disorder Lennox-Gaston. Reports of its use for bipolar depression are compelling, however, and future studies should decide how helpful a medicine it will be for bipolar disorder. Lamictal should be started at 25 mg for 10 days to two
weeks and then increased by 12.5 mg every ten days to two weeks until a target dose of
100-150 is reached.
Abilify is a new antipsychotic medication approved by the US Food and Drug Administration in November 2002 for the treatment of schizophrenia. This drug treats for symptoms
that are also found in major manic episodes of bipolar disorder and in schizoaffective disorder. Two things that appear to distinguish Abilify from other antipsychotic medications
are a fewer side-effect and a positive effect on depression. Abilify treats the same symptoms of schizophrenia as other drugs such as Zyprexa, Risperdal and Geodon, that are
also found in major manic episodes of bipolar disorder and in schizoaffective disorder
(Delusions Paranoia Hallucinations (visual and auditory) and altered senses).
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 30 of 88
The mechanism of Abilify - generic name Aripiprazole - is different from other medications
used for the same symptoms. Most antipsychotics work by shutting down dopamine receptors. Abilify appears to work by forcing these receptors to behave more normally. At
this time, clinical trials indicate that Abilify does not lead to weight gain, tardive dyskinesia
(muscle and movement problems) or other problems found in older medications. It is important to remember, though, that it takes years for a full evaluation of any drug, for example, no one knew at first that Prozac and Depakote could lead to substantial weight
gain. That was only proved over time. Abilify is only beginning to be studied in children.
There is no good data on its use.
What about the problem of weight gain with these mood stabilizer medications?
Weight gain due to medications is a real issue for many with bipolar disorder. Both the
mood stabilizers and the selective serotonin reuptake inhibitors (SSRI antidepressants)
can be the culprit. As many as two-thirds of those taking mood stabilizers will have significant weight gain. For those taking SSRIs, there is usually an increase by 20 to 30
pounds. However, recent research is finding that the anticonvulsant, topiramate (Topamax), often prescribed as a mood stabilizer may stimulate weight loss. The antidepressant, bupropion (Wellbutrin, Zyban), also seems to help with this issue
How long should we try one medication?
This is a difficult question with no right answer. First, never stop taking one medication or
add another without talking to a psychiatrist. Second, always call the physician or psychiatrist for immediate advice if the “side effects” increase or are uncomfortable.
Reports from the clinical research show that a combination of two mood stabilizers is often necessary to “achieve symptom remission” or remove the behavior/thoughts that are
a problem. Therefore, if one medication seemed to cause only some positive change, it
does not necessarily mean that the first drug trialed is of no value.
If antidepressants have been administered prior to the trial of a mood stabilizer (between
one week to three months) or are prescribed at the same time, it will be difficult to judge
the effectiveness of the mood stabilizer. Antidepressants are destabilizing for the majority
of children with bipolar disorder. While some clinicians believe that high doses of mood
stabilizers will buffer the activating effects of the anti- depressants, this still remains to be
established by clinical trials. (The National Institute of Mental Health is currently planning
a four-center study that will hopefully answer this question. They will be using Prozac in
combination with mood stabilizers for children and adolescents ages 8-18.)
Now the question becomes, how long a child should be kept on a mood stabilizer before
making another or better choice. Currently, a reasonable time period to continue a mood
stabilizer once a high therapeutic level has been established (and this can take weeks), is
between 5 and 6 weeks. Remember that this has not been objectively established, Right
now, finding the right medication is a matter of patience and communication. A decision
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 31 of 88
about the amount and type of medication should be made together by the child/youth,
psychiatrist and parents.
What does “off label” mean?
Many treatments are available. The treatments include both medications and psychotherapy: behavioral therapy, treatment of impaired social skills, parental and family therapy,
and group therapy. The therapy used is based on the child's diagnosis and individual
needs.
When the decision is reached that a child should take medication, active monitoring by all
caretakers (parents, teachers, and others who have charge of the child) is essential. Children should be watched and questioned for side effects because many children, especially younger ones, do not volunteer information. They should also be monitored to see
that they are actually taking the medication and taking the proper dosage on the correct
schedule.
Based on clinical experience and medication knowledge, a physician may prescribe to
young children a medication that has been approved by the FDA for use in adults or older
children. This use of the medication is called "off-label." Most medications prescribed for
childhood mental disorders, including many of the newer medications that are proving
helpful, are prescribed off-label because only a few of them have been systematically
studied for safety and efficacy in children. Medications that have not undergone such testing are dispensed with the statement that "safety and efficacy have not been established
in pediatric patients." The FDA has been urging that products be appropriately studied in
children and has offered incentives to drug manufacturers to carry out such testing. The
National Institutes of Health and the FDA are examining the issue of medication research
in children and are developing new research approaches.
Is there a better schedule of medication times?
Unlike some prescription drugs, which must be taken several times during the day, some
antipsychotic medications can be taken just once a day. In order to reduce daytime side
effects such as sleepiness, medications can be scheduled to be taken at bedtime. A few
antipsychotic medications are available in "depot" forms that can be injected once or
twice a month. Injecting medication, while guaranteeing that the medication is taken, has
two major drawbacks: the child does not learn to take the medication regularly and having a shot means a visit to the doctor (unless the parent is administering the injection). A
thorough discussion about control and resentment issues between the child and the parent should occur with the psychiatrist and the child’s therapist before a parent accepts the
role of injecting medication. The less control and buy-in the child has about medication,
the less likely he or she is to continue taking it without problems.
You need to consider two opposite needs: taking the medication in low enough dosages
multiple times a day so there is an even dosage level in the blood stream versus not having to disrupt the day (or miss a dose) because it is inconvenient to take more than once
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 32 of 88
or twice a day. Both needs are important so the balance and agreement by the child or
teen taking the medication is crucial. Remember that a mid-day dose will need to be
taken in the nurse’s office at school. This is often an embarrassing task for children and
youth. Because other students often serve as a “nurse’s assistant”, it is important that the
child or youth taking the medication is ready and willing to address any gossip that may
be generated by the “nurse’s assistant”. Obviously, the entire issue is avoided if no medication is taken during the day while at school.
What is a maintenance dose?
In some cases a person who has experienced one or two severe episodes may need
medication indefinitely. In these cases, medication may be kept at low dosage just to control the symptoms. This approach, called maintenance treatment, prevents relapse in
many people and removes or reduces symptoms for others.
What about the effects of other drugs or herbal supplements?
There are no current reports of herbal remedies that take the place of antipsychotic medication. Antipsychotic medications can produce unwanted effects when taken with other
medications. Therefore, the doctor should be told about all medicines being taken, including over-the-counter medications and vitamin, mineral, and herbal supplements. St.
John’s Wort that may help with mild depression can bring on manic episodes just like
prescribed antidepressants. Some antipsychotic medications interfere with antihypertensive medications (taken for high blood pressure), anticonvulsants (taken for epilepsy),
and medications used for Parkinson's disease.
The use of alcohol can also interfere with the usefulness of the antipsychotic or mood
stabilizing medication. Other antipsychotics add to the effect of alcohol and other central
nervous system depressants such as antihistamines, antidepressants, barbiturates, some
sleeping and pain medications, and narcotics.
What about alcohol and street drugs?
Teenagers may be tempted to self-medicate by using marijuana to calm themselves or
Ecstasy to relieve the depression. The more you can talk openly about the choice of selfmedication, the easier it may be to identify what medications are actually working to address the original symptoms rather than those produced by the drugs, prescribed or otherwise acquired.
The potency of alcohol may be increased by medications since both are metabolized by
the liver; one drink may feel like two. The use of alcohol should be really minimized.
The effect of the quick high of alcohol followed by the depression from the post-sugar
high may also contribute to rapid cycling. Bipolar disorder is not a good illness to try to
self-medicate.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 33 of 88
What about the long-term side effects of the antipsychotic medications?
Long-term treatment with one of the older, or "conventional," antipsychotics may cause a
person to develop tardive dyskinesia (TD). Tardive dyskinesia is a condition characterized
by involuntary movements, most often tongue movements and facial tics. It may range
from mild to severe. In some people, it cannot be reversed, while others recover partially
or completely. However, it is most often seen after long-term treatment with older antipsychotic medications. The risk has been reduced with the newer "atypical" medications.
There is a higher incidence in women, and the risk rises with age. The possible risks of
long-term treatment with an antipsychotic medication must be weighed against the benefits in each case. The risk for TD is 5 percent per year with older medications; it is less
with the newer medications. Many of the new antipsychotic medications can do serious
damage to the liver and kidneys, if the level of medication is not monitored closely.
There is also little information about the long term effects when the appropriate level is
maintained.
What are the side effects of Lithium?
Lithium is the medication used most often to treat bipolar disorder. Lithium is a salt believed to be missing from the person with bipolar disorder. Lithium evens out mood
swings in both directions, from mania to depression and depression to mania. It is used
not just for manic attacks or flare-ups of the illness but also as an ongoing maintenance
treatment for bipolar disorder.
Although lithium will reduce severe manic symptoms in about 5 to 14 days, it may be
weeks to several months before the condition is fully controlled. Antipsychotic medications are sometimes used in the first several days of treatment to control manic symptoms
until the lithium begins to take effect. Antidepressants may also be added to lithium during
the depressive phase of bipolar disorder.
A person may have one episode of bipolar disorder and never have another, or be free of
illness for several years. But for those who have more than one manic episode, doctors
usually give serious consideration to maintenance (continuing) treatment with lithium.
When people first take lithium, they may experience side effects such as drowsiness,
weakness, nausea, fatigue, hand tremor, or increased thirst and urination. Some may
disappear or decrease quickly, although hand tremor may persist. Weight gain may also
occur. Dieting will help but crash diets should be avoided because they may raise or
lower the lithium level. Drinking low-calorie or no-calorie beverages, especially water, will
help keep weight down. Kidney changes, increased urination and, in children, enuresis
(bed wetting) may develop with this medication. These changes are generally manageable and are reduced by lowering the dosage. Because lithium may cause the thyroid
gland to become underactive (hypothyroidism) or sometimes enlarged (goiter), thyroid
function monitoring is a part of the therapy. To restore normal thyroid function, thyroid
hormone may be given along with lithium.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 34 of 88
Because of possible complications, doctors either may not recommend lithium or may
prescribe it with caution when a person has thyroid, kidney, or heart disorders, epilepsy,
or brain damage. Women of childbearing age should be aware that lithium increases the
risk of congenital malformations in babies. Special caution should be taken during the first
3 months of pregnancy.
Anything that lowers the level of sodium in the body, such as, reduced intake of table salt,
a switch to a low-salt diet, heavy sweating from an unusual amount of exercise or a very
hot climate, fever, vomiting, or diarrhea--may cause a lithium buildup and lead to toxicity.
It is important to be aware of conditions that lower sodium or cause dehydration and to
tell the doctor if any of these conditions are present so the dose can be changed.
Lithium, when combined with certain other medications, can have unwanted effects.
Some diuretics--substances that remove water from the body--increase the level of lithium and can cause toxicity. Other diuretics, like coffee and tea, can lower the level of lithium. Signs of lithium toxicity may include nausea, vomiting, drowsiness, mental dullness,
slurred speech, blurred vision, confusion, dizziness, muscle twitching, irregular heartbeat,
and, ultimately, seizures. A lithium overdose can be life-threatening. People who are taking lithium should tell every doctor who is treating them, including dentists, about all
medications they are taking.
Is there an alternative to Lithium?
Some people with symptoms of mania who do not benefit from or would prefer to avoid
lithium have been found to respond to anticonvulsant medications commonly prescribed
to treat seizures. The anticonvulsant valproic acid (Depakote, divalproex sodium) is the
main alternative therapy for bipolar disorder. It is as effective in non-rapid-cycling bipolar
disorder as lithium and appears to be superior to lithium in rapid-cycling bipolar disorder.
Although Depakote can cause gastrointestinal side effects, the incidence is low. Other
adverse effects occasionally reported are headache, double vision, dizziness, anxiety, or
confusion. Because in some cases Depakote has caused liver dysfunction, liver function
tests should be performed before therapy and at frequent intervals thereafter, particularly
during the first 6 months of therapy Studies in Finland have shown Depakote increases
testosterone levels and can cause obesity, body hair, (amenorrhea)stopping of menstrual
cycle and polycystic ovary syndrome. Young females should be carefully monitored if
they take this medication.
Other anticonvulsants used for bipolar disorder include carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurontin), and topiramate (Topamax). The evidence for
anticonvulsant effectiveness is stronger for acute mania than for long-term maintenance
of bipolar disorder. Some studies suggest particular effectiveness of Lamital with bipolar
depression. At present, the lack of formal FDA approval of anticonvulsants other than
Depakote for bipolar disorder may limit insurance coverage for these medications.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 35 of 88
Are there potential medical problems from taking these medications?
Antipsychotics like Geodon is associated with a generally high risk of Type 2 diabetes but
the risk is lower with some of these drugs than with others. The mechanisms include the
drug-induced weight gain that is common with antipsychotics but there is also evidence
for a direct metabolic effect. This may be related to antagonism at the 5-HT2C or histamine H, receptors or to elevation of serum leptin beyond that induced by increased body
weight alone.
Stopping the antipsychotic commonly allows the diabetes to resolve. Given the compounding effects of weight gain and diabetes on coronary heart disease (the major cause
of premature death in schizophrenia), aggravated by smoking and inactivity (frequent features of schizophrenia), antipsychotics with low potential for weight gain and diabetes
should be preferred. Among the atypical antipsychotics, Risperdal, has been shown to
reduce the long-term risk of relapse compared with the conventional neuroleptic, Haldol.
Particular attention should be paid to patients taking Clozaril or Zyprexa. Management of
schizophrenia in general should include a greater attention to medical risks, and effective
diet and exercise programs are needed.
Aren’t anti-depressants prescribed along with the mood stabilizers?
Many youth who have been diagnosed with bipolar disorder take more than one medication. Along with the mood stabilizer--lithium and/or an anticonvulsant--they may take a
medication for accompanying agitation, anxiety, insomnia, or depression. It is important to
continue taking the mood stabilizer when taking an antidepressant because research has
shown that treatment with an antidepressant alone increases the risk that the patient will
switch to mania or hypomania, or develop rapid cycling.
Although not common, some people have experienced withdrawal symptoms when stopping an antidepressant too abruptly. Therefore, when discontinuing an antidepressant,
gradual withdrawal is generally advisable.
The most common side effects of tricyclic antidepressants, and ways to deal with them,
are as follows: dry mouth (it is helpful to drink sips of water; chew sugarless gum; brush
teeth daily), constipation (add more bran cereals, prunes, fruit, and vegetables to the
diet), bladder problems (emptying the bladder completely may be difficult and the urine
stream may not be as strong as usual but pain is a sign of immediate problem), sexual
arousal impairment (a very serious problem for older teens); blurred vision (usually temporary and will not necessitate new glasses but may have some effect on glaucoma), dizziness (slow movement is recommended which will seriously compromise any youth active in sports or physical activity), drowsiness as a daytime problem until the medication is
adjusted so the drowsiness can come at bedtime and increased heart and pulse rate.
The past decade has seen the introduction of many new antidepressants that work as
well as the older ones but have fewer side effects. Some of these medications primarily
affect one neurotransmitter, serotonin, and are called selective serotonin reuptake inhibi-
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 36 of 88
tors (SSRIs). These include fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox),
paroxetine (Paxil), and citalopram (Celexa).
