Download Pediatric Bipolar Disorder

Pediatric Bipolar
Disorder:
Neuropsychological and
Educational Issues
By Shelly Johns
Pediatric Bipolar
Disorder
• Pediatric Bipolar Disorder seems to
diagnosed more often in children and
adolescents.
• video.smi
Symptoms of Bipolar
Disorder
• There are no medical tests to diagnose Bipolar
Disorder, but the diagnosis must be made by a
psychiatrist
• The diagnosis is usually based on the
psychiatrist’s observations and the observations
and reports of the child and family. (Psychological
testing also helps with diagnosis.)
• Children can be diagnosed with Bipolar I, Bipolar
II disorder, or Bipolar Disorder NOS.
Symptoms of Bipolar
Disorder
• Doctors diagnose according to the criteria found in the
DSM-IV (APA, 2000 and Papolos & Papolos, 2002).
– This criteria is based on adult symptoms.
– The symptoms in children and adolescents manifest
somewhat differently then in adults
– Treatment usually involves medication and counseling.
– Research indicates a possible connection between
symptoms and neurological/biological factors.
Although there are separate categories for
Bipolar Disorder, common symptoms will be
presented.
Symptoms of Depression
According to the DSM-IV-TR
(APA, 2000)
Depressed, irritable mood or significant decreased
interest in pleasurable activates (such as, in
playing) present for at least two weeks.
• Loss of weight, increase in appetite, or decrease in
appetite
• Too much sleep, can’t stay or fall asleep
• Appearing to have slow movements or restless movements.
• Feeling worthless, or experience inappropriate guilt
• Little – no energy
• Problems concentrating and making decisions
• Thoughts of death, thoughts of suicide, or a suicide
attempt
Manic Symptoms
• For at least one week, “…abnormally and persistently
elevated, expansive, or irritable mood…” (APA,2000)
– Grandiose thoughts and feelings about oneself (possibly
delusions)
– Significant decrease in need for sleep
– Extremely and unusually talkative or appearing as if one
cannot stop talking
– Racing thoughts or ideas appearing to not connect
– Significant “increase in goal-directed activities” (APA,
2000) or appearing extremely restless
– Significant increase with involvement in “pleasurable
activities” that could have risky or dangerous
consequences.
– Hallucinations (in severe cases)
Symptoms Exhibited by
Children with Bipolar Disorder
(Papolos & Papolos, 2002 and Child and Adolescent Bipolar
Foundation, 2007)
• Rages and extreme temper
tantrums
• Rapid change in mood (over
hours or days)
• Easily set off by
environmental or emotional
stressors
• Hard time waking up in the
morning
• Defiant and oppositional
behavior
• Aggressive behaviors
• Nightmares and/or bedwetting
• Hypersexual behaviors
• Obsessive or compulsive
behaviors
• “Dare-devil Behaviors”
• Interested in violent or
“morbid” topics
• Manipulative, excessively
bossy, or bullying
• Appearing excessively silly
or goofy
Symptoms Exhibited by Children
with Bipolar Disorder continued…
(Papolos & Papolos, 2002 and Child and Adolescent Bipolar
Foundation, 2002)
• Hyperactive,
impulsive, easily
distracted,
disorganized, or
frequent day dreaming
• Learning disabilities or
problems with short
term memory
•
•
•
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Low self-esteem
Lying
Paranoia
Craving Carbohydrates
Separation or Social
Anxiety
Children with Bipolar Disorder may be
diagnosed with other disorders such as ADHD,
Oppositional Defiant Disorder, Generalized
Anxiety Disorder, Tourette’s Disorder, etc.
Pediatric Bipolar Disorder and
the Brain
(Papolos & Papolos, 2006, p. 209, BPChildren.com).
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Autonomic Nervous System
Limbic System
– “receives, regulates, and
assembles highly
organized information
derived from sensations,
momentary events,
memories of events, and
emotions associated with
those events”
– also plays a part in “sexual
desire,” hunger, thirst,
fear, and fight or flight
•
•
Amygdala and fear responses
Septum and rage
Pediatric Bipolar Disorder and
the Brain Continued
(Papolos & Papolos, 2006, p. 216).
