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WHAT IS BIPOLAR DISORDER?

DIAGNOSISBipolar disorder is a hereditary illness believed to occur in at least  1 - 2 % of the adolescent and adult population, with bipolar spectrum disorders believed to occur in 5 - 7 %.

The lifetime mortality rate (from suicide) is higher than some forms of cancer.

SPECTRUM

GENETIC FACTORS

BIPOLAR DISORDERS EFFECTS ON THE BRAIN

• Decreases in the number and density of glial cells in the prefrontal cortex.

• Decreases in the number of neurons in part of the hippocampus.

• Increases in the levels of some neuropeptides in the hypothalamus.

• White matter hyperintensities: small abnormal areas in the white matter of the brain (especially in the frontal lobe) as seen using magnetic resonance imaging. These abnormalities may be caused by the loss of myelin or axons.

• Decreases in the size of the cerebellum.

• Reduced activity in the prefrontal cortex during the depressive stage.

BIPOLAR’ S EFFECT ON NEUROTRANSMITTERS

PREDNISONE

BIPOLAR DISORDER AND CHILDREN

The number of children diagnosed with bipolar disorder is rising as doctors begin to recognize signs of the disorder in children.

Children with bipolar disorder are at risk for school failure, substance abuse and suicide.

TYPES OF BIPOLAR DISORDER

Bipolar I A person affected by bipolar I disorder has had at least one manic episode in his or her life. A manic episode is a period of abnormally elevated mood, accompanied by abnormal behavior that disrupts life.

Bipolar II is similar to bipolar I disorder, with moods cycling between high and low over time. However, in bipolar II disorder, the "up" moods never reach full-on mania.

TYPES OF BIPOLAR DISORDER CONTINUED

Rapid Cycling In rapid cycling, a person with bipolar disorder experiences four or more episodes of mania or depression in one year. About 10% to 20% of people with bipolar disorder have rapid cycling.

Mixed Bipolar In most forms of bipolar disorder, moods alternate between elevated and depressed over time. But with mixed bipolar disorder, a person experiences both mania and depression simultaneously or in rapid sequence.

Cyclothymia (cyclothymic disorder) is a relatively mild mood disorder. People with cyclothymic disorder have milder symptoms than in full-blown bipolar disorder.

SYMPTOMS OF BIPOLAR DISORDER IN CHILDREN AND ADOLESCENTS

Elation. Elated children may laugh hysterically and act infectiously happy without any reason at home, school or in church. If someone who did not know them saw their behaviors, they would think the child was on his/her way to Disneyland. Parents and teachers often see this as "Jim Carey-like" behaviors.

Grandiose behaviors. Grandiose behaviors are when children act as if the rules do not pertain to them. For example, they believe they are so smart that they can tell the teacher what to teach, tell other students what to learn and call the school principal to complain about teachers they do not like. Some children are convinced that they can do superhuman deeds (e.g., that they are Superman) without getting seriously hurt, e.g. "flying" out of windows.Flight of ideas. Children display flight of ideas when they jump from topic to topic in rapid succession during a normal conversation—not just when a special event has happened.

SYMPTOMS OF BIPOLAR DISORDER IN CHILDREN AND ADOLESCENTS

Decreased need for sleep. Children who sleep only 4-6 hours and are not tired the next day display a decreased need for sleep. These children may stay up playing on the computer and ordering things or rearranging furniture.

Hypersexuality. Hypersexual behavior can occur in children without any evidence of physical or sexual abuse in children who are manic. These children act flirtatious beyond their years, may try to touch the private areas of adults (including teachers) and use explicit sexual language.In addition, it is most common for children with mania to have multiple cycles during the day from giddy, silly highs to morose, gloomy suicidal depressions. It is very important to recognize these depressed cycles because of the danger of suicide.

