“The Storm in my Brain:” A Teacher’s Guide to Pediatric Bipolar Disorder

1. “The Storm in my Brain:”A Teacher’s Guide toPediatric Bipolar Disorder

2. Pediatric Bipolar Disorder (PBPD) is a neurologically based mood disorder found in children 12 years and under. A serious, but treatable mental illness, it causes rapid shifts of mood that commonly cycle many times within a single day.PBPD affects all aspects of a child’s life: • Emotion • Behavior • Cognitive skills • Social interactions

3. The Child & Adolescent Bipolar Foundation (CABF) estimatesthat at least three quarters of a million American children and teenagers, mostly undiagnosed, may currently suffer from this illness. Children as young as three-years-old have been diagnosed with PBPD; preschool students may talk of wanting to ”make myself dead.”

4. Crying for no reason Extreme irritability Depression Explosive, lengthy rages Separation anxiety Defiance of authority Hyperactivity Sleeping too little or too much & night terrors Hallucinations Elation Excessive involvement in multiple projects Impaired judgment, impulsivity, racing thoughts Inappropriate sexual behavior Grandiosity Strong, frequent cravings for carbs & sweets Suicidal thoughts Also known as “manic-depression,” this disorder manifests itself differently in kids; abrupt swings of mood and energy occur much more frequently than they do in bipolar adults.Characteristics of PBPD include:

5. Diagnosing PBPD • Family history is an important consideration. The illness has a strong genetic component, although it can skip a generation; the risk of a parent with bipolar disorder passing it on to a child is 13%. A family history of BPD is found in 95% of PBPD patients. A family history of alcohol abuse is often related to PBPD. • The symptoms of this disorder resemble symptoms of Attention Deficit Hyperactivity Disorder (ADHD). Over 80% of children with early-onset BPD will meet the full criteria of ADHD. Treatment with a stimulant typically prescribed for ADHD can aggravate symptoms in children with bipolar disorder or trigger mania in a child with a family history of the illness.

6. There are significant differences between PBPD and ADHD. Bipolar children: 1.) are much more irritable; 2.) have more violent, destructive and lengthy outbursts; 3.) are more grandiose (“I am the best”); 4.) have more frequent and intense mood changes (i.e. “rapid cycling”) 5.) exhibit an early interest in sexual activity.

7. A few important notes about medication: No single medication works in all children. Since symptoms wax and wane, and children’s bodies change as they grow, managing medication to ensure continued stability is an ongoing challenge. Also, controlled long-term studies of the effects of lithium and other mood stabilizers in bipolar children is nearly non- existent. Medication Mood stabilizers (Lithium, Depakote, Tegratol) Antipsychotic medications (Risperdal, Zyprexa) Benzodiazepines for sleep disturbances Close monitoring of symptoms Education for child and family about the symptoms, course and treatment of the disorder Psychotherapy for the child and family Stress reduction Good nutrition, regular sleep and exercise Participation in a network of support Accommodations at school Treatment for PBPD includes:

8. How PBPD Affects Learning • Disorder can cause cognitive deficits including the ability to: • pay attention • remember and recall information • think critically • categorize and organize information • employ problem-solving skills • quickly coordinate eye-hand movements • Disorder can cause child to be • talkative • impulsive • distractible • withdrawn • unmotivated • difficult to engage • Medication can cause • cognitive dulling • sleepiness • slurring of speech, memory recall difficulties • physical discomfort such as nausea or thirst

9. Suggested Guidelines for Teachers • Be informed • Learn about PBPD; request additional in-service training. • Work closely with the student’s family to understand the symptoms & course of the illness, changes in medication, etc. • Demonstrate good conflict management skills; strive to be flexible, calm, patient, firm, loving and consistent. • Focus on quality not quantity of the student’s work • Provide • Structure and predictability since change is so difficult • Seating with few distractions (with buffer space & model children) • Praise and encouragement at least once every 5 minutes • Sufficient supervision • Designate a “safe” person – an adult to go to when the student is feeling overwhelmed and a safe place to regain composure 2) Assign one-on-one adult supervision if needed outside the classroom during times of transition, lunch, recess, etc. • Request an aide within the classroom to help manage & support student, if necessary.