The SSRIs, have some of the same type of side effects: Sexual problems and agitation
or feeling jittery. Then there are additional or different types of side effects: temporary
headache, nausea, nervousness and insomnia. Any of these side effects may be amplified when an SSRI is combined with other medications that affect serotonin. In the most
extreme cases, such a combination of medications (e.g., an SSRI and an MAOI) may result in a potentially serious or even fatal "serotonin syndrome," characterized by fever,
confusion, muscle rigidity, and cardiac, liver or kidney problems.
Other new medications that affect both norepinephrine and serotonin but have fewer side
effects include venlafaxine (Effexor) and nefazadone (Serzone). But cases of lifethreatening hepatic failure (liver dysfunction like yellowing of the skin or white of eyes,
unusually dark urine, loss of appetite that lasts for several days, nausea or abdominal
pain) have been reported in patients treated with nefazodone (Serzone).
Other newer antidepressant medications chemically unrelated to the other antidepressants are the sedating mirtazepine (Remeron) and the more activating bupropion (Wellbutrin). Wellbutrin has not been associated with weight gain or sexual dysfunction but
cannot be used for people with, or at risk for, a seizure disorder.
What are the risks older teens and pregnancy?
There is a risk of birth defects with some psychotropic medications during early pregnancy. Lithium, Tegretol and Depakote should be discontinued during the first trimester
(first three months). There are no studies on the effect of Lamictal and Neurontin.
Pregnancy prevention may also be a problem. The estrogen in birth control pills may affect the breakdown of medications by the body, such as, increasing side effects of some
antianxiety medications or reducing their ability to relieve symptoms of anxiety. Also,
some medications, including carbamazepine (Tegretol) and some antibiotics, and an
herbal supplement, St. John's Wort, can cause an oral contraceptive to be ineffective.
What happens after a pregnancy or abortion?
Women with bipolar disorder are at particularly high risk for a postpartum depression. It
may be important to resume the medication just prior to delivery or shortly thereafter. Also
important is the need to be especially careful to maintain their normal sleep-wake cycle.
The next consideration is that small amounts of medication do pass into the breast milk.
Sometimes it is possible to offset the schedules, breastfeeding long after the taking of the
medication, so there is minimal amount passing through to the baby.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 37 of 88
Isn’t weight gain a side effect and how can it be avoided?
Weight gain due to medications is a real issue for many youth with bipolar disorder. Both
the mood stabilizers and the selective serotonin reuptake inhibitors (SSRI antidepressants) can be the culprit. According to Dr. Norman Sussman, a clinical professor of psychiatry at the New York University School of Medicine, as many as two-thirds of those
taking mood stabilizers will have significant weight gain. For those taking SSRIs, there is
usually an increase by 20 to 30 pounds. Weight gain for preteens and teenagers is more
than a cosmetic issue since the school and teen culture so heavily factors appearance.
An increase in weight will often result in the youth not taking their medication. Discussing
the issue and attempting an activity schedule that will offset the weight gain is as crucial
as discussing whether a medication is necessary to take. Fat teens are more likely to not
be involved in every day school and social activity offsetting possible gains made on the
depression by the medication.
Some recent research is finding that the anticonvulsant, topiramate (Topamax), often prescribed as a mood stabilizer may stimulate weight loss. The antidepressant, bupropion
(Wellbutrin, Zyban), also seems to help with this issue. These may offer a solution, if the
side effects of these medications are well tolerated without many side effects.
Self Care
Is medication the only thing that will help control the moods?
Medication provides chemicals for stabilization of the person but stress management
tools help the person to become in good emotional shape. Stress management tools develop emotional stability “muscles” just like exercise develops physical muscles. Stress
management tools are necessary whether in addition to or a substitute for medication.
Obviously there are events and people that will upset any one’s routine. The key to
stress management is to have layers of protection. The base of protection is routine
sleep and regular meals. The second layer is a support system to help maintain a regular
schedule or help identify when things appear to be “out of kilter”. The third layer is prevention. The prevention stress management tools are techniques like deep breathing,
progressive muscle relaxation, journal writing or self-reflection, routine activities, exercise,
hobbies, a regular work or volunteer schedule, regular play or fun times, routine inspiring
activities, counseling and time management skills
What are the important in stress management tools?
Often bipolar symptoms, especially manic episodes, are worsened by stressful times. So,
by maintaining a regular schedule and engaging in common stress management techniques, you can help reduce the likelihood of facilitating a manic or depressive episode.
The most important routine is sleep. Routine sleep means to have a regular bedtime and
a usual wake up time. Teenagers have a dual problem because it is “cool” to stay up on
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 38 of 88
weekends plus the normal teenager needs more sleep. The research on the teenage biological clock shows that it is more natural to stay up later toward midnight and sleep to 9
or 10 am. So, if the routine sleep cycle changes for the weekend, it is very important to
have at least 8-10 hours of sleep and as quickly as possible reinstate the normal bedtime
and wake-up time.
In a study of 39 people with bipolar disorder, Frank and colleagues found that 65% of patients had at least one serious disruption in their daily rhythm in the two months before
the onset of a manic or depressive episode. In contrast, only 20% of the same patients
had a disruption in sleep or schedule in a two-month period prior to relatively calm time
during the same year. Loss of sleep seemed to make the biggest difference between
those who had a manic episode and those who remained on an even keel. Even a single
night of sleep loss may be enough to set off a manic episode.
Enough sleep, and on a regular schedule, is one of the most powerful tools in preventing
manic attacks. When you are sleep-deprived, the brain seems to tingle and sparkle and
yet everything seems to move so slowly. Sleep deprivation alters the brain chemistry.
There are relaxation techniques that can help you sleep. A physican can also prescribe
one of the newer sleep inducing medications for a week or so to assist you to get back on
schedule.
Meals at regular times also stabilize the body as well as putting order to the day. Some
studies suggest that diets high in animal proteins or sugar tend to trigger mood changes.
Studies also suggest that artificial food coloring and flavorings also trigger agitation or
mania. Each person is different and it is a good idea to add or take away one food or ingredient at a time to make certain that the change in mood is due to that food or ingredient and not something else.
Studies indicate exercise does have an affect on improving mood in every one, not just
people with bipolar disorder. People with a bipolar disorder do report that consistent
regular exercise helps to balance out some of the mood swings. Exercise can also be
used to increase the habit of taking medication regularly because the effects of exercise
are helpful in counteracting weight gain, a common side effects of the mood stabilizers
(lithium, Depakote etc) and the antipsychotic (Zyprexa, Respiredal etc) medications.
Weight gain it is one of the most common reason adolescents stop taking the medication.
How do I track the moods or stress level?
The first step is to make sure you have some way of getting feedback about how you are
doing. One way is to keep tract of your own moods. Some people write their daily
thought and activities in a journal or diary. Some people keep a doodle or art diary of
their moods or ideas. Others keep a chart of their moods.
The point of the journal, diary or chart is to tract for signs of mood changes. Small or
short changes in response to events are generally fine. The regular routine and normal
stress management tools will probably take care of staying balanced and on an even
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 39 of 88
keel. But large or abrupt changes may be a sign of a mood swing. Noticeable changes
in activity level or moods require some quick action to reestablish regular routines. This
is when friends and family can help to make sure there is regular exercise, sleep, meals
and little stress in your daily life. For some, it is time to adjust the medication or have an
extra counseling session. For others, it is time to just return to a low stress routine.
Most importantly, the life-long task is to track the moods, have a back-up plan of action
or reduction in action that you and close friends and family can help in implementing and
then when the chart shows the changes. Put the back-up plan in gear!
Mood Chart
Morning
Afternoon
Evening
Overall Rating
Medications
Sunday
Medications
Monday
Medications
Tuesday
Medications
Wednesday
Medications
Thursday
Medications
Friday
Medications
Saturday
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 40 of 88
.
What can be done when stress is unavoidable?
There is a “serenity prayer” that is taught in Alcoholics Anonymous that is very helpful:
“Grant me the serenity to accept the things I cannot change; courage to change the
things I can; and wisdom to know the difference”. In other words, stick to the routine and
focus on doing what worked before the stress when things are out of your control. When
the support system lets you know that the stress is because of something you can
change, use those time and stress management techniques. When in doubt, stick to the
routine and consult a counselor you trust.
Think with your mind not your feelings. Use your support system to help you look at
yourself. Having a bipolar disorder is similar to having diabetes. The sugars need to be
managed with diabetes and the moods need it with bipolar disorder. People with diabetes cannot eat the same thing as others and stress makes the symptoms worse. Bipolar
disorder is similar, except maybe you can eat sugars! But, if you have ups and downs
that others in your situation don’t have, you might need medication or do some intense
work with a counselor about stress and moods. If you are stressed and others are also
stressed in the same situation, then …just get back to your routine to take the pressure of
yourself and then do consult a counselor for support
After a while, won’t I need to quit worrying about having mood changes?
Usually after the moods have stopped changing so wildly there is a tendency to start to
think that the bipolar symptoms are “under control”. But this is a stage that means the
relief has turned into denial about the full implications of the illness. In reality, you will
soon realize that your “core personality” is driven by this illness. Even with a regular routine (with or without medication), life will never be the same as it was before. There will
be a temptation to pretend that nothing is wrong and you can just slip back into not having
regular routines. Teenagers will be tempted to just go hang out with the crowd and not
sleep for a weekend, stop taking the medications, experiment with drugs and alcohol, skip
the counseling and so on. The denial is that everything is ok now because there was a
period of calm and routine. Nothing can be further from the truth because the bipolar disorder is still there and will remain there.
The next stage is anger. As you remain in a routine, you will be furious with life, yourself,
your parents, your friends and your counselor about missed chances, screw-ups and the
past.. No one will escape totally untouched from the anger because now that you are no
longer in denial, this is a stage when you want the bipolar disorder to just disappear or
blame someone for the fact that it has not disappeared. This is a normal stage. Be angry
but use it to empower yourself rather than disempowering yourself or to harm yourself or
others. The crucial point is that you understand and acknowledge your anger. Own it, accept it, and make it yours to the extent necessary to get through it. Is this permission to
wallow in it indefinitely? No way! But you cannot move onward unless you've dealt with
this critical aspect of learning to survive with a brain chemistry that will confuse or create
moods just like the diabetic’s blood sugar that becomes regularly out of balance. Be an-
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 41 of 88
gry; it's ok, and you need no one else's permission to be so. Having a brain chemistry
disorder is not something anyone would choose to have (just like no one would choose to
have diabetes).
The next stage is guilt. Of all the many things you will feel as you try to adjust to officially
having bipolar disorder, guilt is perhaps the most burdensome and difficult to get a grip
on. There's guilt over your past obnoxious behaviors and (if you are a teenager or older)
overt sexual indiscretions, the way you've treated family and friends, the lack of attention
or care you've given your pets, the inability to maintain in school or relationships and the
nagging self-doubt about your own sense of worth. But despite all the foregoing, remember this, in fact, make it your personal motto: guilt is a wasted emotion. It comes from an
exaggerated sense of responsibility aimed at the wrong kinds of things and for all the
wrong reasons. Sometimes it comes from all those do's and don’ts you've had drilled into
you by family, school society and the church. Forget them, unless they were principles
you personally chose after very careful thought. What matters now is the future you
choose to follow. From this point on, the choice and the responsibility are all yours. That's
a little intimidating but it's also a very freeing kind of thought as well. Try it on for size; you
might come to appreciate it. If nothing else, it unties that old guilt-knot in one's stomach.
Probably the most difficult and depressing aspect of this disorder is encountered after
having passed through the struggle with denial and guilt. It is the point when mere resignation settles on you that you are going to make a trade off: give up some of the
euphoric highs of hypomania for more stability and fewer “highs.” At first you will mourn
the times of the super bursts of creative energy, the ability to do the work of ten others,
stay up at the local coffee shop or friend’s house all night, the quick punning and life-ofthe-party charisma. But remember that you will not mourn the dark moods that also
come after those high times. So, the stage of resignation is to mourn for the parts of your
personality that may become muted or disappear entirely in the trade off. During this
stage you may 1) experience a sense of resignation regarding your situation 2) mourn
and suffer for feeling forced into that resignation, 3) entertain the notion of dumping your
medications down the toilet and finally, 4) expect life to get immediately better and you
will be disappointed at the fact that it doesn't. This is another tough time to ride out.
Some things will improve very quickly but others won't. People with a bipolar disorder
are not usually the patient type but the process of adaptation does take time.
As you have reconciled your past with the rather scary present, by this stage you have
learned more about yourself and discovered a wealth of internal strength to carry you
through the ups and downs that most certainly will come your way in the future. This is
also the period during which you will spend a great deal of time thinking about where you
end and the medications begin. Mixed in with these considerations will be an ongoing
quest to find the real you underneath and/or cohabiting with the bipolar you. Sound peculiar? It should. But ask any person with bipolar disorder and you will find that all have
spent some time trying to figure out which of their cherished personality traits is due to
their being bipolar and which is due to some unique, core "self". People that have considered themselves loners or just plain different from others may wonder whether it was
the disorder protecting them from a world that was always just too much to handle. All of
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 42 of 88
this questioning is an essential part of a process called acceptance. When you have accepted that there is no magic cure for what you have, and that you will have it forever,
you can move on to making your life as fulfilling and stable as it can be. Not until you
reach a point where you are both reconciled to your brain chemistry disorder or illness
and accepting of the treatment it mandates can you really begin to grow and live a full life.
Do I really need to learn stress management?
Stress management is critical to staying sane and non-manic. Stress can trigger manic
attacks. Sometimes it is not even personal stress but tension that comes from watching
the news or movies that show horrors of the world. Sometimes it is internal and requires
the development of strategies for dealing with life's curve balls. Anger may set off manic
attacks, too. Alcohol may begin a depression but in some it actually begins a manic episode. Each person has his or her own triggers.
The key is to learn about yourself, your own brain chemistry illness is how to control those
triggers, as much as possible. Generally people with bipolar disorder really need to
closely monitor and modify their life and not set off a mania onset. This means
1. Monitor medication. Take it as prescribed. Know which medication should be
increased or added if mania or other symptoms begin. Have a medication to take
when the sleep cycle is interrupted.
2. Eat healthy meals in a routine time frame. People in a manic state often forget
about eating. Loss of weight is one of the signs of the mania onset.
3. Monitor caffeine. Caffeine (cigarettes, tea, coffee, soda and chocolate) is often
used to self-medicate out of a temporary slump or depression. Too much caffeine
and the sleep cycle gets off balance and may set up a mania episode.
4. Monitor alcohol, drugs and places where they are available. Self-medication is
tempting but quite dangerous. Some drugs just make the depression last longer.
Other drugs can increase rather than decrease the mood and push you into a
more rapid cycling from one to the other. Alcohol can act as a stimulant rather
than a depressant.
5. Moderate exercise. Keep the activity level higher during the morning and day
and taper off in the evenings. This will help prompt a normal schedule of sleeping
at night and burst of energy for work, school and play during the day.
6. Journaling or some other written record. Use something like a journal to record
how the days go: mood level, type of activity, activity level, amount of rest, medication or self-medication and the people you see or telephone. Journaling can take
the guesswork out of how long you have been feeling a certain way or doing
things. It is also fun.
