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This chart is intended to provide a summary of the critical information Defining the Problem available on helping children with Bipolar disorder, formerly called manic-depressive illness, bipolar disorder to insure that every child gets the most appropriate and is a chronic condition characterized by extreme fluctuations comprehensive consideration. in mood, energy, thought, and behavior that interfere significantly with normal, healthy functioning. Although the American

Psychiatric Association Diagnostic and Statistical Manual of Assessing Bipolar Disorder Mental Disorders, Fourth Edition (DSM-IV) currently uses the same criteria to identify bipolar disorder in children and teens Some treatments for attention-deficit/ hyperactivity disorder (ADHD) and as it does in adults, recent research indicates that children oppositional defiant disorder (ODD) with bipolar disorder may not manifest the same precise may precipitate or significantly worsen symptoms. manic symptoms. For this reason, a diagnosis of bipolar disorder should be While adults may experience symptoms of a single mood for an extended period of time, bipolar considered when assessing the causes disorder in children and teens is often continuous and rapid-cycling. The shift from a manic of extreme behaviors. (excitable, elevated, expansive, or irritable) mood to a depressed (sad, low-energy, and The assessment of bipolar disorder should include: uninterested) state can occur several times within a single day. With children, symptoms of both moods frequently occur simultaneously. When manic, children and teens are likely to be irritable z Patient history, including symptoms, behaviors, and functioning levels (continued on p. 2) z Comprehensive family history, including information about any Counseling Children and improve compliance with the medication family members known to have a regimen and reduce the need for mood disorder or a history of drug Teens with Bipolar Disorder or alcohol abuse hospitalization. The most effective treatments for bipolar z Standardized structured rating disorder combine medication and psychologi- z Support groups can teach coping skills, instruments, such as Washington cal interventions. Counseling should be provid- reduce isolation, and increase social University in St. Louis Kiddie Schedule for Affective Disorders ed for both the child and the family. functioning. and Schizophrenia (WASH-U- For the child or teen with bipolar disorder: z Psychotherapeutic counseling can help the KSADS), the Child Behavior z Cognitive behavioral treatments can child or teen develop awareness, adapt to Checklist (ASEBA), and the Young Mania Rating Scale (British Journal stresses, and improve self-esteem. of Psychiatry, 1978, 133: 429-435) Goals in Developing a Treatment Plan For the family of the child with bipolar disorder: z Observation of symptoms z To identify early signs of extreme moods Comorbid conditions or conditions with z To teach children and teens to regulate z Psychoeducational training can help symptoms that mask bipolar disorder their moods parents understand the condition, develop include the following: z To change cognitive distortions associ- strategies for managing behavioral issues, ated with depression z Depression and learn skills for positive parenting. z To develop self-calming techniques for z Attention-deficit/hyperactivity manic or explosive moods z Stress reduction training can develop skills, disorder (ADHD) z To recognize signs of severe depres- including the use of relaxation techniques, z Oppositional defiant disorder (ODD) sion and suicidal thoughts helpful to the child and parent. z Obsessive-compulsive disorder z To educate about the risks of alcohol (OCD) z Support groups can assist parents to and drug use z Anxiety z To support the family of the bipolar child increase awareness of their own responses z Panic disorder or teen and reactions, extend their coping skills, z Reactive attachment disorder z To develop a closely monitored medica- and decrease their feelings of isolation and tion and therapeutic protocol (RAD) helplessness. Defining the Problem (continued) Fast Facts and explosive, rather than expansive. When depressed, children may be have great z 59% of surveyed adults with bipolar depressed, they may complain of physical ail- difficulty getting out of bed and show no disorder reported that symptoms ments, cry frequently, and be unable to engage interest in play or school. Children in a manic appeared during or before adolescence. in school, social, or family activities. phase may laugh hysterically for no apparent z The lifetime mortality rate from The DSM-IV establishes no lower age limit for reason. Their distorted cognitions may range suicide in bipolar disorder is higher bipolar disorder, but until recently young from believing that they already know every- than that for some childhood cancers. thing they might learn in school to thinking that people were rarely diagnosed with this z Famous people with symptoms of condition. Since the initial symptoms of bipolar they can fly. They may exhibit destructive bipolar disorder include Abraham disorder in children may have many features of rages, demonstrate precocious sexuality, and Lincoln, Charles Dickens, Ludwig van Beethoven, Winston Churchill, attention-deficit/hyperactivity disorder (ADHD) experience delusions and hallucinations. and Virginia Woolf. or oppositional defiant disorder (ODD), and Children with bipolar disorder are also at high z Studies indicate that the majority of these disorders may also coexist with bipolar risk for substance abuse and suicidal behavior. teens with untreated bipolar disorder have abused alcohol or drugs. disorder, identifying bipolar disorder in children Studies indicate there is a strong genetic z Mothers of children with bipolar dis- has been challenging. However, the decreased component to bipolar disorder. Although the order often report that, in infancy, need for sleep, grandiose behavior, elated risk of bipolar disorder in the general popula- their children slept erratically, seemed excessively attached, and mood, flight of ideas, and hypersexuality tion is around 1%, when one parent has had frequent uncontrolled tantrums. associated with bipolar disorder rarely occur in bipolar disorder the risk is 15%–30%. If both z The prevalence of alcoholism children diagnosed with only ADHD or ODD. parents have bipolar disorder, the risk among relatives of children with bipolar disorder is two to three times Although mood swings are considered a nor- increases to 50%–75%. Some evidence the alcoholism rate of relatives of children without the disorder. mal part of childhood and adolescent develop- indicates that when the disorder begins in childhood or early adolescence it may be a z In a recent longitudinal study, nearly ment, the characteristics of pediatric bipolar half of the children diagnosed before disorder can be extreme and intense. When more severe form of the illness. puberty with major depression developed mania by age 20.