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

DEPRESSIVE SYMPTOMS INCLUDEPersistent

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 worthlessne

ss or inappropriat

e guilt

Difficulty concentratin

g

Recurrent thoughts of

death or suicide

BIPOLAR MEDICATION SIDE EFFECTS

Cognitive dulling

Hyperactivity

Muscle tremors Drowsiness Fidgeting

or pacingRestlessne

ss

Chills or hot flashes

(rare)

Vision problems

Weight gain

BIPOLAR MEDICATION SIDE EFFECTS

Nausea

Increased or

decreased appetite

Excessive thirst

Frequent urination

Disinhibition Irritability Aggression

(rare)

Diarrhea or constipatio

nDry mouth

HOW TO HELP A BIPOLAR CHILD/TEEN

Maintain a stable sleep pattern.  Go to bed around the same time each night and get up about the same time each morning.  Disrupted sleep patterns appear to cause chemical changes in your body that can trigger mood episodes.  If your child has trouble sleeping, or is sleeping too much, be sure to tell the doctor. 

Maintain a regular pattern of activity.  It is common for teens to drive themselves impossibly hard and be involved in too many activities.

Help keep them away from the use alcohol or illicit drugs. These chemicals cause an imbalance in how the brain works.  This can, and often does, trigger mood episodes and interferes with medications.  If your child has a problem with substances, ask your doctor for help, consider self-help groups such as Marijuana Anonymous, or admit your child to a treatment center or residential program.

Be very careful about "everyday" use of small amounts of  caffeine, and some over-the-counter medications for colds, allergies, or pain.  Even small amounts of these substances can interfere with sleep, mood, or medicine.  Also, some of these seemingly harmless medications are abused, such as Coricidin.

Support from family and friends can help a lot.  Even the "calmest" family will sometimes need outside help in dealing with the stress of a loved one who has continued symptoms.  Ask your doctor or therapist to help educate both your child and your family about bipolar disorder.  Family therapy or joining a support group can be very helpful.

BEHAVIORAL SYMPTOMS

Until recently, doctors rarely diagnosed bipolar disorder in childhood because they were unaware that its symptoms in children can differ from the more widely recognized adult form. Symptoms may be present since early childhood, or may suddenly emerge in adolescence or adulthood. This are beyond the normal mood fluctuations, temper outbursts, fantasies, etc. associated with normal child development.

BEHAVIORAL SYMPTOMS

Bipolar disorder influences mood, energy, thinking and behavior. Unlike adults, who experience episodes of distinct "highs" and "lows," many children with the disorder suffer from an ongoing, continuous mood disturbance that is a mix of mania and depression. This produces chronic irritability and few periods of wellness or clearly discernible episodes. Moreover, since many children with bipolar disorder have other psychiatric disorders such as ADHD, ODD, OCD, and RAD it is difficult for parents and clinicians to clearly see distinct episodes of mania or depression.  It is important for clinicians to look at the cardinal symptoms of the disorder such as the elevated/expansive mood, grandiosity, decreased need for sleep, racing thoughts and increases in goal directed activities as identifiers of the episodicity of mania to distinguish between the two disorders.

Although not all children with severe tantrums have bipolar disorder, many children with bipolar disorder often had uncontrollable, severe tantrums or rages out of proportion to any event.  Some children with this disorder exhaust their self-control during the school day and therefore exhibit more severe symptoms in the relative safety and privacy of the home.

MAIN IMPACT OF BIPOLAR DISORDER IN SCHOOL

While elevated mood may be the symptom most often associated with mania, irritable mood may actually be the most prominent symptom and the individual may appear very labile (or quick-changing) in their moods — expansive at one moment and irritable when thwarted.

Sleep disorders associated with both depression and Bipolar Disorder will impact the student’s ability to wake up in the morning, get to school on time, and concentrate (particularly in the morning).

Medications used to treat Bipolar Disorder may produce increased thirst, lethargy, tremors, appetite change, diarrhea, nausea, and vomiting, among other side effects.

MAIN IMPACT OF BIPOLAR DISORDER IN SCHOOL

Panic Disorder has also been found to be comorbid with Bipolar Disorder in almost 1 in 5 cases. Students who have both Panic Disorder and Bipolar Disorder are more likely to have psychotic symptoms and suicidal thinking.