7. Budget and monitor shopping and spending money. This may be the quickest
clue that your moods are changing. A manic onset usually comes with a shopping
or spending spree. And if you enjoy shopping, be aware that not being able to
drag yourself to the store or e-bay may be an indication of depression. This is why
journaling can be so important, enthusiastic shopping several times a week or not
going to the store for necessities should cause warning bells to clang!
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 43 of 88
8. Make a log of phone calls and phone time (even if you are a teenager). Suddenly wanting to share everything with old time buds and relatives is a danger
sign. Calling different people as if they are long-time friends or chatting on the
Internet with acquaintances instead of sleeping is a clue that something is going
wrong. The log will help keep from fooling yourself into thinking that this is normal
behavior. The danger zone is when you cannot remember who you called or what
you talked about!
9. Listen to friends and family when they say to “slow down and rest”. To get back
into a routine you have to put down those car keys, try to relax, lie down, read a
book or just stay at home and don't wander aimlessly around feeling tired or manic.
10. Monitor personal grooming. Often, people that are depressed have to drag
themselves into the shower or wash their hair. In a manic state, people often compulsively seek that squeaky-clean feeling and activity. Showering or bathing may
be a part of the system of relaxation. The key is moderation.
Are there other risk factors?
Yes, in addition to stress, certain medical conditions can precipitate a manic episode:
stroke, traumatic brain injury, multiple sclerosis, epilepsy, HIV infection, AIDS, systemic
lupus erythematosus, Wilson's disease, hyperthyroidism, vitamin B12 deficiency, Cushing's disease, herpes simplex, uremia and sleep deprivation. These medical conditions
need to be aggressively treated in addition to managing bipolar illness. Communication
amongst the psychiatrist, counselor and physician is strongly recommended.
Some substance use could precipitate mania in people with bipolar disorder: alcohol,
bronchodilators, caffeine, steroids, antidepressants (particularly tricyclic antidepressants),
interferon, dopamine agonists and pseudoephedrine
Some other substances that can precipitate mania are also illegal or misused: alcohol,
cocaine, stimulants and hallucinogens. Educating youth and families about the inherent
mood destabilizing effects of illegal drugs is critical. A treatment plan to concurrently address both bipolar illness and substance abuse/dependence will be essential.
Finally, mania may also be brought on by increased exposure to light. Summers predispose people with bipolar disorder to the risk of a manic relapse while autumns tend to
precipitate depressive episodes. Exposure to artificial light and travel between time zones
that extends the period of daylight can possibly lead to a manic relapse. Whether the risk
of relapse is simply a function of sleep disruption, dysregulation of circadian pacemaking,
or dysregulation of neuro-transmitters such as melatonin or serotonin (which may be in
involved in the etiology of bipolar disorder) is not known.
What about support groups?
In addition to counseling, support groups can be one of the most effective ways of maintenance and self-care. A support group has other people who are or have struggled
through similar issues. Support groups also have many successful people from whom to
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 44 of 88
draw inspiration. During a support group you can expect to share a little about yourself
and why you are attending. People share ideas and experiences about their own selfcare techniques and the trials and tribulations of managing a life with bipolar disorder.
As any group gathering, some groups will be a fit for one person but not everyone who
attends. Support is sometimes very serious and sometimes just sharing stories, making
friends and having a good laugh.
You can connect to local support groups in Alaska by asking your counselor or contacting
Alaska Youth and Family Network (AYFN) at [email protected] for an in-person group or
internet chat room. There are internet chat rooms and bulletin boards but most are not
“staffed” and can get fairly wild. AYFN has a monitored chat room that functions more
like a discussion group.
Some books may also be helpful. Kay Redfield Jamison wrote “A Memoir of Moods and
Madness” about her struggle with manic depression, the stigma of mental illness and the
decisions she made as a writer and a psychiatric researcher. One of the better resource
books is “The Bipolar Child” by Janice and Demitri Papolos. Other books that may be
helpful: for 4-11 year olds by Tracy Anglada “Brandon and the Bipolar Bear: A Story for
Children with Bipolar Disorder,” for 8-12year olds by Caroline C McGee “Matt The Moody
Hermit Crab by Caroline C. McGee and for the adolescent by Lizzie Simon “Detour: My
Bipolar Road Trip in 4-D”. There is a summary of these and other books at
http://www.bipolarchild.com/bookshelf.html
What are self-help groups?
Self-Help groups can be more appropriately called "mutual help" groups. Essentially there
are four characteristics that make them what they are:
Mutual help - This is the primary dynamic process that takes place within the group. It is
people helping one another and helping themselves in the process. Experiences are
shared, knowledge is pooled, options are multiplied, hopes are reinforced, and efforts are
joined as members strive to help one another.
Member-Run - Member run and "owned". Providing a sense of belonging and reflecting
members' felt needs. They are not professionally run groups. If professionals are involved
(and in many cases they are) they serve in ancillary supportive roles, i.e., they are "on
tap, not on top" as some groups describe it.
Composed of Peers - Members share the same problem/experience, providing a powerful "you are not alone" sense of understanding, which can often lead to an almost instant
sense of community at the first meeting.
Voluntary Non-Profit organization - Volunteer-run, no fees, dues if any are minimal.
They are, as described by A. Tofler in his 1980 book, The Third Wave, as "prosumers,"
rather than "consumers.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 45 of 88
Some researchers have partnered with self-help groups to articulate the value gained
through self-help groups. One of the most comprehensive compilations of outcome studies that has examined only self-help groups is “Research on Self-Help/Mutual Aid
Groups” by Drs. Kyrouz and Humphreys at Stanford School of Medicine. Generally, selfhelps groups result in the participants rating their quality of life and their knowledge higher
after participating than similar people who did not participate in these types of groups.
Self-care group are helpful across many different types of issues or problems. This is
true even when the group leader does not have special experience. The research on
self-care or self-help groups also use objective tests to measure the positive change; for
example, people in self-care group with skin cancer had an increase in natural killer cells
and a threefold increase of survival; women with breast cancer had a survival rate double
that of the control group; adults discharged from psychiatric hospitalization were half as
likely to be re-hospitalization during the next ten months and when they did it they were
hospitalized for only one-third of the time (7 v. 25 days) and used 36% fewer outpatient
services; and parents of young drug and alcohol abusers reported that their participation
was associated with improvement in their children's drug problem, improvement of general discipline problems and in adjustment outside the home.
Behavioral Health Services and other resources
What are the different types of behavioral health professionals?
Behavioral health professionals are people who have training and experience in providing
mental health and/or substance abuse treatment services. Generally these professional
are placed in one of three categories:
1. Professionals who can prescribe medications or hospitalize someone:
a. Psychiatrist- A psychiatrist is a medically trained physician, MD or DO who has
completed a residency and has specialized training in the diagnosis and treatment
of mental health problems. Typically, a general practitioner (GP), pediatrician or
someone in family medicine will refer to a psychiatrist when an assessment or
medication is needed. Psychiatrists are usually associated with or work in hospitals but can also be part of a community mental health center or in private practice.
Physicians who pass the national examination administered by the American
Board of Psychiatry and Neurology are board certified in psychiatry. Psychiatrists
provide medical/psychiatric evaluation and treatment for emotional and behavioral
problems and psychiatric disorders. As physicians,
psychiatrists can prescribe
and monitor medications. Like all physicians, psychiatrists must be licensed by the
State of Alaska and you can find that information on the State of Alaska web site
under the Department of Labor at the
Workforce Information page
http://146.63.75.47/?PAGEID=67&SUBID=194. Psychiatrists should have a diploma that shows they completed a residency or specialized training in psychiatry.
Generally psychiatrists specialize in working with adults or adolescents or children.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 46 of 88
b. Child and Adolescent Psychiatrist — A child and adolescent psychiatrist is a licensed (M.D. or D.O.) physician who is a fully trained psychiatrist and who has two
additional years beyond general psychiatry of advanced training with children,
adolescents and families. Child and adolescent psychiatrists who pass the national
examination administered by the American Board of Psychiatry and Neurology are
board certified in child and adolescent psychiatry. Child and adolescent psychiatrists provide medical/psychiatric evaluation and a full range of treatment interventions for emotional and behavioral problems and psychiatric disorders. As physicians, child and adolescent psychiatrists can prescribe and monitor medication.
c. Psychologist — Some psychologists possess a master's degree (M.S.) in psychology while others have a doctoral degree (Ph.D., Psy.D, or Ed.D) in clinical,
educational, counseling or research psychology. Psychologists are licensed by
most states. Neuropsychologists or psychologists with specialized training can
prescribe medication related to the treatment of mental disorders. Generally, psychologists provide psychological evaluation and treatment for emotional and behavioral problems and disorders. Psychologists also do psychological testing and
assessments.
d. Psychiatric Nurse Practitioner - This is a Registered Nurse who has received
additional training and experience in mental health services as well as independent
functioning similar to a physician in general medicine or some specialty area like
psychiatry. A psychiatric nurse practitioner is licensed by the State and can prescribe medication as well as provide psychological treatment. Generally psychiatric nurse practitioners work as part of a team in hospitals, residential treatment
center or in community based clinics.
2. Professionals who can conduct assessments and do psychological treatment are generally people with master’s degrees and hold a license with the state.
a. Psychologist in Alaska must have a Ph.D. and have passed a national examination. Psychologist provide testing, develop treatment plans and provide most
forms of psychotherapy but generally specialize in treating certain type of clients
and using a few mental health or substance abuse treatment techniques.
b. Social Worker - Some social workers have a bachelor's degree (B.A., B.S.W.,
or B.S.), however to use the title of “social worker” most social workers have
earned a master's degree (M.S. or M.S.W.). In most states and nationally social
workers can take an examination to be licensed as clinical social workers. In
Alaska, a licensed social worker must have at least a master’s degree and have
passed a national examination. Social workers develop treatment plans but generally specialize in treating certain type of clients and using a few mental health or
substance abuse treatment techniques.
c. Licensed Professional Counselors – This includes people with many differing
types of master’s or doctorate degrees and have passed a national examination in
the field of psychology and counseling. They differ from social workers by being
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 47 of 88
trained not in a school of social work and often have more training in assessment
and counseling. They differ from psychologist by not having as much specialization in testing and neuropsychology. LPCs in Alaska can develop treatment plans
and specialize in treating certain type of clients and using a few mental health or
substance abuse treatment techniques.
d. Marriage and Family Therapists – Similarly to LPC, these includes people with
differing types of master’s or doctorate degrees and have passed a national examination in the field of family systems and treatment of family groups. They, like
LPC and licensed social workers, can develop treatment plans and specialize in
treating certain type of clients and using a few mental health or substance abuse
treatment techniques.
e. Psychiatric Nurse – A registered nurse who has additional specialized training
and internship in mental health services. A registered nurse is licensed by the
state. Generally, psychiatric nurses work in residential settings or as case managers in community settings. They can develop treatment plans and specialize in
treating certain type of clients and using a few mental health or substance abuse
treatment techniques.
f. Chemical Dependency Professionals - These counselors specialize in providing
assessment and treatment of addiction. Addiction may be related to the use of alcohol, inhalants, illegal drugs, misuse of over-the-counter drugs and prescription
drugs. There is state and national certification but no state license for these professionals In Alaska, they can perform substance abuse assessment, develop
treatment plans and specialize in treating certain type of clients.
3. Allied health or adjunctive therapy or other specialists. Generally these are professionals with a bachelor’s or master’s degree who specialize in one type of treatment:
a. Allied health - most of these professions are licensed by the state or certified
by a national organization in areas such as: physical therapy,(generally
large
muscle group training or retraining (walking, moving arms, etc); occupational therapy, generally small muscle group training or retraining (eye-hand coordination,
fine finger dexterity, increasing attention span); speech and audiology therapy,
anything that has to do with use of the language (discerning sounds, articulating
certain letters or sounds, learning to swallow without choking): vocational therapy,
preparation for work (how to interact in a work environment, using public transportation, learning new tasks).
b. Adjunctive therapy - most of these professionals have five year bachelor’s or
master’s degree and are certified by a national organization in areas such as: music therapy, providing therapy through the listening or making of certain types of
music; dance or movement therapy, providing therapy through the use of movement or dance that simulates problem solving or emotional release; drama therapy, providing reenactment or simulation of problem solving or emotional release;
art therapy, providing therapy through non-verbal
art projects that simulates
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 48 of 88
the issues either through content or medium of the art process; bibliotherapy, providing therapy through the reading of certain literature related to the person’s issues; recreation therapy, providing opportunities to develop positive physical images and group interaction through organized avocational activity or sports.
c. Other specialists - In Alaska, bachelor’s level professionals often provide case
management or specialized skills training. Case management has the goal of ensuring that the entire treatment team is working in a unified manner and that the
individuals receiving services learn how to manage their own lives and knows how
to access and use community resources. Skills training, especially with children
and adolescents is often done is small group settings and generally focuses on
teaching or practicing practical skills that were not learned or are difficult to learn
because of the illness; such as, anger management, relapse prevention, meal
planning and cooking, financial management and developing a new social support
system.
What kind of professional is right for a child with bi-polar disorder?
Parents should always ask about the professional’s training and experience. Before
choosing a professional, it is a good idea to check with the licensing or certification
agency to ensure that the professional does have current credentials with no significant
history of complaints. A resume will also provide information about the professional’s
experience and perhaps and indication of how long he or she is likely to remain in the
same agency or town. There is a shortage of health professionals which results in fairly
high mobility between agencies. Health professionals with a reputation for good treatment outcomes are greatly in demand.
Parents should find a mental health professional who has advanced training and experience with evaluation and treatment of bipolar and related disorders. Also, checking with
a parent or youth advocacy group, such as Alaska Youth and Family Network, will provide
other parents’ and youths’ opinions and experiences with that professional. Consumer
reports in behavioral health services are as important as in automobile purchases!
Finally, it is most important to find a comfortable match between your child, your family,
and the mental health professional. The mental health professional will become a mentor
and role model as well as a therapeutic agent.
What questions do I ask of a potential provider of services?
Before a child begins treatment, parents may want to ask the following:
•
•
•
•
•
What are the recommended treatment options for my child?
How will I be involved with my child's treatment?
How will we know if the treatment is working?
How long should it take before I see improvement?
Does my child need medication?
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 49 of 88
•
•
What should I do if the problems get worse?
What are the arrangements if I need to reach you after-hours or in an emergency?
Although serious emotional problems are not common in childhood and adolescence,
they are also highly treatable. By advocating for early identification, comprehensive
evaluation and appropriate intervention, parents can make sure their children get the help
they need, and reduce the risk of long term emotional difficulties.
How do I know when the counselor is “right” for my child?
After you have sorted through credentials, cost, location and type of program, there is one
last factor: does this counselor “click” with the child? The first session is generally without a fee since it allows the therapist to determine whether he or she can provide the
scope of treatment required. During the next one or two sessions, it is important to determine if the counselor puts you and the child at ease.
Research has shown that the relationship or bond between the counselor and client is the
single greatest element in the facilitation of positive change and growth for the client. No
matter which technique is used by the counselor/therapist, the common characteristics of
effective therapists are: warmth, acceptance, trust, empathy and good communication
skills. The bottom line is that the client must feel valued, respected and have a sense
that change is occurring as a result of the visits.
What are client’s rights?
All counselors or therapists or mental health practitioners must abide by a Code of Ethics
or Ethical Standards. Each profession has its own version but the common elements are:
1. You have every right to expect your therapist to display respect for you and to convey this respect by keeping appointments as scheduled, by contacting you if
scheduling changes are necessary, and by giving her/his complete attention to you
during therapy sessions.