What Parents Need to Know

Research indicates that parental observation provides the most accurate information in deter- mining the diagnosis of bipolar disorder in children and teens. The parent’s role is equally important in the treatment and management of the illness. Because bipolar disorder can result in many high-risk behaviors, it is essential that parents: z Find the right doctor. If there is a family history of bipolar or other mood disorder, family problems with alcohol or substance abuse, or your child is experiencing possible manic symptoms, you need a doctor experienced in diagnosing and treating bipolar disorder. You can find more information about getting help from the American Academy of Child and Adolescent Psychiatry at www.aacap.org/index.htm. z Keep your child with bipolar disorder safe. This may involve, among other precautions, storing medications in a locked box, removing weapons from the home, learning proper restraint techniques, listening for suicidal statements, and remaining vigilant about possible drug or alcohol use. z Assure that your child receives early and regular treatment. This will require medication management, psychological services, and academic accommodation. z Monitor your child’s moods. You are the best informant about any changes that your child is experiencing and can help to anticipate any needed modifications in the treatment regimen. z Learn effective strategies. Parents can implement positive parenting skills, establish stress reduction routines as part of the family functioning, and help the child develop useful coping skills. z Get support and guidance for yourself. Raising a child with bipolar disorder can be challenging and sometimes overwhelming. Getting the proper understanding and assistance can make it rewarding as well.

2 • Instant Help for Children and Teens with Bipolar Disorder Instant Help Publications (www.InstantHelpBooks.com) The Dos and Don’ts of Communicating

DON’T DO

• Ignore statements like “I want to be dead.” • Take suicidal statements seriously.

• Blame the child or yourself. • Stay positive.

• Focus on minor issues. • Let go of less important matters.

• Emphasize negative behaviors. • Acknowledge accomplishments.

• Overreact to manic symptoms. • Maintain a calm, consistent attitude.

What Teachers Need to Know

Bipolar disorder, and the medications used to treat it, can affect a child’s attendance, energy, concentration, motivation, problem-solving skills, memory, organization, and responsiveness to light, noise, and stress. The significant impact of bipolar disorder on a child’s ability to function academi- cally and socially requires the teacher to be both sensitive and skilled. The child with bipolar disorder can benefit from:

z A team approach that encourages regular communication about changes in the child’s behavior and needs, and involves parents, teachers, administrators, counselors, therapists, and physicians in formulating and implementing appropriate educational plans and accommodations.

z A classroom atmosphere that is both structured and flexible, so that the routine can reduce stress and the adaptability can accommodate the child’s changing mood state.

z A behavior intervention plan, including staff experienced in verbal de-escalation techniques and restraint training, that can help school personnel control the child’s negative behavior and can help the child learn appropriate techniques to control his or her own actions.

z Accommodations that modify the physical environment, behavioral expectations, and academic requirements to help insure that the child with bipolar disorder has a successful school experience. These accommodations, geared to the specific needs of the individual student, may include:

Light adjustment. Children may be agitated by bright light or made sleepy by darkness.

