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					The Bipolar Child

    Miriam E. Halpern, MD
What is it?

• Bipolar Disorder
  • condition characterized by periods
    of high mood and low moods
  • Studies show that 1.5% of the
    population will have at least one
    hypomanic or manic episode in
    their adult lives

• When a person is hypomanic
  • Feels unusually good and competent, or
    simply irritable
  • Thoughts race, speech is often
  • Distractible and flit from topic to topic
  • Sleep seems less necessary
  • Drive for pleasurable activities with
    uncharacteristic disregard for risk

• the other pole of Bipolar Disorder
  • may vary in severity from a relative
    decrease in enjoyment and interest, to a
    painful lack of pleasure in anything
  • disturbances in concentration, sleep,
    appetite and energy as well as paralysis
    of decision making
  • guilt and low self-esteem are common
• The thought that a child can be too happy,
  too cocky, too exuberant, is an anathema
  to many people. But when we're talking
  about childhood bipolar I disorder, we are
  talking about children who are so silly and
  giddy that families are asked not to bring
  them to church; who are so cocky,
  expansive, and grandiose that they go to
  the principal's office and tell them to fire
  teachers they don't like; bright kids who
  fail classes because they are fully
  convinced they know it all and don't
  study," .
Recent Changes
• Brady Case and Anthony Russo,
  researchers at New York University,
  reported that the number of children
  under 18 who had been diagnosed
  with bipolar disorder increased
  fourfold between 1999 and 2000
  (Groopman, 2007). Another report
  shows up to a 600% increase in
  children under the age of 13
  diagnosed with bipolar disorder in
  the past 10 years (Groopman, 2007)
New understanding
• The authors presented a
  groundbreaking premise that not
  only do children and adolescents
  actually develop bipolar disorder in
  childhood, but much more commonly
  than anyone had conceived. They
  also strongly supported the
  hypothesis that the symptoms of
  bipolar disorder in children are
  different than those seen in adults.
Renewed concept

• study contributes to a growing
  awareness that serious mental
  illnesses do not emerge de novo
  when individuals reach
  adulthood but rather reflect
  early developmental processes.
New awareness

• it is important that physicians
  are aware that mania in
  children does exist and that
  they know, at least at this time,
  that outcomes are poor, so that
  they can appropriately counsel
  families. Arch Gen Psychiatry.
In addition
• Childhood sexual and physical abuse
  are associated with mental health
  problems and psychiatric disorders
  in adulthood (MacMillian et al. 2001;
  Molnar et al. 2001). Among adults
  with SMI, childhood abuse is
  associated with greater psychiatric
  symptoms, including depression,
  psychosis, dissociation, and
  posttraumatic stress (Craine et al.
  1988; Malow et al. 2006
The Risk
• A conservative estimate of an individual's
  risk of having full-blown bipolar disorder is
  1 percent. Disorders in the bipolar
  spectrum may affect 4-6%.
• When one parent has bipolar disorder, the
  risk to each child is l5-30%.
• When both parents have bipolar disorder,
  the risk increases to 50-75%.
• The risk in siblings and fraternal twins is
• The risk in identical twins is approximately

• In every generation since World War
  II, there is a higher incidence and an
  earlier age of onset of bipolar
  disorder and depression. On average,
  children with bipolar disorder
  experience their first episode of
  illness 10 years earlier than their
  parents' generation did. The reason
  for this is unknown.
Keep in mind

• The family trees of many
  children who develop early-
  onset bipolar disorder include
  individuals who suffered from
  substance abuse and/or mood
  disorders (often undiagnosed).
Common Symptoms
•   Separation anxiety
•   Rages & explosive temper tantrums
•   Marked irritability
•   Oppositional behavior
•   Frequent mood swing
•   Distractibility
•   Hyperactivity
•   Impulsivity
•   Restlessness/ fidgetiness
•   Silliness, goofiness, giddiness
Common Symptoms
•   Racing thoughts
•   Aggressive behavior
•   Grandiosity
•   Carbohydrate cravings
•   Risk-taking behaviors
•   Depressed mood
•   Lethargy
•   Low self-esteem
•   Difficulty getting up in the morning
•   Social anxiety
•   Oversensitivity to emotional or
    environmental triggers
Common Symptoms
• Bed-wetting (especially in boys)
• Night terrors
• Rapid or pressured speech
• Obsessive, perseverative behaviors
• Excessive daydreaming
• Compulsive behavior
• Motor & vocal tics
• Learning disabilities (especially non-
• Poor short-term memory
Common Symptoms
•   Lack of organization
•   Fascination with gore or morbid topics
•   Hyper-sexuality
•   Manipulative behavior
•   Bossiness
•   Lying
•   Suicidal thoughts
•   Destruction of property
•   Paranoia
•   Hallucinations & delusions
Less Common