2. At any point during therapy, you are encouraged to ask questions regarding your
therapist's qualifications, training, experience, specialization areas and limitations,
and personal values. You will receive thoughtful and respectful answers.
3. Since your needs are primary to your treatment, you are encouraged to negotiate
therapeutic goals, and renegotiate them whenever you wish. You are further encouraged to ask questions regarding the therapy process, specific treatment methods, therapy fees, methods of payment, estimated length of treatment, office policy
and practices, and diagnosis.
4. You may refuse any intervention or treatment strategy suggested by your therapist
and you may refuse to answer any questions.
5. Within the limits of published ethical standards and the law, information you reveal
to your therapist will be maintained as confidential and will not be communicated to
another person or agency without your written permission. The rare legal limits to
confidentiality will be clearly described at your intake session, and you may dis-
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 50 of 88
cuss any aspect of your treatment with others, including consulting with another
therapist.
6. Your counselor/therapist adheres to a Code of Ethical Standards. Under no circumstances are "dual relationships" permitted between therapist and patient, especially including business, social, romantic, or sexual contact of any kind. If you
have a doubt or grievance regarding your therapist's conduct, you should contact
that counselor or therapist’s licensing/credentialing Board to receive assistance.
A client’s rights poster should be visible wherever you have an appointment with a counselor/therapist. The poster should also state how or where you file a complaint about a
violation of your rights. An explanation of this should also be given to the child and the
parent to take home after the first “intake” interview.
What is involved in an evaluation?
Comprehensive evaluations usually require several hours over one or more office visits
for the child and parents. With the parents' permission, other significant people (such as
the family physician, school personnel or other relatives) may be contacted for additional
information.
The comprehensive evaluation frequently includes the following:
1. Description of present problems and symptoms
2. Information about health, illness and treatment (both physical and psychiatric),
including current medications
3. Parent and family health and psychiatric histories
4. Information about the child's development
5. Information about school and friends
6. Information about family relationships
7. In-depth interview of the child or adolescent
8. If needed, laboratory studies such as blood tests, x-rays, or special assessments, such as, psychological, educational, substance use, speech and language evaluation.
After the interview sessions and before the professional has written the final report, there
is usually a final interview. During this session, the professional will describe the child's
problems and explain them in terms that the parents and child can understand. Time
should be made available to answer the parents' and child's questions. The questions
that most people ask should be answered at this time, including:
1. Is my child normal? Am I normal? Am I to blame?
2. Am I silly to worry?
3. Can you help us? Can you help my child?
4. What is wrong? What is the diagnosis? What does it mean?
5. Does my child need additional assessment and/or testing (medical,
psychological etc.)?
6. What are your recommendations? How can the family help?
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 51 of 88
7. Does my child need treatment? Do I need treatment?
8. Where and how can we get this treatment? What will treatment cost, and how
long will it take?
Parents are often worried about how they will be viewed during the evaluation. Child and
adolescent psychiatrists are there to support families and to be a partner, not to judge or
blame. They listen to concerns, and help the child or adolescent and his/her family define
the goals of the evaluation. When a treatable problem is identified, recommendations are
provided and a specific treatment plan is developed. Parents and children should always
ask for explanations of words or terms they do not understand.
What should you do to prepare to see a mental health professional?
During the time between making the appointment and the actual day of the appointment,
it is helpful to pull together information into a Resource Binder. This is information about
the child and the child’s development. The resource binder is a method for having all the
important information in one place and in an order that can be found quickly. A three-ring
binder with tabs for each section will be most helpful. This should be put together at least
three weeks before the meeting with the mental health professional so that the parent and
the child/teen are comfortable with the order and contents of the binder.
The first page of each section should carry a summary of each year and then when the
child enters school, a page for each school year:
1. Place of birth
2. Important developmental markers (date of first sitting up, first step, first words,
first time running, favorite toys, favorite foods, illnesses, injuries, etc)
3. Name of babysitters, preschool or other important people in the child’s life that
year.
4. School picture, Grade, Name of School, Name of teacher(s). Each section
should have information about that school year:
a. Important school contacts and telephone numbers (physician, therapist,
psychiatrist, soccer coach)
b. Reports or letters from the professionals working with the student; such
as, psychological testing results, sports tournament results, medication
list by dates, copy of IEP or §504 plan
c. Grade reports/cards
d. A summary of important events and people of the student’s life
e. Examples of the student’s work which exemplify areas of difficulty and
areas of giftedness.
f. Important developmental markers (accomplishments, favorite activities,
books, movies, music, illnesses, injuries, significant events,etc)
Specifically for the appointment with the mental health professional:
1. Make a new page in the Resource Binder for this appointment. Write down the
date and time and the professional’s name, address and telephone number.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 52 of 88
Next write down all the questions you want to ask the professional leaving
enough space for the answers.
2. Take the Resource Binder and pencil with you to write down the important information given to you during the interview and in answer to your questions.
3. If you don’t write down the information during the interview, write it down immediately upon leaving the interview. Take the time to do it in the office waiting
area if is private or in the car near the building. Everyone who was in the room
should contribute to the review of the questions and answers.
4. Sometimes, people will take an advocate for this last session so that the other
person can remind you of questions to ask and can also make notes for you.
What happens at the end of the evaluation?
At the conclusion of the evaluation, the professional will recommend a certain type of service(s) or program(s) from the continuum available locally. The professional is then usually required to obtain approval from the insurance company or organization managing
mental health benefits (e.g. managed care organization). In the case of programs funded
publicly, a specific state agency must authorize the recommended program(s) or service(s). If the program or service is not authorized, it will not be paid. Many of the programs on the continuum offer a variety of different treatments, such as individual psychotherapy, family therapy, group therapy and medications.
What is a continuum of care?
A brief description of the different services or programs in a continuum of care follows:
1. Office or outpatient clinic – Visits are usually under one hour. The number of
visits per week depends on the youngster's needs.
2. Intensive case management - Specially trained individuals coordinate or provide psychiatric, financial, legal, and medical services to help the child or adolescent live successfully at home and in the community.
3. Home-based treatment services - A team of specially trained staff go into a
home and develop a treatment program to help the child and family.
4. Family support services - Services to help families care for their child such as
parent training, parent support group, etc.
5. Day treatment program - This intensive treatment program provides psychiatric
treatment with special education. The child usually attends five days per week.
6. Partial hospitalization (day hospital) - This provides all the treatment services
of a psychiatric hospital, but the patients go home each evening.
7. Emergency/crisis services - 24-hour-per-day services for emergencies (for example, hospital emergency room, mobile crisis team).
8. Respite care services - A patient stays briefly away from home with specially
trained individuals.
9. Therapeutic foster/group homes - This therapeutic program usually includes 6
to 10 children or adolescents per home, and may be linked with a day treatment
program or specialized educational program.
10. Crisis residence - This setting provides short-term, usually fewer than 15 days,
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 53 of 88
crisis intervention and treatment. Patients receive 24-hour-per-day supervision.
11. Residential treatment center - Seriously disturbed patients receive intensive
and comprehensive psychiatric treatment in a campus-like setting on a longerterm basis.
12. Hospitalization - Patients receive comprehensive psychiatric treatment in a
hospital. Treatment programs should be specifically designed for either children or adolescents. Length of treatment depends on different variables.
Parents should always ask questions when a professional recommends psychiatric
treatment for their child or adolescent. For instance, which types of treatment are provided, and by whom? Parents should also ask about the length of time? What is the cost?
How much of the cost is covered by insurance or public funding? What are the advantages and disadvantages of the recommended service or program? How does this compare with the “best practice” in the field? Parents should always feel free to obtain a second opinion about the best type of program for their child or adolescent. Youth also
should collaborate with their parents or guardian to understand the second opinion in order to feel comfortable about the treatment options.
What about hospitalization or residential treatment?
Hospitalization in a psychiatric facility is one of a range of available treatment options
when a child or adolescent is mentally ill. Parents are naturally concerned and may be
frightened and confused when inpatient treatment is recommended for their child. By asking the following questions, parents will gain a better understanding of the proposed stay
in an inpatient facility:
1. Why is psychiatric inpatient treatment being recommended for our child, and how
will it help our child?
2. What are the other treatment alternatives to hospital treatment, and how do they
compare?
3. Is a child and adolescent psychiatrist admitting our child to the hospital?
4. What does the inpatient treatment include, and how will our child be able to keep
up with school work?
5. What are the responsibilities of our child and adolescent psychiatrist and other
people on the treatment team?
6. How long will our child be in the hospital, how much will it cost, and how do we pay
for these services?
7. What will happen if we can no longer afford to keep our child in this hospital or if
the insurance company denies coverage and inpatient treatment is still necessary?
8. Will our child be on a unit specifically designed for the treatment of children and
adolescents and is this hospital accredited by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) as a treatment facility for youngsters of our child's age?
9. Are chemical or physical restraints used? If our child is mistreated, what is the
complaint and remedy process?
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 54 of 88
10. Have there been complaints filed about the treatment of other children? Where
can we read them?
11. How will we as parents be involved in our child's hospital treatment, including the
decision for discharge and after-care treatment?
12. How will the decision be made to discharge our child from the hospital?
13. Once our child is discharged, what are the plans for continuing or follow-up treatment?
Hospital treatment is a serious matter for parents, children and adolescents and should
be the treatment of last resort. Parents should raise these questions before their child or
adolescent is admitted to the hospital. Parents who are informed and included as part of
their child's hospital treatment are important contributors and partners in the treatment
process. If after asking the above questions, parents still have serious questions or
doubts, they should feel free to ask for a second opinion.
In Alaska, children are often sent out of state for long-term residential treatment. One of
the reasons is that there are few placements from which a child or youth cannot walk
away. If this type of placement is necessary, it is important that the parents and youth
have a good understanding and agree what will be required before the youth is discharged home and how the out-of-state residential treatment staff will facilitate the transition. Out-of-state placement may not be necessary if community based “wrap-around”
services are put in place. Wrap-around services are services available as much as 24
hours a day to ensure that there is positive treatment. This may mean a series of short
hospital or residential treatment admissions with one-to-one counseling for three to four
hours a day while the youth is in school, doing community activities or at home.
What are some of the different types of therapy or treatment?
There are many different approaches to therapy or “talk” therapy. The following is a list of
the more common.
1. Cognitive Behavior Therapy (CBT) helps improve a child's moods and behavior by examining confused or distorted patterns of thinking. During CBT the child learns that
thoughts cause feelings and moods which can influence behavior. For example, if a child
is experiencing unwanted feelings or has problematic behaviors, the therapist works to
identify the underlying thinking that is causing them. The therapist then helps the child replace this thinking with thoughts that result in more appropriate feelings and behaviors.
Research shows that CBT can be effective in treating depression and anxiety.
2. Dialectical Behavior Therapy (DBT) can be used to treat older adolescents who have
chronic suicidal feelings/thoughts, engage in intentional self-harm or have Borderline Personality Disorder. DBT emphasizes taking responsibility for one's problems and helps the
person examine how they deal with conflict and negative feelings. This often involves a
combination of group and individual sessions.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 55 of 88
3. Family Therapy focuses on helping the family function in more positive and constructive ways by exploring patterns of communication and providing support and education.
Family therapy sessions can include the child or adolescent along with parents, siblings
and grandparents. Couples therapy is a specific type of family therapy that focuses on a
couple's communication and interactions (e.g. parents having marital problems).
4. Group Therapy uses the power of group dynamics and peer interactions to increase
understanding and improve social skills. There are many different types of group therapy
(e.g. psychodynamic, social skills, substance abuse, multi-family, parent support, etc.)
5. Interpersonal Therapy (IPT) is a brief treatment specifically developed and tested for
depression. The goals of IPT are to improve interpersonal functioning by decreasing the
symptoms of depression. IPT has been shown to be effective in adolescents with depression.
6. Play Therapy involves the use of toys, blocks, dolls, puppets, drawings and games to
help the child recognize, identify and verbalize feelings. The psychotherapist observes
how the child uses play materials and identifies themes or patterns to understand the
child's problems. Through a combination of talk and play the child has an opportunity to
better understand and manage their conflicts, feelings and behavior.
7. Psychodynamic Psychotherapy emphasizes understanding the issues that motivate
and influence a child's behavior, thoughts and feelings. It can help identify a child's typical
behavior patterns, defenses and responses to inner conflicts and struggles. Psychoanalysis is a specialized, more intensive form of psychodynamic psychotherapy which usually
involved several sessions per week. Psychodynamic psychotherapies are based on the
assumption that a child's behavior and feelings will improve once the inner struggles are
brought to light.
Therapy is not a quick fix or an easy answer. It is a complex and rich process that can reduce symptoms, provide insight and improve a child or adolescent's functioning and quality of life. Child and adolescent professionals are trained in different forms of therapy and,
if indicated, are able to combine these forms of treatment with medications to alleviate the
child or adolescent's emotional and/or behavioral problems.
Therapy is a form of treatment that can help children and families understand and resolve
problems, modify behavior, and make positive changes in their lives. There are several
types of therapy that involve different approaches, techniques and interventions. At times,
a combination of different therapeutic approaches may be helpful. In some cases a combination of medication with psychotherapy may be more effective.
What should you do to prepare for a regular visit to see a mental health professional?
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 56 of 88
1. If it is an on-going or regular visit, list any symptoms and side effects of medication or
stressful events since the last visit. This will help the professional to assess if the present
treatment is working well, or not.
2. Ask the professional who prescribed medications if any of the newer treatments would
be more suitable, especially if your child has had distressing side effects.
3. Be sure to ask for information leaflets about medication from the psychiatrist or the
pharmacist or download them from the internet at http://www.medscape.com/homepage.
Make certain that physical health checks are routinely done since some medications can
have a negative effect on the liver, blood pressure or cause other health concerns.
4, If only medication has been prescribed, find out if “talk” therapy or other “adjunctive”
therapy would be helpful.
5. Find out if there are parent/child/youth support groups in the area.
What if medications are prescribed?
If the physician recommends medications, the Resource Binder will be very helpful. To
choose the right medications, the professional needs to know:
1. The medical history
2. Other medications taken and their effects
3. Current medications and their doses
4. The use of any alcohol or drugs
5. Life plans such as planning to go on vacation where there is a lot of sun (since
some medication effect sun sensitivity) or the possibility
The Food and Drug Administration (FDA) and professional organizations recommend that
the patient or a family member ask the following questions when a medication is prescribed:
1. What is the name of the medication, and what is it supposed to do?
2. How and when is it taken and when is it supposed to be stopped?
3. What foods, drinks, or other medications should be avoided while taking the
prescribed medication?
4. Should it be taken with food or on an empty stomach?
5. Is it safe to drink alcohol or take drugs while on this medication?
6. What are the side effects and what should be done if they occur?
7. Is a Patient Package Insert for the medication available?
After taking the medication for a short time, there should be another visit during which
there is a review of the favorable results as well as side effects. Since many of the potent
medications prescribed for children and youth with bi-polar disorder do not have published studies of their long term benefits or side-effects, it is very important that the
youth’s medical condition be monitored closely and blood tests be performed regularly.
What if alcohol and drugs are involved?
Many children and adolescents use alcohol and other drugs. Some develop serious problems which require professional help to control. Such as inpatient treatment, outpatient
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 57 of 88
treatment, twelve step programs, and dual diagnosis units for individuals with emotional
and substance abuse problems.