Noise control. Earplugs or headphones can minimize distractions.

One-on-one classroom aide.

Designation of a “safe place” to go when the child is feeling overwhelmed.

Unlimited access to drinking water and the bathroom.

Extended time for taking tests.

Activities that focus on creative expression.

Assignment modification. Short, clearly defined assignments and frequent checking can help during both depressed and manic phases.

Delayed school-day start time.

Consideration of special school placement.

Instant Help Publications (www.InstantHelpBooks.com) Instant Help for Children and Teens with Bipolar Disorder • 3 This Instant Help Chart was written by Grace Murphy Instant Help for Published by Instant Help Publications Children and Teens with Bipolar Disorder 4 Berkeley Street Norwalk, CT 06850 www.InstantHelpBooks.com

Medication Protocol Medication and Bipolar Disorder Research on the effective- z Antipsychotic medications, such Recent guidelines from the American Academy of Child and Adolescent Psychiatry ness and safety of medica- as Risperdal, Zyprexa, and have provided strategies for treating bipolar tions for bipolar disorder Seroquel, used for manic states, disorder in children, based on research in children and teens particularly when delusions or studies, case reports, and expert consensus. is ongoing, and hallucinations are present. An effective medication treatment plan should include: treatment has z Calcium channel blockers, such z Correct diagnosis and early treatment with been based pri- as verapamil and isradipine, cur- mood-stabilizing drugs. marily on the rently being evaluated for use as z Essential monitoring of possible side experience of mood stabilizers. effects, including weight gain, cognitive medications with consequences, and hormonal changes. z Anti-anxiety medications, such as adults. Frequently, management of z Appropriate diagnosis and treatment of Klonapin, Xanax, and Ativan, bipolar disorder requires the use of comorbid conditions, such as ADHD, used to reduce agitation and pro- several medications. These include: ODD, anxiety disorders, and substance mote sleep. abuse. z Mood stabilizers, such as lithium, The National Institute of Mental z Careful combination of medications to Depakote, Tegretol, and Gabrital, achieve optimum results with the Health has issued a cautionary note the basic tools for managing the minimum of adverse effects. on the use of antidepressants (with- high-risk symptoms of pediatric Since the management of pediatric bipolar out mood stabilizers) or stimulants in disorder frequently requires the use of several bipolar disorder. Some mood sta- the treatment of pediatric bipolar medications, a process of trial and error bilizers used with adults, such as disorder, since they may worsen should be expected, until the best medication Valproate, are not recommended regimen has been achieved. manic symptoms. for children.

The Brain and Bipolar Disorder Studies of bipolar disorder and brain functioning indicate multiple structural, metabolic, and bio- chemical abnormalities in the brain’s cortex, subcortex, and deep regions, including reduced amygdalar volumes and overactivity of certain enzymes. And although this disorder is genetically linked, it is also highly responsive to environmental stressors. The growing knowledge of the impaired brain functioning that leads to the disturbed thinking, impulsivity, and poor judgment evidenced in bipolar disorder may soon lead to more targeted, effective, and quick-acting treatments.

Resources for Helping Children and Teens with Bipolar Disorder

If Your Child Is Bipolar: The Parent-to- Matt the Moody Hermit Crab. C. McGee, Bipolar Disorder. B. Birmaher, Crown, 2004 Books for Parents Parent Guide to Living with and Loving a McGee and Woods, 2002 Pediatric Bipolar Disorder. R.L. Findling, Raising a Moody Child: How to Cope with Bipolar Child. C. Singer and S. Gurrentz, Everything You Need to Know about Taylor and Francis, 2002 Depression and Bipolar Disorder. Perspective Publishing, 2003 Bipolar Disorder and Manic Depressive M.A. Fristad and J.S. Goldberg Arnold, Cognitive-Behavioral Therapy for Bipolar Books for Kids Illness. M.A. Summers, Rosen Publishing Guilford, 2003 Disorder. M. Basco and A.J. Rush, My Bipolar Roller Coaster Feelings Book. Group, 2003 Guilford, 2005 The Ups and Downs of Raising a Bipolar B. Hebert, Trafford, 2005 Books for Professionals Child. J. Lederman and C. Fink, Simon and Schuster, 2003 New Hope for Children and Teens with

4 • Instant Help for Children and Teens with Bipolar Disorder Instant Help Publications (www.InstantHelpBooks.com)