• Migraine headaches

• Binging

• Self-mutilating behaviors

• Cruelty to animals
Children, more than
• experience faster mood swings,
  often cycling (changing from
  mania to depression) many
  times within a day
• exhibit a "mixed" state that is a
  mix of mania and depression

• with bipolar disorder are at risk
  for school failure, substance
  abuse, and suicide.
• The lifetime mortality rate for
  bipolar disorder (from suicide) is
  higher than some childhood

• Since hyperactivity can be seen
  in both bipolar disorder and
  ADHD, many children who are
  diagnosed with “severe ADHD”
  may actually have undiagnosed
  bipolar disorder.
Academic issues

• The disorder affects learning
  •   difficulties with sleep
  •   energy
  •   school attendance
  •   concentration
  •   executive function
  •   cognition
Co-occurring Learning
• Many of these children are
  bright or creative but they often
  have co-occurring learning
  • Non verbal learning disorders
    • Autobiographical narrative issues
Difficulties in

• Paying attention
• Remembering and recalling
• Thinking critically, categorizing, and
  organizing information
• Employing problem-solving skills
• Coordinating eye-hand movements

•   Consistent scheduling
•   Planned and unplanned breaks
•   Seating with few distractions
•   Providing buffer space and
    model children

• Shortened assignments
• Homework focusing on quality,
  not quantity
• Prior notice of transitions or
  changes in routine
• Minimizing surprises

• Scheduling the student’s most
 challenging tasks at a time of
 day when the child is best
 able to perform
 • allowing for medication-related
   tiredness, hunger, etc.
Needs - continued

• Reduce exposure to stressors
• Help build coping skills
• Structure and predictability

• Experts recommend some
  praise for all children at least
  once every 5 minutes, or 12
  positive comments for every
  negative statement.

• Focus on facts and solving
  problems (rather than blame).
• Inform parents regularly about
  how the student is performing.
  • via a notebook that goes back and
    forth to school with the child, or a
    daily chart or e-mail that records
    successes, progress, difficulties,
    and mood information.
More Suggestions

• Provide opportunities for the
  student to move around during
• Work on computers, or use
• Encourage him/her to get
  involved in other interactive
Don’t forget

• Children in a depressed state find it
  extremely hard to wake up in time
  for school.
• They should not be penalized for
  tardiness that is biologically based.
• Any talk of suicide must be taken
  seriously and reported to the child’s
“No tolerance”
• Defiance and aggression are the
  most challenging moods to manage.
• The best strategy:
  • Do not take it personally
  • Keep your composure
  • Do not get involved in power struggles.
  • Remain a positive model.
  • Prompt children who are rude to
    rephrase statements politely and try
  • Be firm and consistent.

• Try to ignore inappropriate,
  attention-getting behaviors as
  much as possible.
• Use “bossiness” to everyone’s
  advantage by making the child a
  leader or teacher.
Use Social Stories
• Guidelines for writing your own
  social stories:
  •   Picture the goal
  •   Gather information
  •   Tailor the text
  •   Teach with the title
• Additional Resources
Think Education!

• Build the child’s skills that
  lead to appropriate reactions
  and behavior, including emotion
  labeling, empathy, anger
  management, social rules,
  nonverbal communication and
 making amends
Safe place

• Students with bipolar disorder
  need an established “safe”
  person—an adult to go to when
  feeling overwhelmed—and a
  safe place.
• modified time constraints
• altered or simpler instructions
• oral testing or the use of a scribe
• an altered environment (such as a room
  with few or no other students)
• multiple-choice or matching rather than
  open-ended questions
• tools such as a calculator or word bank
• offering an alternative type of assignment
  to reduce the stress of testing

• An OHI classification clearly
  defines the child’s heightened
  levels of impulsivity,
  distractibility, sensory
  integration deficiencies, and
  poor decision-making skills as
  being due to this neurological

• On June 9, 2004, the task force
  of experts and stakeholders,
  established in 2003 by NAMI’s
  Policy Research Institute
  (NPRI), released a report
  addressing issues related to the
  use of psychotropic
  medications for children and
The Bad News

• About 1 in 10 children in the
  U.S. suffers from a mental
  illness severe enough to cause
Treatment Problems