There are a variety of substance abuse treatment programs. The decision to get treatment for a child or adolescent is difficult, and parents are encouraged to seek consultation from a child and adolescent psychiatrist when making decisions about substance
abuse treatment. Other psychiatric disorders often co-exist with substance abuse problems and need assessment and treatment.
When substance abuse treatment is recommended, parents can obtain the information
they need by asking the following questions from professionals:
1. Why do you believe this treatment in this program is indicated for my child? How
does it compare to the “best practice” and other programs or services which are
available?
2. What are the credentials and experience of the members of the treatment team,
and will the team include a child and adolescent psychiatrist with knowledge and
skills in substance abuse treatment?
3. What treatment approaches does this program use regarding chemical dependency; detoxification; abstinence; individual, family, and group therapy; use of medications; a twelve-step program; mutual-help groups; relapse prevention; and a
continuing recovery process? Based on your evaluation, does my child have other
psychiatric problems in addition to the substance abuse problem? If so, will these
be addressed in the treatment process?
4. How will our family be involved in our child's substance abuse treatment -- including the decision for discharge and the after-care?
5. What will treatment cost? Are the costs covered by my insurance or health plan?
6. How will my child continue education while in treatment?
7. If this treatment is provided in a hospital or residential program, is it approved by
the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO)?
Is this substance abuse treatment program a separate unit accredited for youngsters of our child's age?
8. How will the issue of confidentiality be handled during and after treatment?
9. How long will this phase of the treatment process continue? Will we reach our insurance limit before treatment in this phase is completed?
10. Are chemical or physical restraints used? If our child is mistreated, what is the
complaint and remedy process?
11. Have there been complaints filed about the treatment of other children? Where
can we read them?
12. How will we as parents be involved in our child's hospital treatment, including the
decision for discharge and
13. When my child is discharged from this phase of treatment, how will it be decided
what types of ongoing treatment will be necessary, how often, and for how long?
14. As my child's problem improves, does this program provide less intensive/stepdown treatment services?
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 58 of 88
Severe substance abuse and chemical dependence in adolescence may be a chronic relapsing disorder. Parents should ask what treatment services are available for continued
or future treatment. If questions or doubts persist about either admission to a substance
abuse treatment program or about a denial of treatment, a second opinion may be helpful.
What is involved in adolescent substance abuse treatment?
Research has identified nine key elements of effective adolescent substance abuse
treatment. These are:
1. Assessment and Treatment Matching -- Accurate assessment is an important first step
in diagnosing substance abuse disorders as well as psychiatric conditions. A treatment
plan should be created that matches the severity of the problem.
2. Comprehensive, Integrated Treatment Approach -- Program services must address all
aspects of a teen's life, including school, juvenile justice, mental and physical health, and
the community.
3. Family Involvement in Treatment -- Parents have a powerful influence on their teen's
development. Research shows that involving parents in the teen's treatment produces
better outcomes.
4. Developmentally Appropriate Program -- Treatment programs and materials need to
be tailored to adolescents, who are more concrete thinkers than adults and also have
less-developed verbal skills.
5. Engage and Retain Teens in Treatment -- Program strategies and activities should
build a therapeutic alliance-a climate of trust between the therapist and the client-which
facilitates behavior change.
6. Qualified Staff -- Staff need to be knowledgeable about adolescent development and
co-occurring mental disorders as well as substance abuse and addiction.
7. Gender and Cultural Competence -- Treatment experts agree that programs should
recognize both gender and cultural differences in their treatment approach, since recent
research points to significant differences between male and female adolescent drug users.
8. Continuing Care -- Continuing care services include relapse prevention training, followup plans and referrals to community resources.
9. Treatment Outcomes -- Adolescent research is in its infancy and only a few programs
adequately address evaluation of their effectiveness in dealing with teen substance abuse
issues.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 59 of 88
Will insurance cover the treatment my child needs?
Insurance benefits for mental health services have changed a lot in recent years. These
changes are consistent with the nationwide trend to control the expense of health care. It
is important to understand your mental health care coverage so that you can be an active
advocate for your child's needs within the guidelines of your particular plan. Here are
some useful questions to ask when evaluating the mental health benefits of an insurance
plan:
•
•
•
•
•
•
•
•
•
Do I have to get a referral from my child's primary care physician or employee assistance program to receive mental health services?
Is there a "preferred list of providers" or "network" that you must see? Are child
psychiatrists included? What happens if I want my child to see someone outside
the network?
Is there an annual deductible that I pay before the plan pays? What will I actually
pay for services? What services are paid for by the plan: office visits, medication,
respite care, day hospital, inpatient?
Are there limits on the number of visits? Will my provider have to send reports to
the insurance company, the managed care company or some type of review board
(sometimes called utilization review”)?
What can I do if I am unhappy with either the provider of the care or the recommendations of the "utilization review" process?
What hospitals can be used under the plan?
Does the plan exclude certain diagnoses or pre-existing conditions?
Is there a "lifetime dollar limit" or an "annual limit" for mental health coverage, and
what is it?
Does the plan have a track record in Alaska?
Some of the language used in describing health care plans may be unfamiliar to you.
Managed care refers to the process of someone reviewing and monitoring the need for
and use of services. Your insurance company may do its own review and monitoring or
may hire a "managed care company" to do the reviewing. Medicaid in Alaska has a company named First Health doing the reviews. The actual review of care is commonly
known as "utilization review" and is done by professionals, mostly social workers and
nurses, known as "utilization reviewers" or "case managers." The child psychiatrist treating your child may have to discuss the treatment with a reviewer in order for the care to
be authorized and paid for by your insurance. The reviewers are trained to use the guidelines developed by your health care plan or the State of Alaska Medicaid rules. A review
by a child and adolescent psychiatrist reviewer usually must be specially requested.
The review process often takes place over the telephone. Written treatment plans may
also be required. Some plans may require that the entire medical record be copied and
sent for review. Reviewers usually authorize payment for a limited number of outpatient
sessions or a few days of inpatient care. In order for additional treatment to be authorized, the psychiatrist must call the reviewer back to discuss the child's progress and existing problems. Managed care emphasizes short term treatment with a focus on changing
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 60 of 88
specific behaviors. The decisions of the reviewers can be appealed and you should not
hesitate to do so if care or payment is denied.
Preferred providers are groups of doctors, social workers, or psychologists which your
insurer has agreed to pay. If you choose to see doctors outside of this list, (out of network
caregivers), your insurer may not pay for the services. You will still be responsible for the
bill. Similarly, care given in hospitals designated as "in network" is paid for by your insurance, while care given in hospitals "out of network" is usually not paid by your insurance
and becomes your responsibility. Even when using preferred providers and hospitals,
utilization reviewers still closely monitor treatment.
A limiting feature of some mental health care plans is a low lifetime maximum or a low
annual dollar amount that can be used for mental health care. (i.e. Once the maximum
amount is used, the plan coverage ends.) You, as parent or guardian, are responsible for
paying the non-covered bill. If your child/adolescent needs continued care, you may need
to seek help from Denali Kid Care (Medicaid for children in Alaska) or a provider who receives grant funds from the State of Alaska. This may mean changing doctors which may
disrupt your child's care.
It is important to understand as much as possible about your particular insurance plan.
Understanding your coverage will put you in a better position to help your child. Sometimes you may need to advocate for services that are not a part of your plan but which
you and your child's psychiatrist feel are necessary. Advocacy groups like Alaska Youth &
Family Network can provide you with important information about local services. The support of other parents is also useful and important when engaged in advocacy efforts,
http://www.ayfn.org .
What if I don’t have insurance or enough insurance?
In Alaska a child who is out of the home can qualify for Medicaid through Denali Kid Care
http://www.hss.state.ak.us/dhcs/DenaliKidCare/pov_lev.htm without regard to their parents’ income. This allows a child who is hospitalized for 30 days or longer to be able to
continue receiving treatment either in Alaska or elsewhere without the parents having to
declare bankruptcy or sell their home or other assets. It also allows the parents to continue earning money to support themselves and other children without having to apply for
“welfare” or public assistance.
What resources are available in Alaska?
There are two resource guides that can be downloaded from the internet: the mental
health and substance abuse services in Alaska are listed in the 2003 publication by the
Alaska Mental Health Board http://www.alaska.net/%7Eamhb/ and the 2002 publication
from the Governor’s Council on Disabilities and Special Education that list services for
persons with developmental disabilities or special needs and their families,
http://www.hss.state.ak.us/gcdse/Publications/. Also you can call for advice on Medicaid
eligible services at 907-561-6720 on by looking on the internet at
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 61 of 88
http://alaska.fhsc.com/LookUp/CareCoordination.asp. You can also look up any agency
that provides health, education or social services by using the internet http://www.ak.org/
or by calling 1-800-478-2221.
Making some sense of the organization of services in Alaska
Alaska’s system is somewhat less complicated than other states. The better description
of the individual parts of the system is the Services and Information Directory by the
Alaska Mental Health Board.
Read the booklet on line or download it from
http://www.alaska.net/%7Eamhb/
Emergency and hospitalization services. There is only one state run psychiatric hospital,
Alaska Psychiatric Institute in Anchorage. It serves people over the age of 12 but may on
an exception basis serve younger children. This is the only locked facility (other than
adult and juvenile corrections) in Alaska. There are two private short-term (30 days or
less) psychiatric hospitals for children and adolescents, Northstar in Anchorage and Wasilla and Providence Breakthrough in Anchorage. If there are no vacancies and there is
a need for hospitalization in Alaska and outside of Anchorage, there are a few “designated beds” in regular hospitals. A “designated bed” is only available for a few hours or
days and is generally not intended for children and adolescents. These services accept
private insurance as well as Medicaid.
There are two types of commitment proceedings that can be applied to children and
youth: Under Alaska Statute 47.37.170 a person incapacitated by alcohol or drugs can
be taken into protective custody. Under Alaska Statute 47.37.190 a person who is a danger to themselves or another or is gravely disabled (cannot take care of him or herself
because of a mental illness or abuse of substances) because of a psychiatric can be held
for assessment and treatment. A parent can request the assistance of a police officer or
a medical professional in this process.
Outpatient services. There is a network of comprehensive and alternative mental health
centers. The comprehensive mental health centers are located in all the major population
centers (Anchorage, Barrow, Bethel, Copper River, Cordova, Craig, Dillingham, Fairbanks, Haines, Healy, Homer, Juneau, Kenai, Ketchikan, Kodiak, Kotzebue, McGrath,
Metlakatla, Nenana, Nome, Seward, Sitka, St. Paul, Tok, Unalaska, Valdez, Wasilla,
Wrangell and generally have a staff stationed in the larger villages. Look for “mental
health center” or “community counseling” in the name. Also, most centers have a substance abuse program or coordinate with one. All of these programs accept private insurance as well as Medicaid.
There are also private providers or agencies in the more populated areas. They is no
systematic way to describe them beyond the discussion in “Mental Health Professionals
and other resources”. Some private agencies have as many or more resources than
mental health center and some have only one or two clinicians. Not all agencies or private providers are licensed. Most licensed providers accept private insurance and Medicaid.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 62 of 88
Residential Treatment- A residential treatment center provides treatment for a few months
but does not intend to provide years of treatment. There are a few resources scattered
throughout Alaska. Most are operated by private non-profit agencies or native organizations. The most current list is found by calling First Health or on the internet
http://alaska.fhsc.com/LookUp/CareCoordination.asp. Residential treatment centers tend
to specialize in either a particular approach or a particular population, such as Phillips
Ayagnirvik in Bethel addresses inhalant abuse or Alaska Children Services in Anchorage
has one of its residences that work with juvenile sex offenders. All residential treatment
centers accept private insurance and Medicaid.
In Alaska there are different levels of residential treatment centers. Some have 24 staffing to provide for a program of 5-15 children or youth living there and going to school on
the grounds. Some are more like group homes with only 5-12 children or youth living
there with trained houseparents. Because the residential treatment centers are unique in
their characteristics or location, it is important to visit them before considering placement.
What are useful Alaskan web-sites?
http://www.ayfn.org – Alaska Youth and Family Network is an Alaskan based web site to
provide support and information to parents with emotionally or behaviorally disturbed
children and youth. This site provides information parents and youth ask about: education, medication, readable research and links to national sites. There is also a page specifically for youth.
http://www.nami-alaska.org – The Alaska Chapter of the National Alliance for the Mentally
Ill has information on the 12 chapters in Alaska and their activities. It is a link to many local and national web sites.
http://www.alaskachd.org/ The Alaska Center for Development offers developmentally
disabled individuals and families information about community provider agencies around
the state.
http://www.dlcak.org/ - The Disability Law Center of Alaska web site provides information
and links on education. Laws, regulations related to all disabilities.
http://www.stonesoupgroup.org/ - The Stone Soup Group is a statewide collaboration located in Anchorage aimed at improving services for families who have children with developmental disabilities, providing parent navigation services. FASD parent support
groups and services to the medically fragile.
http://www.parentsinc.org - PARENTS is a partnership of Alaska families with disabilities
that provides support, training resources, and advocacy statewide.
http://www.sesa.org/ - Special Education Service Agency is a publicly funded agency
which provides assistance to Alaskan school districts and early intervention programs
serving students with low incidence disabilities.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 63 of 88
http://www.psychrights.org/ - Law Project for Psychiatric Rights is an Alaskan web site
about consumer rights and specifically addressing mental health commitment and medication controversy.
What national web based resources are available?
In the past few years, a tremendous amount of information has been made available
through web sites. This is an inexpensive way to get information but there is also some
misinformation on web sites so the following are offered because they have reliable information:
http://www.medscape.com - You must register to use this web site. Registration is free.
There are many useful features on this very large web site. At the bottom of the home
page is a box where you can do a keyword search for a topic like “bipolar in children” and
search Medscape or MEDLINE or you can get information about a drug like “lithium” by
checking the DrugInfo.
http://www.bipolarbrain.com/main2.html - web site by Juliet, a 37 woman who was not diagnosed until age 30. The web site has readable general information and many links to
support (some are personal web sites and government web site about mental health).
http://www.bazelon.org/ - The Bazelon Center for Mental Health Law is the leading national legal advocate for people with mental illnesses or mental retardation. Through
precedent-setting litigation and in the public policy arena, the Bazelon Center works to
advance and preserve the rights of people with mental illnesses and developmental disabilities
http://www.psych.org/ - American Psychiatric Association web site
http://www.apa.org/psychnet/ - American Psychological Association
http://www.bpso.org/practice.httm - Practice Parameters for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder by Council of the American
Academy of Child and Adolescent Psychiatry on June 5, 1996. J. Am. Acad. Child Adolesc. Psychiatry, 1997, 36(l):138-157. Jon McClellan. M.D., and John Werry, M.D.
http://www.bipolarchild.com/ - Commercial site with information on research surveys,
books, workshops, consultants, newsletters and other interesting information.
http://www.ndmda.org/ - National Depressive and Manic-Depressive Association 275
chapters. Founded 1986. This organization offers mutual support and information for persons with depressive and manic-depressive illness, and their families. It also offers public
education on the nature of depressive illnesses. Annual conferences, chapter development guidelines. Quarterly newsletter. Bookstore, catalog, mail orders.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 64 of 88
http://www.mdsg.org - MDSG-NY (Mood Disorders Support Group, Inc.) 3 affiliated
groups in NY. Founded 1981. Support and education for people with manic-depression or
depression and their families and friends. Guest lectures, newsletter, rap groups, assistance in starting groups.