10. Suggested Accommodations • Scheduling • Permission to arrive later when necessary • Shorter school day • Scheduling difficult tasks for a time of day when student is best able to perform • Scheduling stimulating courses early in day to get interest going • Warnings before changes in activities; minimize surprises • More time for turning in homework of large projects • Break up assignments into shorter segments & allow more time for completion • Plan for breaks; lulls in the day • Periodic checks on progress during an assignment to make sure student is on schedule • Testing Situations • Modified time constraints • Altered or simpler instructions • Oral testing or use of a scribe • Altered environment with less distractions • Tools such as a calculator or word bank • Offering alternative assignments to reduce stress of testing • When developing an IEP, the classification Other Health Impaired (OHI) is advised to acknowledge the biological nature of this illness.To see a draft IEP for a bipolar student: http://www.bipolarchild.com/iep_print.html

11. Living with Bipolar Disorder: Prognosis & Long Term Options • Chronic, lifetime condition that can be managed but not cured with medication and lifestyle changes. • Children with bipolar disorder are at risk for school failure, addiction, and suicide. The lifetime mortality rate from bipolar disorder from suicide is higher than that for some childhood cancers. • Many students with PBPD are successful in a regular classroom setting. Depending on the child, there are other options available: • Self-contained classroom within the public school setting • Therapeutic day school with small class size (6 to 8) students and a trained special education teacher and a trained aide. • With the right support and treatment plan, a student with PBPD can thrive in school and develop satisfying peer relationships.

12. References • Baldessarini, R., Faedda, G., Suppes, T. et al (1995). Pediatric-Onset Bipolar Disorder: A Neglected Clinical and Public Health Problem. Harvard Rev Psychiatry, 3 (4), 171-195. • Birmaher, B., Naylor, M. & Pavuluri, M. (2005). Pediatric Bipolar Disorder: A Review of the Past 10 Years. Journal of the American Academy of Child and Adolescent Psychiatry, 44 (9), 846-871. • Forness, S., Kavale, K. & Walker, H. (2003). Psychiatric Disorders and Treatments: A Primer for Teachers. Teaching Exceptional Children, 36 (2), 42-49. • Kowatch, R., Fristad, M., Birmaher, B. et al (2005). Treatment Guidelines for Children and Adolescents with Bipolar Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 44 (3), 213 - 235. • McClure, E., Treland, J., Snow, J. et al (2005). Memory and Learning in Pediatric Bipolar Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 44 (5), 461-469. • Naparstek, N. (2002). Successful educators: a practical guide for understanding children’s learning problems and mental health issues. Westport, CN: Bergin & Garvey. • Papolos, D. & Papolos, J. (1999). The bipolar child: the definitive and reassuring guide to childhood’s most misunderstood disorder. New York: Broadway Books. • Child and Adolescent Bipolar Foundation. (2004). Educatingthe child with bipolar disorder (Brochure).Wilmette, Ill.: Child and Adolescent Bipolar Foundation. • Child & Adolescent Bipolar Foundation, Depression & Bipolar Support Alliance (2003). The Storm in my Brain: Kids and Mood Disorders (Bipolar Disorder and Depression). Internet Resources • Child & Adolescent Bipolar Foundation (copies of The Storm in my Brain available) http://www.bpkids.org/site/PageServer • Depression & Bipolar Support Alliance http://www.DBSAlliance.org • Juvenile Bipolar Research Foundation http://www.bpchildresearch.org Listen to National Public Radio programs on PBPD http://www.npr.org/templates/story/story.php?storyId=4457271 http://www.npr.org/templates/story/story.php?storyId=1439204 http://www.npr.org/templates/story/story.php?storyId=1444271 http://www.npr.org/templates/story/story.php?storyId=1151407