•   Not as effective in children
•   Inadequately studied
•   Off label use
•   Medical malpractice
•   Informed consent
Diagnostic Confusion
• Diagnoses that mimic, mask, or co-occur
  with pediatric bipolar disorder include:
  • Attention-deficit hyperactivity disorder (ADHD)*
  • Depression
  • Oppositional-defiant disorder (ODD)
       • Conduct disorder (CD)
  •   Pervasive developmental disorder (PDD)
  •   Generalized anxiety disorder (GAD)
  •   Panic disorder
  •   Obsessive-compulsive disorder (OCD)
  •   Tourette syndrome (TS)
  •   Seizure disorders
  •   Reactive attachment disorder (RAD)
The Dilemma

• It is estimated that 85% of
  children with bipolar disorder
  also have ADHD and up to 22%
  of children with ADHD have
  bipolar disorder.
Gold Standard

• Lithium Carbonate
 • Eskalith, Lithobid
 • Lithium alters sodium transport in
   nerve and muscle cells and effects
   a shift toward intraneuronal
   metabolism of catecholamines
 • Excellent anti-manic agent
 • Not anti-depressant
Target Symptoms

• pressure of speech, motor
  hyperactivity, reduced need for
  sleep, flight of ideas,
  grandiosity, elation, poor
  judgment, aggressiveness, and
  possibly hostility
The Other Side

• Lithium toxicity is closely related to
  serum lithium levels, and can occur
  at doses close to therapeutic levels
• Diarrhea, vomiting, drowsiness,
  muscular weakness, and lack of
  coordination may be early signs of
  lithium intoxication
Common Side Effects

•   Thirst
•   Tremor
•   Sleepiness
•   Gastrointestinal upset
•   Cognitive slowing
Other Mood Stabilizers

• Anti-epileptics
• Anti-psychotics
• Nicotine

• Depakote (divalproex)
  •   Most studied
  •   Moderately effective in studies
  •   Blood monitoring
  •   Side effects include sedation,
      gastrointestinal effects, hepatic
      effects (especially young children)

• No correlation with therapeutic
  range (sometimes have to push
  up high)
• Hair loss or thinning
• PCOS in females
• Weight gain
• Osteoporosis
Tegretol, Trileptal

• Not well studied in adolescents
• Well tolerated
• Effectiveness may not relate to
  drug levels
• Some evidence of use for ADHD
  in Europe
Other AEDs

•   Keppra
•   Neurontin
•   Lamictal
•   Topamax

• Atypical neuroleptics
  •   Risperdal (Risperidone)
  •   Zyprexa (Olanzepine)
  •   Abilify (Aripiprazole)
  •   Geodon (Ziprasidone)
  •   Seroquel (Quetiapine)

• Essentially off label use in
  children under age 13 years
• Long term side effects
  (metabolic syndrome)
• Efficacy not well studied in
Nicotinic Receptor

• Comorbid bipolar disorder in
  Tourette’s syndrome responds
  to the nicotinic receptor
  antagonist mecamylamine
Omega Fatty Acids

• recognized to have intracellular
  effects similar to lithium and
• well tolerated and improved the
  short-term course of illness in a
  preliminary study of adults with
  bipolar disorder

•   ADHD
•   Tic Disorders
•   Depression
•   Personality Disorder
•   Self harming
•   Mental Retardation
•   Autism

• Controversial usage of
• Limited effectiveness over time
  of stimulants
• Worsening of symptoms vs.
  delayed diagnosis
Tic Disorders

• Co-morbidity between TS and
  BD does not appear to be due to
  chance co-occurrence of the
  two disorders.
• Family history, gene theories

• Agitated depression is more
  common in children and teens
  than in adults.
Personality Disorder

• Need a good developmental
  model for borderline personality
  disorder in children
• Present classification system
  not helpful
Self harming

• When present, what
  medications are indicated?
• Obsessive compulsive
• Social construct/ group activity
Mental Retardation
• According to the DSM-IV, all types of
  disorders are found in mentally retarded
  persons, with an incidence at least 3-4x
  higher than in the general population.
  Rutter, Graham, and Yule (1970), in their
  epidemiological study on the Isle of Wight,
  found psychiatric problems in 30% to 42%
  of retarded children and adolescents, as
  opposed to 7% of the children with normal
  intelligence levels.
Autism and Familial Major Mood
Disorder: Are They Related?
Robert DeLong, M.D., D.S.
• Medications that proved to be
  beneficial are the same as those
  used for mood disorder in the non-
  autistic population, atypical
  antipsychotics, and mood stabilizers
  (lithium or antiepileptic agents). This
  does not prove that autism and mood
  disorder are the same, but strongly
  suggests that their neurotransmitter
  and receptor characteristics must be

• Childhood Bipolar Disorder is
  real and in a school near you
• Medications are not yet the
• CBD has an effect on academic
  performance of the child

• The Bipolar Child, by Papolos
  and Papolos