[email protected] - DRADA (Depression and Related Affective Disorders
Assn) 60 affiliated groups. Founded 1986. Aims to alleviate the suffering arising from depression and manic-depression by assisting self-help groups, providing education and
information, and supporting research. Newsletter, literature, phone support. Assistance in
starting new groups. Young People's Outreach Project.
The Best Navigation Tool to have- The Resource Book
The resource binder is a method for having all the important information in one place and
in an order that can be found quickly. A three-ring binder with tabs for each section will
be most helpful. This should be put together immediately. Most importantly it should be
kept up-to-date.
The pre-school age sections are discussed on pages 51 and 52 under the section as
preparation to see a mental health professional. The school age sections are described
on page 69 and 70 as preparation for the IEP in schools.
The most useful Resource Book is one that contains all the medical, psychological, educational and social information about the child from the first time there are records, pictures and historical anecdotes about the child’s life. It is best when it always up-to-date.
Education
A child struggling with a bipolar disorder is often intellectually gifted but may have difficulty making transitions and may have other symptoms that make him or her distractible,
inattentive, anxious or very perfectionist. He or she may also be sleepy from medications
or may be having cognitive difficulties as a result of them. Frequently, children with bipolar disorder have associated learning disabilities that make it extremely difficult for them
to organize and break complex tasks into a series of simple tasks.
What is IDEA and Section 504?
Both IDEA and Section 504 are parts of the civil rights law that apply to the educational
system, K-12. Individuals with Disabilities Education Act, called IDEA1 for short, and Section 504 of the Rehabilitation Act2, called Section 504 or just 504 for short. School districts are required to “seek and find” all children between the ages of 3 and 21 with disabilities who need special educational benefit and other services. They are required to
1
The citation for IDEA is found in the Code of Federal Regulations at 34 CFR 300 (it is read as Title 34
Section 300 of the Code of Federal Regulations)
2
The citation for Section 504 of the Rehabilitation Act is found in the Code of Federal Regulations at
34CFR 104
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 65 of 88
evaluate any child they suspect may have a disability that affects his or her learning, regardless of the severity of the disability, and to determine if that child needs special education and related services.
To be eligible under IDEA, a child
1. must fit into one of the specified disability categories, and
2. the disability must adversely affect the child’s ability to learn, and
3. the child must need specially designed instruction (special education).
The disability categories include the common areas of mental retardation, blindness and
deafness. The categories also include other areas most applicable for children who may
have a diagnosis of bipolar disorder: severe emotional disturbance, autism, specific learning disability or other health impairments such as ADD/ADHD.
Special education is not a specific program or classroom. It is a set of services that
meets the unique needs of a child with disability. Special education can include such
things as modified classroom instruction, behavioral interventions plans, assisted teaching with an aide, vocational services, transition services and assistive technology. It can
be provided in the child’s school, home, hospital or residential treatment center. Special
education can also include related or supportive services that are necessary to assist a
child with a disability to learn.
Related services include services, such as: speech and audiology, psychological treatment or counseling, physical and occupational therapy, social work, parent training, motivational therapy, medical services, rehabilitation counseling, school health services and
transportation.
It is important to remember that just having a diagnosis of bipolar disorder does not automatically make a child eligible for special education. The student must experience difficulty with learning that is in some way connected to the bipolar disorder or some other
disability. If the child does well in school and creates no particular problem in the classroom, the school does not have to provide an IEP since the normal classroom appears to
be meeting the need.
When is Section 504 used instead of IDEA?
Children waiting for an eligibility determination may be eligible for services under Section
504. Since the development and implementation of an IEP may take as long as three
months, it is important that some obvious services be provided during this interim period.
Often those are services about which the teacher, parent and student are in agreement
and can be provided in the home school or in lieu of school.
Children who are not eligible for services under IDEA still may be eligible under Section
504. The school district is required to give the parent written information about Section
504 eligibility if they do not find the child eligible under IDEA. Section 504 mandates that
individuals with impairments that substantially limit a major life activity, such as learning,
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 66 of 88
are entitled to academic adjustments and auxiliary aids and services, so that courses, examinations, and services will be accessible to them. A Section 504 Accommodation Plan
could include as little as an agreed procedure to be used by the student and teachers/principal whenever the student cannot handle the stress in a regular classroom or
when the medication interferes with the normal learning process. The Section 504 Accommodation Plan can also include providing the student with a computer based or home
course as a substitute for the school environment that is too stressful during one consolidated multiclass environment.
Why have a child certified under the IDEA instead of under Section 504?
Section 504 is intended primarily for use in the mainstream classroom. It is intended for a
child who needs minor accommodations, such as a bathroom pass because he or she
has frequent urination as a result of a drug such as lithium, or needs seating close to the
teacher so that he or she can pay better attention. However, bipolar disorder is by nature an episodic illness which may have times of crisis. A student with this illness typically
needs more services outside the classroom and may need accommodations such as time
spent in a resource room, an aide, or a later start to the school day. These more flexible,
all-encompassing accommodations are rarely available unless the student has an Individual Education Plan provided by an IDEA classification.
The IDEA provides federal funds to elementary and secondary schools for public education, whereas no such funding supports a Section 504. This makes it difficult for a school
to provide sustained services or services that require more time or more expertise than
the regular teacher can provide.
How does a student get IDEA services?
Under IDEA, schools are responsible for identifying and evaluating students with disabilities who may need special education and services. It requires schools to continue providing services for the student as long as they are needed through their K-12 schooling and
up to age 22. The services are provided through a plan or blueprint called an Individualized Education Program—the IEP.
The first step requires the parent to request or agree to an assessment of the student.
The student must be tested and found eligible for services to determine that there is evidence of a disability adversely affects the student’s educational performance.
Of the 13 categories under IDEA which entitle a child to services and accommodations
throughout the school day. The two that most often apply to a child with a bipolar disorder
are “other health impaired” (OHI), or “seriously emotionally disturbed” (SED) or “multiple
disabilities”. The phrase “emotionally disturbed (ED)” or “severely emotionally disturbed”
may sound exceedingly ominous to parents but an ED/SED label may make it easier to
access better services such as a therapeutic day school or residential school if this becomes necessary.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 67 of 88
Once the process begins the student will be observed in the classroom, and a number of
standardized tests that assess IQ, academic strengths and weaknesses, language and
communication abilities will be administered. Various psychological assessment tests
may be administered as well. Additionally, an observation by a qualified person, a school
psychologist, must be made as part of the assessment to qualify and place a student in a
special education program.
All the testing will be done by the school system at no expense to the parents. Parents
may bring their own independent assessments. It is a good idea to have outside testing
or evaluations completed in time for the reports to reach the school’s assessment team
within the first few weeks of the testing period. The school cannot use the evaluations
instead of their own but the additional reports will assist the school in making a more
thorough evaluation.
The next step is the meeting of all persons involved with the student, including the student. The meeting is usually held in the classroom or a conference room at the school.
This meeting should result in a writing of the Individual Educational Plan, the IEP.
What should be tested for the IEP for a child with bipolar disorder?
The history and current interpersonal relationship patterns need to be considered if the
student is not able to remain in a regular classroom. The current therapist, psychologist,
or psychiatrist are likely to have a summary treatment plans for behavioral deficits and
accomplishments to date.
The symptoms of a mood disorder impact a child’s ability to interact and to learn. Evidence is emerging that learning disabilities, attentional problems, and deficits in the area
known as executive functions are a significantly associated feature of early-onset bipolar
disorder.
A learning disability is assumed to be present when a child has a discrepancy between
ability and achievement. This is typically documented when a student has a normal or
high IQ but is still two years behind in academic learning. Generally, a learning disability
is “a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, may manifest itself in imperfect ability to listen, think, speak, read, write, spell or do mathematical calculations.” ED/SED students
often do not have a specific learning disability, that is, a breakdown in one particular task
area but rather have “executive function deficits” that cuts across many domains and impacts all arenas of life, both academic and non-academic. Executive function deficits affect the student’s ability to organize, strategize, and plan, among other things. There is a
major impact on the ability to pay attention, inhibit impulses, devise plans, carry them
through, and alter them if needed. The child with glitches in this area will appear distractible, impulsive and restless, and disorganized. Sometimes it can be seen in every day
activity: things will be lost or forgotten; rooms or desks will be a mess or the child will
have difficulty holding information in short-term memory while manipulating it toward
problem solving or sequencing it in a logical order. The problem or problems in the do-
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 68 of 88
main of executive functioning, governed by the frontal lobes may account for the comorbidity between ADHD and bipolar disorder, Tourette’s syndrome and Oppositional Defiant Disorder. It is likely that deficits in the area of executive functions will not be apparent until schoolwork gets more complicated, requires more independent work and more
planning and strategizing.
Unless a child is tested and identified as experiencing these deficits, the snowballing effect of problems in this area may not become apparent until middle school or early high
school. If the child shuts down and refuses to do school work at this point, parents and
therapists will look to medication failure and the thriving of hormones before thinking that
it may be “silent” executive function deficits.
The deficit in executive function is why a child with bipolar disorder should be tested with
a comprehensive battery of intelligence, academic, neuropsychological, and psychological tests. These tests identify area of strength and weakness and do much to explain present difficulties and warn of future difficulties as the academic work-load becomes more
demanding and intense in the higher grades. This type of testing is best done by a neuropsychologist. These professionals are licensed in Alaska by the Board of Psychologists
and found at http://www.dced.state.ak.us/occ/ppsy.htm.
What is the testing to determine executive function deficits?
A comprehensive battery of tests can easily require eight hours of direct consultation, as
well as additional hours for reviewing records, data analysis, and the preparation of a written report. The cost for such an assessment will run in the range of $2,500-$3,000. Some
insurance companies may reimburse a portion of the fees but many do not. It’s a good
idea to call your insurance company for preauthorization.
The school’s assessment will not be a complete neuropsychological evaluation since
most school psychologists are not licensed to administer and interpret the neuropsychological battery of tests. Some schools may accept the test results that you bring them
and be heartened that a seasoned professional has pinpointed areas of difficulty. It is
best to keep the atmosphere positive since the IDEA does not require schools to accept a
non-school professional’s findings.
If the school’s recommendations appear very different from the non-school professionals,
you may want to consult with a qualified education advocate at the Disability Law Center
of Alaska, 1-800-478-1234, or a private attorney specializing in education law.
What should the parent/student do to prepare for the IEP meeting?
Parents must be prepared to educate the school team, develop a resource binder, rehearse the meeting beforehand, and decide who will be at the meeting with them.
Any reports or written materials about early-onset bipolar disorder that you want the special education team at school to review (perhaps this article, and the Frequently Asked
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 69 of 88
Questions from this site http://www.bpchild/research.org should be sent about three weeks
before the scheduled meeting so that the IEP team will have time to digest the materials
and better understand how to write the IEP. Few could skim and grasp the implications
of this illness and construct an IEP in the hour or two allotted to the process without prior
knowledge about the student’s challenges and illness.
What is a resource binder for the IEP meeting?
The resource binder is a method for having all the important information in one place and
in an order that can be found quickly. A three-ring binder with tabs for each section will
be most helpful. This should be put together at least three weeks before the IEP meeting
so that the parent and student are comfortable with the order and contents of the binder.
The first page of each section should carry a summary of the school year:
1. Picture of the student
2. Grade, Name of School, Name of teacher(s)
3. Important developmental markers (date of first sitting up, first step, first words,
first time running, favorite toys, favorite foods, illnesses, injuries, etc
4. Name of babysitters, preschool or other important people n the child’s life that
year
Each section should have information about that school year:
1. Important school contacts and telephone numbers (physican, therapist, psychiatrist, soccer coach
2. Reports or letters from the professionals working with the student; such as, psychological testing results, sports tournament results, medication list by dates
3. Grade reports/cards
4. A summary of important events of the student’s life
5. Examples of the student’s work which exemplify areas of difficulty and
areas of giftedness.
Either at the front or the back, there should be a reference section:
1. A complete list of accommodations under Section 504
2. A sample IEP for guidance
3. A list of symptoms and medication side effects (to educate the teacher about
accommodating the student’s difficulties or making the school day more productive, if medication schedule is an issue)
4. The Behavior/Symptom/Accommodation chart from this article is a visual aide to
help the IEP team better understand how to interpret disruptive behaviors and recommend how to develop interventions which will reduce these unruly behaviors.
What should be discussed during the IEP meeting?
There are four categories the IEP team should consider when developing an appropriate
IEP for a student with a mood disorder are:
1 Symptoms caused by the mood disorder
2. Side effects of the medications used to treat the condition
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 70 of 88
3. Attention and organizational difficulties
4. Specific learning disabilities
The IEP, constructed by the school team, is a written statement of the goals, objectives,
and services that will be provided to assist a child with exceptional educational needs. A
well-written IEP will incorporate long term goals and very specific measurable objectives
accompanied by a timetable in which those objectives will be met. Federal law mandates
that an IEP include seven required parts:
1. A statement of the child’s present level of performance.
2. A statement of the goals and objectives.
3. A statement of special education services to be provided (including location, duration, and frequency of services).
4. A statement of the extent to which the child will participate in regular education.
5. The date the special educational services are to begin and the expected ending
date.
6. The criteria for determining if the objectives are being met.
7. A statement of transition services needed.
The IEP goals should be written for all academic areas of need (math, reading, writing,
etc) and for any school-related areas of need (such as attendance, school behavior, selfhelp, social, emotional, etc.) The language should be very specific.
In addition to the written goals, the document should answer the following questions:
1. What services are to be provided?
2. Who will provide the services? Specialists, teachers, aides?
3. Which teaching methods will be used?
4. Where will services be provided: regular classroom, resource room, and/or special education classroom? Will it be one-on-one? With a small group?
5. How often will the services be provided?
6. How long will each session be?
7. When will the services begin?
What is the “least restrictive environment”?
The IDEA requires school districts to educate students with disabilities to the maximum
extent possible with children who are not disabled but still meeting the students’ educational needs. The students should be first placed in a regular classroom unless supplementary aids and services are not sufficient. Next, the student should be maintained with
non-disabled children as much as is possible during each day. Special education services in the home school should be attempted before another school is recommended.
Finally, if the home school is not appropriate, a school as close to home as possible
should be utilized.
If parents do accept the ED/SED classification, the IEP team should not recommend
placement of the child in an inappropriate placement that is more restrictive than needed
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 71 of 88
or with students who have delinquent behaviors or are developmentally disabled. With
the ”no child left behind”3 legislation, parents may also consider placement in another
public, charter or private school that could better meet the educational needs of the student in the least restrictive environment.
If the student continues to struggle or does not make progress in the general education
classroom, the team may decide (with the parents’ agreement) to place the child in a selfcontained classroom within the public school setting. Here the class size will be reduced
and there will be more accountability to the individual student. There are typically one or
two special education teachers and a trained aide or two working with the student in the
self-contained classroom. Depending on the student and the special education program,
the child may be “mainstreamed” into regular education classes for some academic subjects and for elective periods such as music, art, gym, computer, etc.