• when the “neuronal activity” in the limbic system has been
disrupted, it could cause children to have problems
“registering emotional meaning” and to become “over alert
to stimuli”
• The disturbance in the limbic system may cause children to
exhibit “extremes of atttentional focus (hypervigilance),
emotional arousal, and an overreactive startle response”
• These children could overreact to stressors from the
environment, and may be more likely to exhibit anxiety and
panic
• It is not uncommon for individual’s with Bipolar Disorder,
both adults and children, to suffer from symptoms of
anxiety
Pediatric Bipolar Disorder
and the Brain
(BPChildren.com)
• Frontal Lobe smaller
(concentration, emotional
expression, creativity,
inhibition)
• Hippocampus smaller
(“processing and
distributing information”)
• Decrease in Nacetylaspartate in the
Hippocampus (emotion
regulation and memory)
Pediatric Bipolar Disorder and
the Brain Continued
(Papolos & Papolos, 2006, p. 226).
• Norepinephrine and
alertness
– Problems with attention,
focus, and being easily
distracted, may be
related to norepinenphrine
• Serotonin
– Serotonin appears to be
found in areas of the
brain related to arousal
– Issues related to sleep
have been found to be
related to serotonin.
• Dopamine
–
Fluctuations in dopamine
can affect “self-esteem;
may contribute to
abnormal mood states,
such as elation and
melancholia; and may
result in marked
variations in
activity/hyperactivity and
pressured speech seen in
mania and hypomania”
Bipolar Disorder and
Neuropsychological Issues
(Papolos & Papolos, 2006, p. 351).
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•
Experts are beginning to think
that children with Bipolar
Disorder have problems related
to the frontal lobes, which causes
problems with executive
functions, such as attending and
problem solving
Children with Bipolar Disorder
may experience difficulty with
executive functions, such as
disorganization, using the same
strategy even if it is not working,
difficulty acting on a plan or
developing the parts of the plan,
difficulty with attention,
difficulty with “follow through,”
and difficulty with trying
something new.
•
Researchers have also found that
children and adolescents with
Bipolar Disorder also have
difficulties with working memory,
meaning that they have problems
holding information in “shortterm memory while manipulating it
toward problem solving or
sequencing it in a logical order”
Possible Learning
Difficulties
(Child and Adolescent Bipolar Foundation, 2007 and Juvenile Bipolar
Research Foundation, 2002)
• Children may have difficulty with:
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Memory and recall
Being able to think critically and problem solve
Energy fluctuations
Problems with executive functioning
Side effects of medication (“cognitive dulling,”
thirst, hunger, increase in need to urinate, and
diarrhea)
Teaching Strategies and
suggestions
(Child and Adolescent Bipolar Foundation, 2007)
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Try to offer a structured and
consistent day.
Interact with the students in
a calm manner.
Ignore minor behavioral
problems and praise positive
behaviors.
Be open to adapting
assignments and curriculum
when needed.
Have some activities prepared
for when the student has
fluctuations in mood and
energy (if manic – provide
physical jobs or activities).
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Learn “conflict management
skills” in order to help to
calmly solve conflicts.
Be open to communicating and
working with the child’s
parents and outside service
providers.
Try to keep a sense of humor.
Place the child in an area of
the class that has less
distractions, possibly seating
the child by “model students.”
Teaching Strategies and
suggestions
(Child and Adolescent Bipolar Foundation, 2007)
•
•
•
•
•
Try to offer a structured and
consistent day.
Interact with the students in
a calm manner.
Ignore minor behavioral
problems and praise positive
behaviors.
Be open to adapting
assignments and curriculum
when needed.
Have some activities prepared
for when the student has
fluctuations in mood and
energy (if manic – provide
physical jobs or activities).
