Question:

When I started teaching fourth grade fifteen years ago, I had never heard of children having bipolar disorder. What exactly is this? And, what do I do about it?

Answer:

Thank you for your very timely question. Below you will find a brief discussion of pediatric bipolar disorder and the controversy surrounding it, a list of symptoms you might observe in your classroom if you have a student with this diagnosis, and a list of things you can do to support your student.

Bipolar disorder, also known as manic depression, is a mood disorder characterized by episodes of depression, episodes of mania, and/or “mixed” episodes (periods of behaviors associated depression and mania). This condition has been recognized in adults for a very long time, but the application of this diagnosis to children is relatively new and remains controversial. Despite the controversy, diagnoses of pediatric bipolar disorder have been increasing dramatically; during the past decade, there has been a forty-fold increase in the diagnosis of children and adolescents with bipolar disorder. Mental health professionals are unsure about the extent to which that increase reflects previous under-diagnosis, a current trend toward over-diagnosis, an actual increase in children with this disorder, or some combination of these factors.

Students with bipolar disorder have unstable moods and tend to shift between symptoms of depression and more elevated, expansive, and/or explosive moods. When these elevated mood symptoms are extensive enough to meet the criteria for mania, a diagnosis of bipolar disorder is given. Your student with a bipolar diagnosis appears to have a “f aulty emotional thermostat” and may bounce rapidly between extreme mood states with only brief interludes of emotional equilibrium.

For signs of depression in students, please refer to the answer posted in this column last month. If a student in your class experiences mania, you will probably observe the student showing some of the following symptoms in your classroom:

• Extremely high energy and activity level.
• Elevated, expansive mood – your student may be unusually outgoing and invested in being involved in everything.
• Inflated self-esteem, sometimes with belief in having special powers.
• Overexcitement, extreme silliness, or hysterical laughter, sometimes followed by crying spells.
• Intense agitation and irritability.
• Increased frustration and sensitivity to criticism.
• Rages and explosive outbursts – your student responds to small provocations with extreme intensity; is difficult, if not impossible, to console; and takes a long time to recover.
• Increased risk-taking.
• Rapid speech with constant shifting from one subject to another.
• Defiance , feeling that the rules do not apply to him/her.
• Fluctuations in concentration, alertness, and speed of mental processing.
• Impaired ability to plan, organize, and follow through.

It is important to keep in mind that:

• Bipolar disorder is very difficult to distinguish from other disorders in children. Most children who are diagnosed with bipolar disorder have a previous diagnosis of depression or attention-deficit/hyperactivity disorder (ADHD).
• A diagnosis of bipolar disorder does not preclude other conditions, such as developmental or learning disabilities. Symptoms of all applicable diagnoses should be targets of interventions.
• Because of radical mood shifts, your student experiences the world completely differently from one moment to the next. The student’s behavior is no more predictable to him/her than it is to you, causing considerable distress to both of you.
• The treatment of children diagnosed with bipolar disorder nearly always includes medication. The medications used may have uncomfortable side effects and may affect alertness, memory, and speed of processing information.

There are a number of ways that teachers and other school personnel can support students with bipolar disorder and help increase their positive participation in school. Choice of interventions and supports will depend on your student’s individual characteristics and needs at a particular point in time. Here are some general recommendations:

• Provide a calm, stable, and predictable classroom setting and routine.
• Designate a case manager who checks in with student at the beginning of the day and whom student can go to when feeling overwhelmed.
• Adjust expectations – when a student is going through difficult time, set smaller, easily attainable goals until symptoms improve. Give extra time to complete work and allow your student, when necessary, to stop an activity and resume it when calm.
• Model appropriate verbal responses to replace irritable behavior. For example, gently suggest, “Perhaps you could say, ‘I can’t focus on that right now’ instead of, ‘Why can’t you just leave me alone?’”
• Recognize and reinforce all of your student’s efforts at self-management, such as managing to avoid or even postpone a tantrum or increasing the period of time between disruptive outbursts.
• Identify a quiet, comfortable “time away” place where your student can go when feeling overwhelmed.
• Arrange a subtle, nonverbal signal for your student to use to let you know when he/she needs to leave the room.
• Provide objective, relevant information on student behavior to physicians and caregivers, especially for those students on medications.
• Make an effort to understand and accommodate the side effects of medications (e.g. thirst, more frequent need to use the bathroom).
• If a student is in therapy to develop emotional coping strategies, find out what strategies the student is working on. Prompt the student to use those strategies, when needed, and recognize and reinforce their use.

I hope that you find these suggestions useful. I would love to hear back from anyone who tries these strategies. Please let me know what worked, what did not work, and any other useful strategies you discovered.

Thank you so much and good luck!

References:

Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007 Sep;64(9).

http://www.nimh.nih.gov/science-news/2007/rates-of-bipolar-diagnosis-in-youth-rapidly-climbing-treatment-patterns-similar-to-adults.shtml