The time may come, however, when it becomes clear that a small, therapeutic program in
a private or public school would be a more appropriate placement for the student. When a
student’s illness negatively impacts his or her learning and no progress is being made
academically, socially and/or emotionally, the parents and school team should begin to
discuss a therapeutic day school. This is a separate school, usually with a small number
of students, a small class size (six to eight children), in a classroom with a trained special
education teacher and a trained aide. The child receives academic instruction along with
group therapy, individual therapy, social skills classes, and art and music therapies.
Some schools will make recommendations of therapeutic day schools but some will tell
parents only about programs that are inexpensive for the school district and which may
serve more as a warehousing situation than an appropriate place for education. Nor will
all communities have any kind of therapeutic day school—good or bad.
How often is the IEP reviewed?
The goals of the IEP should be monitored and reviewed every nine weeks to determine if
progress is being made. Parents may request more frequent feedback. Additionally, parents may request an IEP meeting at any time to review progress and to request needed
changes.
Though the school is required by law to conduct a triennial review (every three years)
where the student will be retested, this is generally too long to wait to determine if the
student’s academic weaknesses are being remediated. Parents should have an annual,
independent evaluation or review with each professionals working with the student in
early spring so that a meeting can be called and the results of any evaluations can be
shared with the IEP team. This will ensure that the appropriate program, goals, and objectives are in place for the next school year. In Alaska, the school district usually annually verbally reviews the IEP to continue it or to make minor modification.
3
No Child Left Behind, federal legislation signed into law on 1/8/02, is Public Law 107-110.
http://www.ed.gov/nclb/overview/intro/index.html
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 72 of 88
Annual reviews do not require a complete neuropsychological evaluation. Instead, they
focus on troublesome areas that are being remediated in school or with private tutors. Do
not assume your child will tell you (or be able to identify) that he or she is having a problem or that the work is too difficult. Instead, they become Masters of Defense and develop
the attitude “Who gives a whop?”
Also, understand what “grade level” means. If a dyslexic student has a verbal IQ of 138
and is reading “at grade level,” assume that this is a near-tragic scenario. Any child doing
work three standard deviations below his or her cognitive ability (no matter what the
learning disability) is a child in trouble. Some schools may not recognize this or wish to
point it out to parents.
What if the student does not improve after the IEP?
An IEP may be beautifully written with the best of intentions but a parent may begin to notice that the mandated services are not being provided or are being provided inconsistently. This may occur when mainstream teachers ignore the modifications and/or accommodations set down in the student’s IEP. The parent needs to question when this occur and must document it as well.
The parent’s first course of action is to remind the school in writing that they are required
to follow the IEP. If corrections are not made and the situation heads to mediation or due
process, the better documented case will be the easiest to advocate for the child. Hearing officers do not like to see that schools are out of compliance with an IEP so a parent
needs to document carefully.
Any omission of an accommodation or a service should be noted in a log by the parent,
and a letter detailing this omission should be sent to the special education teacher with
copies to the school administrator and program manager at the district level. If the matter
is handled over the telephone, a letter should be written as a follow-up to confirm the content of the discussion that says: “This is to follow up in writing what we discussed on the
telephone today…”
If matters do not improve with dialogue and follow-up documentation, a parent should
contact the Disability Law Center of Alaska. This organization is a part of a nationwide
network that, among other things, devotes considerable resources to ensuring full access
to inclusive educational programs. A phone call or letter from the Disability Law Center
requesting accommodations or that accommodations already in place be complied with,
or the presence of one of the P&A personnel at an IEP meeting almost always ensures
things happening.
If matters still do not get resolved, the IDEA includes rules of procedure for resolving such
complaints. These rules include mediation, due process hearings, and appeals to the
state or federal courts. It is advisable to consult with the Disability Law Center of Alaska
or a private attorney specializing in educational law whenever the IEP does not appear to
be effective and the school is not anxious to make modification.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 73 of 88
What if there are discipline problems at school?
While many children with bipolar disorder don’t act out in school but save their pent up
frustration and upset for home and mother, some do act out at school. The school may try
to discipline, suspend, or expel the student because of unruly or oppositional behaviors
without understanding that many of the behaviors are a result of the student’s condition. If
you or the student’s child psychiatrist believe that these behaviors are the result of or in
keeping with bipolar symptoms, you should request that the school conduct a Functional
Behavioral Analysis (FBA). Based on the findings of the FBA, the school must write a Behavior Intervention Plan (BIP) into the IEP. This is mandated by law.
What is the FBA and BIP of the IEP?
The FBA (Functional Behavioral Analysis) is a formal assessment which can identify
problem behaviors a student is exhibiting, where they are having them, when they are
having them, and with whom they are having them. The data is analyzed and a Behavioral Intervention Plan is developed which provides goals to replace problem behaviors
with positive behaviors.
Only trained professionals such as psychologists or special education teachers with specialized training are qualified to conduct a Functional Behavioral Analysis. If it becomes
obvious that experienced professionals are not available then the parents are going to
have to insist that the school district brings in such professionals from the community or
the State level. Otherwise school districts will continue developing BIPs which are inherently flawed and subject to failure.
The data from the FBA is used by the BIP team (school psychologist, teachers, support
teachers and any other professionals who work with the child) to develop an appropriate
intervention plan that will:
1. Describe the behavior
2. Determine the functions of behavior
3. Develop interventions that will replace inappropriate behaviors with new behaviors.
4. Develop a timeline for reviewing the plan
The school will implement the plan and, over time, evaluate the outcomes as outlined in
the plan. It is important when observing a student with bipolar disorder to differentiate between behaviors that can be modified and symptoms of the illness. For example, a student may be refusing to work because he is overwhelmed by the stimulation in the room,
does not understand the assignment and/or feels lethargic from the medications, the illness or a combination of these factors. Therefore, he is simply not able to perform to the
teacher’s expectations at that time, as opposed to being defiant to earn the respect of his
peers, or some other outcome, known as a function of the behavior.
The Behavior Intervention Plan should:
1. Identify the antecedents to the problem behavior
2. Focus on positive supports
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 74 of 88
3.
4.
5.
6.
7.
Teach replacement behaviors
Manipulate antecedents
Manipulate consequences
Change curriculum or instruction
Monitor and evaluate effectiveness and modify if necessary
Some examples of these interventions are:
Behavior/Symptom/Intervention Chart
Behavior
Symptom (Antecedent)
Intervention
Child refuses to
do classwork
-Lethargic from meds
-Cognitive dulling
-Overwhelmed by the
assignment
-Allow student to work on a creative or interesting assignment.
- Have an aide work one-on-one with the
child.
- Reduce the length of the assignment.
- Allow the child to work in a study carrel.
Child interacts
inappropriately
Inability to read social
cues
School offers social skills taught by school
psychologist or school social worker
Child pushes
other children
Sensory Integration
Issues
Student stands at the back of the line an
arms length in line away from other children
What about residential treatment centers?
Sometimes the school that best meets the student’s needs just do not exist anywhere
near the child’s home, or the child may become too unstable to stay at home and attend
school. It may become painfully obvious that a change in environment with a twenty-fourhour peer group and nonparental authority figures may help the child blossom and mature
in a safe environment. Maybe they are a danger to themselves or to others and they need
to be in a setting that can monitor their illness, as well as provide them with tools to understand and deal with their illness.
Residential Treatment Centers (RTCs) are medical facilities. They have psychiatrists and
nurses on staff. They administer medications, make medication adjustments, and provide
therapy and schooling. They are required to follow a student’s IEP.
Residential schools can cost anywhere from $56,000 to over $125,000 per year. A school
district may pay part or most of the fee of such a placement but typically only after a due
process hearing.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 75 of 88
Parents should definitely seek the help of a professional consultant and the child psychiatrist should be involved with the search process. Websites that are particularly helpful are:
http://www.petersons.com, http://www.aacrc-dc.org, http://www.strugglingteens.com.
There is one web site that list all the residential and outpatient centers with agreements
with Alaska https://alaska.fhsc.com/LookUp/CareCoordination.asp
What if the school is just unwilling or incapable of helping the student?
Some parents will need to go to mediation or due process to achieve the proper educational accommodations or educational setting for their children; and this is where the relationship between school and parents enters the legal arena and the relationship becomes
adversarial. It is not recommended that parents go through this process alone. The decision to pursue due process is a very serious one. The financial and emotional costs to
the parents and the student can be enormous. Parent should consult with an experienced
private educational attorney or the Disability Law Center of Alaska before making any announcements to the school.
What about homebound instruction?
Homebound schooling is considered a “general education” placement but it is one of the
most restrictive placements because it removes the student from the mainstream and
peers. However, it is frequently used for a student who is too symptomatic, or too emotionally fragile to attend school in the school building. It is considered a temporary placement until the student is able to return to school or until a more appropriate placement
can be found.
Parents need to know that a doctor’s order must accompany the request for home instruction. An IEP meeting will determine how often the tutors for each subject will come to
the house to provide instruction and lessons for the student. Some school districts require
a doctor’s therapy or treatment plan to accompany any application for homebound instruction.
What about homeschooling?
If an appropriate learning situation is not available and if the stresses of school are making it difficult for the child to function or to recover from an episode or hospitalization,
some parents may want to consider the option of homeschooling.
Homeschooling was viewed, not too long ago, as very counterculture, or something that
people did solely because of religious beliefs. As outcomes of homeschooling were
measured, however, and the homeschooled children often tested two years ahead of their
in-schooled peers, homeschooling has become more generally accepted. There are a
number of homeschooling organizations, charter schools and support groups in Alaska.
Thanks to advances in technology, homeschooling can be done richly and effectively on
computers with CD-Rom curricula or even over the Internet. This mode of learning may
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 76 of 88
be particularly beneficial for a bipolar child because it focuses learning and helps students
with attentional problems. Students work at their own pace and a hospitalization should
not interrupt learning. Students don’t miss the work but just pick up where they left off.
To further explore the prospect of homeschooling or to take a look at programs that may
help a child catch up when work is missed, take a look at the following web sites:
http://www.home-school.com - Official web site of Practical Homeschooling Magazine,
Listing of homeschooling organizations in your area, Home Life Catalogue, Discussion
forums.
http://www.HSLDA.org - The Home School Legal Defense Association
http://www.network54.com/Forum/180575 - Interesting discussion forums for parents
who are now providing homeschooling or are thinking about homeschooling.
http://www.aop.com - Switched-On Schoolhouse ‘s CD-Rom Curricula and other Alpha
Omega products
http://www.pathwaypublishers.com - Odyssey Ware CD-ROM curricula, (the secular version of Switched-On Schoolhouse)
ttp://www.welcometoclass.com - On-line accredited schooling from Alpha Omega Publishers (interactive schooling with teachers, counselors and support staff)
http://www.saxonpublishers.com - curricula for homeschooling
http://www.bpchildresearch.org – information from the research foundation on bi-polar
disorder in children.
Model answers to difficult education/school questions
In the best of all possible worlds, the school districts would be able to work with the parents and to follow-through with any services and accommodations that would ensure the
student receives a free and appropriate education (the FAPE). But people are people and
budgets are budgets and certain administrators will think first of his or her budget and the
parent may be met with resistance or unhelpful remarks that can leave an unsuspecting,
unprepared parent stuttering without the appropriate “fall-back line” or reply.
1. I’m sorry, but the school district can’t afford that.
Parents’ reply: “The IEP process calls for this team to decide upon the child’s
needs without regard or consideration of affordability.”
2. No, if we do that for your child, we would have to do it for every child.
Parents’ reply: “We can see how you might feel that this is ‘unfair,’ but fairness is
that every child gets what he or she needs and not every child needs the same thing.”
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 77 of 88
3. We have to educate all children, not just yours.
Parents’ reply: “You are correct and we agree….but today’s meeting is about our
child’s right to a Free and Appropriate Education at the Public’s expense.”
4. That’s not in our program.
Parents’ reply: “We understand that, but it is what our child requires. So, can we
talk about how to get this done, or where else we might find this type of program and services?”
5. We don’t think your child needs that.
Parents’ reply: “You are entitled to your opinion, but can you show us the facts
and/or data that support your position, and can you provide an overview of your training,
expertise and background in teaching children with juvenile bipolar disorder that allows
you professionally to make this kind of assessment?
6. Your child is violating the needs of others.
Parents’ reply: “Our child (as are all children with special needs) is afforded the
civil rights to a Free and Appropriate Education at the Public’s Expense. If there are aspects of our child’s disability that are problematic to others, than it may be reasonable to
assume that the placement is not correct, the services are not appropriate or complete
enough. There may be a combination of factors here at the root cause of the problem.
Therefore, we request that a Functional Behavioral Assessment be conducted to assist
the team in clarifying what may be happening here, for the benefit of all the students.”
Symptoms of Bipolar Disorder as applied to the educational setting:
Symptom: Children with bipolar disorder often have a reversal in their sleep/wake cycle
and it is extremely difficult for them to get to sleep at night and to wake up early in the
morning. He or she seems half comatose or extremely grumpy and sleeps through first
and possibly second period, often missing important class material and doing poorly on
tests in the first two periods.
Accommodations
1) Schedule academic classes later in the day when the student is more alert and emotionally available for learning.
2) Allow the student to take important tests later in the day when the student may be able
to focus better.
3) Allow the student to begin the school day a little later.
Symptom: The student has daily and seasonal fluctuations in mood and energy and is
therefore more attentive to classwork at certain times and less attentive at others.
Accommodations:
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 78 of 88
1) Create formal contingency plans when the student is unstable and is experiencing periods of withdrawal or fatigue (a symptom of the illness and often a side effect of the
medications).
Symptom: The student can experience great irritability, building to a rage if not
recognized and dealt with in an appropriate and timely manner.
Accommodations:
1) Assign a staff/school person who the student can go see when he or she feels
unable to cope. This can be a counselor, school therapist, teacher, or any other person (campus monitor, school nurse, etc.) with whom the student feels safe and whom
the student trusts and chooses. Give the student a permanent pass and a private signal that only he and the teacher understands so that he can make a private exit in
front of the rest of the class.
2) Offer the student a private place to go to calm down when feelings are overwhelming.
3) Schedule regular meetings with the school psychologist to teach the student selfcalming and anger management techniques.
4) Assign an aide in the classroom to prevent situations that may cause the student to
lose control.
5) Administer a Functional Behavior Assessment to identify triggers that cause the student to lose control. Then write a Behavior Intervention Plan to be added to the IEP
which provides appropriate interventions for problematic behaviors. This can be as
simple as identifying stressors which cause untoward behaviors.
Symptom: The student has periods of excessive anxiety and sadness.
Accommodations:
1) Assign a safe place and person where the student can regroup and calm down –
preferably someone with whom the student can talk easily.
2) Have the student keep a journal in which he or she can address anxiety-producing
thoughts and school experiences which can be shared with the school psychologist and the student’s personal therapist.
3) If the treating psychiatrist recommends the use of a light box, provide this daily
during a study period in the resource room.
Symptom: The student is very perfectionistic and has difficulty making transitions.
Accommodations:
1) Reduce writing by allowing the student to use a computer so the page looks neat
to him or her.
2) Allow student to finish tasks before moving on.
3) Have all teachers cue the student as to transitions and the time they will occur.
4) Provide an aide who will give support during non-supervised periods of the school
day (lunch, recess, escort to and from the bus waiting area, etc)
5) Allow student to transition ahead of the rest of the class (going to lunch room, library, etc)
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 79 of 88
Symptom: The student has difficulty with peers. The student may have poor social skills,
be bossy, misperceive the behaviors and intentions of others, and be socially inappropriate at times.