•
•
•
•
Learn “conflict management
skills” in order to help to
calmly solve conflicts.
Be open to communicating and
working with the child’s
parents and outside service
providers.
Try to keep a sense of humor.
Place the child in an area of
the class that has less
distractions, possibly seating
the child by “model students.”
Suggestions for
Accommodations
(Child and Adolescent Bipolar Foundation, 2007 and Juvenile Bipolar
Research Foundation, 2002
• Accommodations for symptoms
– Because of difficulty waking in the morning, allow the
student to start the day later.
– Schedule harder academic courses and/or
tests later in day, to improve chances for
concentration and success.
– Allow the child to take breaks.
– Designate one (safe and trusting) staff member and/or
place for the student to go to when needing to calm
down or when feeling overwhelmed
• Establish a private signal between the child and teacher, so
that he/she can use it with out drawing attention.
• Allow child to have a permanent pass to use to go to
his/her designated staff or place.
Accommodations Continued…
(Child and Adolescent Bipolar Foundation, 2007; Juvenile
Bipolar Research Foundation, 2002
– Consider assigning an aid, for
direct support and intervention
with
behaviors.
– Schedule regular
sessions with the
school psychologist,
social worker, or counselor to
work on anger management,
coping skills, and tools to use for
calming down.
– Develop a Behavioral
Intervention Plan for
interventions to use with
behavior problems, based on the
results of a Functional Behavior
Assessment (to discover the
causes of behaviors).
– Due to anxiety, warn the child
about transitions and changes in
schedule. Possibly allow the
student to transition before the
other students
– Due to possible issues with social
relationships, have the child
participate in a social skills group
run by the school psychologist,
social worker, or counselor.
– Provide a student planner, an
extra set of books for home, and
options for quiet study areas.
– Post assignments daily on the class
web page, or email assignments to
the child’s parents.
Accommodations Continued…
(Child and Adolescent Bipolar Foundation, 2007 and Juvenile
Bipolar Research Foundation, 2002)
– To help with organization,
“color-code” folders and
notebooks to match specific
text books.
– Have the child clean out
his/her locker weekly, and help
him/her to organize it so that
morning materials are in one
area of the locker and
afternoon materials are in
another area of the locker.
– Give the child a prompt at the
end of the day (“What do I
need to take home to do what I
need to do?”)
• Similarly, a checklist can be
created and used daily, to help
the child remember what items
need to go home.
– Due to medication
side effects, allow
the student to have
a bottle of water at
his/her desk
– Develop a private signal for the
child to use when needing to use
the bathroom.
– Designate a location for the
student to take brief naps if
experiencing sleepiness due to
the medication.
– If the student appears fatigued,
or having problems with
“cognitive dulling,” adjust amount
of work and extend completion
time.
References
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American Psychiatric Association. (2000). Diagnostic and
Statistical Manual of Mental Disorders (4th ed., TR).
Washington DC: Author.
BPChildren.com. Brain Abnormalities Associated with Bipolar Disorder.
Retrieved November 7, 2006, from http://www.BPChildren.com
Child and Adolescent Bipolar Foundation (2002, October 27). About
Pediatric Bipolar Disorder. Retrieved October 20, 2006, from
http://www.bpkids.org
Child and Adolescent Bipolar Foundation (2007). Educating the Child
with Bipolar Disorder. Retrieved on June 4, 2007, from
http://www.bpkids.org
Juvenile Bipolar Research Foundation (2002). The Educational
Issues of Students with Bipolar Disorder. Retrieved on
October 20, 2006, from www.bpchildrenresearch.org
Papolos, D & Papolos, J. (2006). The Bipolar Child: The Definitive and
Reassuring Guide to Childhood’s Most Misunderstood
Disorder (3rd edition). New York: Broadway Books.
Helpful Resources
• www.bpkids.org (Child and Adolescent
Bipolar Foundation)
• www.bpchildresearch.org (Juvenile
Bipolar Research Foundation)
• www.bpchildren.com