Obsessive-Compulsive Disorder is often comorbid with Bipolar Disorder and may complicate treatment.

Memory functions and processing speed are often impaired. Medications may also impair memory due to side effects. Many students with Bipolar Disorder will require accommodations for memory problems and retrieval issues.

MAIN IMPACT OF BIPOLAR DISORDER IN SCHOOL

Math is often impaired, even when the student is in a euthymic (“normal”) mood state.

Peer relationships and socialization are often impaired due to the symptoms of the disorder being unacceptable to peers and/or due to deficits in the ability to accurately interpret facial expressions of others during mood episodes. Many students with Bipolar Disorder have difficulty with this and may misinterpret peers’ facial expressions as indicating anger.

Bipolar Disorder seldom occurs by itself. The most common comorbid condition is ADHD, which comes with a whole host of problems. School personnel need to screen for other conditions if a student is diagnosed with Bipolar Disorder.

On a positive note, some students with mood disorders will be highly creative and the “exuberance” of a hypomanic episode may be associated with even greater productivity

TIPS FOR TEACHERS

Talk with the student about physiological symptoms that happen right before they start to escalate (i.e. clenching fists, sweating, eyes watering, etc.).

Let them know that you will try to help them at that point (before the meltdown or before they blow up) if they can work out a signal or a way of telling to that they are escalating.

You may be able to watch for symptoms as you get to know the student.

Brainstorm with the student ideas of ways he can calm himself down (i.e. walk, draw, journaling, specific exercises, etc.).

Always use a non-threatening tone of voice, very matter of fact and non-confrontational – especially when the student is becoming agitated.

Do not ask “why” questions. (i.e. “Why did you do that?”) This will frustrate the both of you. Instead ask “how” or “what” questions. (i.e. “What needs to happen, or “How can we work this out?” Remember that ANY questioning may be viewed as interrogation.

TIPS CONTINUEDBe proactive instead of reactive. Make a plan with the student on how you will both handle it next time the student begins to escalate. Be sure the student has a lot of input of this won’t work. Be very specific such as “When you feel tense, sweating, you will tell me you need to leave the room”; “You will go to the library (or other designated place) for blank minutes and do this activity; After blank minutes, you will return to class or let me know you need additional minutes.

Sometime (not always) physical proximity works – only with the students permission ahead of time. (i.e. when student begins to escalate, the teacher stands near or places hand on student’s shoulder). Remember that if the student has a history of abuse, control over personal space will be a very important to them.

De-escalation, after student has cooled off, makes sure to give the student a chance to tell their side of the story and that no judgment has been made assuming it is their entire fault.

Reassure the student that this is just a problem and that it is solvable so that student knows it is not “the end of the world”!

You may need more than one plan Bipolar Disorder is a condition in which the student “swings” between different types of mood episodes: depression and mania or depression and hypomania.

Pick your Battles

INDIVIDUAL MANAGEMENT PLAN

Simple, clear and positively phrased expectations

Give only one direction at a time

Reward the student for desired behaviors

Expect the best from the student, while clearly understanding their ability

Ignore minor issues – not everything has the be a battle

Create many opportunities for success socially and academically

ESTABLISH A SAFE SPOT

A safe spot should be established in the school. A safe spot is where a teen with bipolar disorder is allowed to go into a meltdown; also, efforts should be made to calm the teen down. The teen should be given the option of calling parents to talk and/or talk with a trusted adult in the building. Once the teen is calmed down, he or she should be given the option of returning to class. When returning to class, it should be at a time when the least amount attention be brought to the teen. Having a meltdown or episode in class is one of the hardest and embarrassing things that can happen to a teen. Every measure should be taken so that he/she don't have an episode during class, but rather can leave the room in time without undue attention. However, if they do lose control of emotions during class time, they should quietly leave. If the student is questioned by other students, they can just say that they didn’t feel good and leave it at that. Students should not feel obligated to tell details of what happened, as most others simply would not understand.

QUESTIONS?