Accommodations:
1) Arrange for the student to learn social skills and group behavior by meeting with
the school social worker, school psychologist, or the guidance counselor.
2) Develop a social skills class and have the student participate in it.
3) Place an aide in the classroom who can monitor social interactions and report incidents of social conflict. The aide can interpret and explain to the student how
things occurred which may be outside the student’s perception. This aide can advocate for the child, act as a friend, make the child feel safe, and alert the school if
there are any incidents of bullying going on.
Symptom: The student becomes overheated and overstimulated in gym classes and begins to suffer discomfort or to cut class.
Accommodations:
1) If the student participates, he or she must always have access to water and rest.
2) The student should have the option of less competitive physical activity such as
Yoga. Tae Kwan Do, weight training, aerobics, etc.
3) The student should be graded based on attendance rather than participation.
4) If necessary for the student’s emotional well-being, have an Adaptive P.E. written
into the IEP until such time as the student is ready for mainstream physical education.
5) If inclusion is an issue or a desire on the student’s part, the student could be appointed score keeper or equipment manager.
Side effects of the medications
Symptom: The student is experiencing excessive thirst, a frequent need to urinate, or
bouts of diarrhea as a result of some of the medications used to treat the illness (especially in the early stages of treatment).
Accommodations:
1) Allow the student to keep a water bottle at his or her side or to have unlimited access to (non-caffeinated) fluids.
2) Allow unlimited access to the bathroom (with a signal to each teacher as to where
the student is going--without announcing it publicly)
3) Educate the staff (especially the school nurse) about medication side effects which
may include drowsiness, diarrhea, stomach aches, and cognitive dulling and the
need to accommodate for these.
Symptom: The student is sleeping in class because his or her body is not yet accustomed to a new medication.
Accommodation:
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 80 of 88
1) Provide a place for the student to take a brief nap so that he or she can continue
with the school day. (Sleepiness usually subsides as the body adjusts to the medication).
Symptom: The student is experiencing cognitive dulling and a lack of endurance as a result of the medication(s).
Accommodations:
1) Schedule frequent breaks.
2) Provide extra time for work completion.
3) Decrease workload and homework.
Attentional and organizational difficulties
Symptom: Student has difficulty staying on task and paying attention for any length of
time. Student is very fidgety in the classroom.
Accommodations:
1) Seat student close to teacher where the teacher can get student’s attention.
2) Schedule frequent breaks.
3) Offer choices such as going to a study carrel in the library or to a quiet area outside the classroom.
4) Assign a study buddy (use the phrase study-partner for an older student). The students can focus each other and acquire strategies for learning from each other.
Symptom: The student is disorganized and often misplaces needed books and materials.
The student often forgets to bring home assignments and/or fails to turn in work.
Accommodations: Use a “travel folder.” This is a pocket portfolio that has necessary
papers to complete on the left-hand side (mark this “To Do”) and all completed homework
is transferred to the right-hand side (mark this “Completed”).
1) Give student a planner book and have teacher check that daily assignments are
recorded properly.
2) Email or fax parents list of assignments and news of upcoming projects or tests.
3) Have teacher or aide give the student a prompt before leaving school: “What do I
need to do tonight and what materials would I need to accomplish it. “I need: my
coat, my recorder, my math book, my study sheet for French, my planner, my
lunch box, my travel folder (French sheet is there...) The teacher or aide could
photocopy lists of materials and clothing and have student check items off as they
are put in the bag. Student must be taught to pack backpack to return to school the
same way: with a prompt such as “What do I need for school today?” (A parent has
to help out here.)
4) Provide a second set of text books for the home work area.
5) Teach the student to number assignments in the order in which they should be
done before beginning a homework session (thus they will focus and begin a mode
of strategy). Have the student start with an assignment that is short and easy, but
avoid saving the hardest or longest assignment for last. Have the student estimate
how much time it will take to complete each assignment and measure the esti-
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 81 of 88
mates against the actual time (these students have difficulty with time management). Have them use a stopwatch to assign chunks of time to each step of a
study plan which will help move them on to the next step.
6) Teach the student to preview questions at the end of each chapter to focus him or
her on important concepts. The student should also preview photos, captions and
headings throughout the chapter before reading and when reviewing for a test.
7) Color-code subject folders and notebooks to match textbooks. For instance, if the
math text is orange, place an orange strip of tape on the math folder and notebook
so that student can quickly locate and assemble all materials needed for math. If
school requires the books to be covered, color coordinate the books and folders.
8) If the student uses a locker, teach him or her to place all morning text books, notebooks and folders on top shelf of locker, and all afternoon materials on lower or
bottom shelf. This will help organize the student and ensure that he or she goes to
class with the correct materials. Have the student (with the help of an assistant if
necessary) clean out locker at least once a week. Schedule that cleanup on Fridays to ensure that P.E. clothes and needed materials arrive home for weekend
use.
Specific learning disabilities
Accommodations for Reading Disabilities or Dyslexia
Children with reading disabilities or dyslexia have problems decoding the phonetic structure of language, which negatively impacts comprehension. Absent previous remedial
reading interventions (such as Orton-Gillingham), the student may need some or all of the
following accommodations.
1. Provide student with larger print materials
2. Arrange for student to receive books on tape through the Recording for the Blind
and Dyslexic in Princeton, NJ. Contact them at: http://www.rfbd.org/catalog.htm
3. Provide books that have information highlighted
4. Have student use tape recorders in the classroom.
5. Provide readers for tests.
6. Allow extra time for tests.
7. Provide materials that use lots of visuals.
8. Provide information in bullet format.
9. Teach the student to take notes and to study using visual techniques instead of
words.
10. Provide hard copies of notes provided to the student.
11. Teach mapping techniques.
12. Allow extra time for assignments.
13. Do not penalize the student for spelling errors.
14. Provide computer-based reading software such as Kurzweil 2000 or Wordsmith
which scans textbooks or other reading material into a computer and audibly reads the
scanned text back to the student. (In Wordsmith, the student has a choice of a male or
female voice or a British or American accent.) Look at http://www.dyslexic.com to
learn more about these products.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 82 of 88
Accommodations for Writing Disabilities or Dysgraphia
Children with writing disabilities or dysgraphia generally have problems with handwriting
(the actual formation of the letters) as well as deficits in written expression. When writing,
these children may omit words or reverse them, and syntax and grammar are often incorrect. These students may also have difficulty deciding on a topic for an essay or organizing it so that the ideas flow in a logical manner. These problems may not show up in expressive language assessments and may be exhibited only in the written language assessments. Students with writing disabilities or dysgraphia will need some or all of the following accommodations:
1. Teach and encourage the student to use a keyboard in class and to complete all
assignments.
2. Assign a scribe to write longer or timed writing assignments.
3. Allow student to tape record classes. Do not penalize quality of note-taking or assume the student is not taking it all in aurally.
4. Provide paper copies of notes to the student.
5. Allow extra time for assignments.
6. Assign a scribe for important tests, or allow the student to give his answers orally.
7. Do not penalize the student for handwriting or spelling errors.
8. Have the parents investigate voice recognition software such as “Dragon Naturally
Speaking ” (also available on http://www.dyslexic.com).
Accommodations for Math Disabilities or Discalculia
Children with math disabilities or dyscalculia generally have problems in math computation, function and application of math concepts and in understanding the basic math functions. For example, they may reverse their numbers when they are writing. Students with
math disabilities or dyscalculia may need some or all of the following accommodations:
1. Provide math books in larger print
2. Give the student graph paper to keep numbers in their correct columns
3. Provide manipulatives to help the student understand in a concrete way the abstract nature of numbers.
4. Provide a student with a calculator for more complicated math functions and teach
the student to use it.
5. Do not penalize student’s grade for the reversing of numbers.
6. Allow extended time for assignments and tests.
What could an IEP look like for a student with bipolar disorder?
The following is example taken from “The Bipolar Child” by Demitri Papolos, M.D. and
Janice Papolos published in 2000.
Elan is a personable individual who shows good attention and task orientation for very
short periods of time. Elan has been diagnosed with bipolar disorder. His emotional and
academic availability is variable and quite unpredictable. Physical complaints are often
present both in and out of school. Presently Elan has a difficult time getting up in the
morning, and he is often late, or does not come to school at all. He can appear tired,
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 83 of 88
bored, irritable, and explosive and has poor judgment and decision-making skills. Other
times, Elan can act extremely energetic (needs to move), he can be talkative and distractible. He can be extremely impulsive.
Elan has difficulty expressing his feelings and frustrations, and he often has negative and
hopeless thoughts. When unable to do something others might consider simple, he feels
a sense of failure. He does not have good problem-solving skills or stress management
techniques. He often resorts to self-inflicted wounds and talks of suicide.
Elan's concentration and ability to attend and focus can be extremely impaired because of
his limited alertness and attendance difficulties. His lack of interpersonal skills cause peer
difficulties and limits his ability to establish healthy relationships with his peers and adults.
At other times--usually when he has high energy levels (he is becoming more manic)--he
feels his understanding is superior to that of his classmates and that this negates his
need to complete assignments. During these times, he can be disrespectful to adults, oppositional, and provoking to his peers.
Currently Elan is very compliant about taking his medications, and he has the desire to do
what it takes to manage his disorder.
Consistent positive understanding and intervention is necessary for improving his selfesteem and allowing him to be accepted through his good and bad times. Staying calm
and speaking to him in a reassuring tone is a must.
Elan is in need of a smaller, very structured setting that would be sensitive to his psychosocial needs. He presently does not do well with change or too much environmental
stimulation. Counseling and support services such as a safe place and/or a person to go
to when he feels overwhelmed or is having negative thoughts is necessary. A support
group with like peers would be ideal if available. Flexibility in this plan is a must.
Goal
Elan will learn and apply strategies to independently divert bad thoughts.
#1:
Objectives:
A.
Elan will go to the school counselor/psychologist twice a week (more frequently as needed).
B.
Elan will explore negative thoughts with counselor and develop strategies
for diverting them independently.
C.
Elan will tell an appropriate adult when he has negative feelings he cannot
manage.
D.
Elan will use a variety of strategies learned and document results in a journal at least two times weekly.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 84 of 88
Goal
#2:
Elan will develop other techniques to relieve anxiety rather than resort to harmful behaviors.
Objectives:
A.
When faced with a stressful situation, Elan will explore options with counselor.
B.
Elan will address anxiety-causing topics, which may be suggested by staff,
in a journal at least one time per week.
C.
Elan will talk to an adult when feeling explosive or becoming out of control.
He will remove himself to a safe place/person before harming self or others.
D.
Elan will identify triggers that contribute to harmful behaviors and problem
solve alternatives with counselor.
Goal #3:
Elan will increase his time on task with only one redirective from 2-3-minutes to 10-15
minutes.
Objectives:
A.
Elan will comply with all redirection such as non-verbal cues, the first time.
B.
Elan will increase the number of daily assignments he completes within a
specified amount of time, determined by the teacher and his ability for that day.
C.
Elan will stay focused for 10-15 minutes--or longer--on any given subject.
D.
Elan will utilize problem-solving strategies when needing a break to refresh
and refocus.
Goal
Elan will increase his communication skills in a variety of settings.
#4:
Objectives:
A.
Elan will seek assistance in problem solving from appropriate adults.
B.
Elan will practice using communication skills at least one time per week with
staff and in his journal.
C.
Elan will ask an adult when he needs to move around and/or go to a safe
place.
D.
Elan will tell an adult when he feels he may be getting out of control.
E.
Elan will converse positively with a peer three times a week. He will note
any positive changes he notices as a result of these interactions.
Goal
#5:
Elan will achieve grade-level work with a success ratio of four out of five assignments
completed in all classes.
Objectives:
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 85 of 88
1. When given an assignment, Elan will complete four out of five of them, accurately,
legibly, and on time.
A.
Elan will ask for extended time, modified work, etc. when he feels overwhelmed. (Parent will have to do this initially.)
B.
Elan will accept redirection cues from the teacher when off task.
C.
Elan will use a homework notebook daily to record all assignments. Teachers will check for accuracy and sign. Parent will sign to verify homework is completed.
Modifications Necessary at This Time:
1.Assignments will be broken down into manageable parts with clear and simple directions, given one at a time.
A.
Preparation for transitions.
B.
Ensure clarity of understanding and alertness.
C.
Allow most difficult subjects to be taken in the afternoon when he is most
alert.
D.
Extra time on tests, class work, and homework.
E.
Allowances made for unpredictable mood swings and skill functioning.
F.
All staff involved with Elan will be provided with training on bipolar disorder.
G.
Awareness of potential victimization from other students.
H.
In extreme cases where Elan gets out of control and may do something impulsive or dangerous, a crisis intervention plan will be implemented.
I.
Positive praise and redirection.
J.
Report any suicidal comments to counselor/psychologist immediately.
K.
If there are ever times when Elan's mood disorder makes it impossible for
him to attend school for an extended period of time, home instruction will be provided to assist him in keeping up with his academics.
L.
An aide will be placed within Elan's classroom to ensure his well-being. The
aide will assist the teacher with all the students who need it also. Since Elan does
not do well with unstructured times, such as lunch and recess, the aide will accompany him as a buddy during those times, without drawing undue attention to
him.
Behavior Plan
Goal # 6:
A. Elan will decrease explosive outbursts. Elan will seek adult assistance before lashing out with aggressive behaviors.
B. Elan will remove himself and seek time out and/or safe place when feeling explosive.
C. Elan will learn and apply strategies for anger control.
D. Elan will postpone making important decisions during a depressive state.
E. Elan will recognize possible early signs of an impending manic or depressive cycle
and talk about them to his psychiatrist.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 86 of 88
F. Elan will earn points for all of the above. Points can be accumulated towards a day
without homework or something special that will motivate this child.
So, how can Alaska Youth & Family Network help me and my child?
The Alaska Youth & Family Network was started when parents who have severely emotionally disturbed children got together and exchanged experiences of what worked and
what did not work to help their children. As the parents learned more about the continuum of care, they offered to assist other parents. This effort was then funded by the Substance Abuse and Mental Health Services Administration in 2001.
Today, AYFN has a web site http://www.ayfn.org to provide information to parents and
youth about mental health and substance abuse issues. The chat room and bulletin
boards are designed to give people a no-cost method for networking or just asking questions. There is a full time Youth Advocate to help teens network, ask and learn from each
other in order to address mental health and substance use issues. The teens meet at
least once a month on the second Friday of each month from 6:30 pm until 9:00 pm at our
computer group room in the AHFC Gateway Learning Center at 801 Karluk in Anchorage
and connect to each other statewide through the chat room at http://www.ayfn.org
Since we are not a provider of mental health or substance abuse services, AYFN can assist you, the parent or youth, to better navigate through the system of services objectively.
We assist you by making certain you understand the terms, know the questions to ask,
have some broad knowledge what the answers should resemble and most importantly
have confidence in asking for what you need.
Our goal is to have informed and vocal parents and youth who will ensure that there is an
adequate amount and quality of services in Alaska for children and youth who have severe emotional/behavioral health issues. Once you can use the system for yourself, we
hope you will join us in teaching others and becoming involved in planning and policymaking efforts, committees or Boards to help make and keep the system of care of services available and useful!
AYFN is the mechanism to connect and inform people. Contact us at [email protected] or
(907) 770-4979.
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 87 of 88
Alaska Youth and Family Network – Bi-Polar Disorder Help Book
Page 88 of 88