Bipolar disorder: causes, symptoms, and treatment

Juvenile/Child Onset Bipolar Disorder
Diagnoses of bipolar disorder in childhood are rare, even among adolescent populations. One of the reasons why bipolar disorder is infrequently diagnosed is the “symptomatic overlap with attention deficit hyperactivity disorder (ADHD),” (Wozniak, Biederman, Kiely, et al., 1995). Diagnoses are likely dependent on contextual variables, as the psychologist or psychiatrist has leeway when assessing the child. Research on child onset bipolar disorder has evolved, though, to offer the clinical community more cogent guidelines for age-appropriate symptom assessment and diagnosis. Preliminary research demonstrates unique features of prepubescent-onset bipolar disorder as being, compared with adult-onset bipolar disorder, “nonepisodic, chronic, rapid-cycling,” characterized by a “mixed manic state that may be comorbid with ADHD and conduct disorder (CD),” (Geller & Luby, 1997, p. 1168). Other possible comorbidities and symptom overlap have been found with autism spectrum disorders, warranting future research on improving the exclusion criteria used to diagnose one or more of these clinical psychiatric disorders (Stahlberg, Soderstrom, Rastam, et al., 2004). Recent neurobiological research has yielded evidence supporting a construct known as bipolar spectrum disorders (BPSD), based on findings of structural abnormalities in cortical, subcortical, and limbic brain systems in youth who may therefore be labeled as at high risk for developing full-fledged bipolar disorder as adults (Bauer, Ramakrishnan, Saxena, et al., 2017). The designation of “high-risk” students remains more common than official bipolar diagnoses. Educators need not concern themselves with the minutia of psychiatric diagnoses, because best practices in instruction, classroom design, educational philosophy, and pedagogy will reflect the needs of individual students.
Definitions and Characteristics
Bipolar disorder is defined not legally, as through legislation like the Individuals with Disabilities Education Act (IDEA), but clinically. The most established, reliable evidence-based definitions are provided by professional organizations like the American Psychiatric Association. The American Psychiatric Association publishes and updates the Diagnostic and Statistical Manual (DSM), to offer the evidence-based diagnostic criteria for formally assessing individuals. Diagnostic criteria are both rigid and flexible, allowing for significant clinical judgment, and also include exclusionary criteria so that psychologists, psychiatrists, and other clinicians can ensure accurate diagnoses for conditions with considerable symptom convergence. For example, one of the key characteristics of bipolar disorder is the expression of manic symptoms or mania: defined by “a period of at least one week during which the person is in an abnormally and persistently elevated or irritable mood,” (Juvenile Bipolar Research Foundation, 2018, p. 1). Mania is considered a “cardinal symptom” of the disorder, for without the presence of mania in the child’s behavioral presentation, the child would be more likely to be diagnosed with a depressive disorder (Juvenile Bipolar Research Foundation, 2018, p. 1). Manic behaviors can, however, resemble those found in ADHD such as “intensified speech,” “distractibility,” and “psychomotor agitation,” (Juvenile Bipolar Research Foundation, 2018, p. 1). These are only a few of the behavioral features of bipolar disorder, though, which is also characterized by the opposite polarity of mania: depression.
The disorder is thus named because of its representing two poles: mania and depression, and was once commonly known as manic depression. Definitions of the disorder therefore must include the presence of a “major depressive episode,” in addition to exhibitions of mania for a specific duration and time frame (Juvenile Bipolar Research Foundation, 2018, p. 1). Depressive episodes can be more difficult to observe, with internalizing behaviors and characteristics that differ sharply from the externalizing ones shown during the manic stage. For example, the child may be fatigued, listless, or withdrawn, showing little interest even in activities that were once found enjoyable or pleasurable. The inability to concentrate is a feature of depression as well as of mania, though, which challenges clinicians to differentiate bipolar symptoms from those of ADHD. Other characteristics of children with bipolar disorder include sleep problems—both insomnia and hypersomnia—changes in eating habits, irritability, and expressing feelings of “worthlessness or excessive, inappropriate, or delusional guilt nearly every day,” (Juvenile Bipolar Research Foundation, 2018, p. 1). Research on child onset bipolar disorder shows that rather than experiencing longer episodes of manic and depressive states, young people cycle rather rapidly (Geller & Luby, 1997). In other words, teachers may notice the child experiencing rapid and sudden mood swings resulting in behavioral, attitudinal, or psychological changes throughout the day.
Furthermore, children do exhibit different symptoms, behaviors, and characteristics than adults. Children also differ in their symptom expression according to factors like age, gender, and environmental factors that increase or exacerbate risk. For example, trauma and child abuse are persistent and severe risk factors, with almost half of individuals diagnosed with BPSD having experienced childhood trauma (Garno, Goldberg, Ramirez, et al., 2018). It is also important to differentiate between subtypes of bipolar disorder: including Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS), each of which has further subtypes to help with diagnosis and treatment interventions. Bipolar I Disorder is characterized by the child having a full manic episode. A full manic episode is differentiated from a “hypomanic” episode in both intensity and duration, with hypomania being less severe than, full-fledged mania (Juvenile Bipolar Research Foundation, 2018, p. 1). If the child has demonstrated a manic episode, then the diagnosis may be Bipolar I Disorder. If no manic episode but only hypomania was evident, then the child is more likely to be diagnosed with Bipolar II Disorder. Most children who have been diagnosed with clinical BPSD will, however, receive the Bipolar NOS diagnosis, which is characterized more by the rapid cycling, and an unclear etiology or prognosis (Geller & Luby, 1997).
Regardless of age cohort, most children with BPSD will be characterized more by their mania, which is differential from ADHD in that it is accompanied by depressive episodes as well. Research shows that there are no significant differences between children at different age levels or even different genders in that all exhibited similar mania criteria and behaviors—even though male children of all ages were more likely to be diagnosed with comorbid ADHD (Geller, Zimerman, Williams, et al., 2000). Also, child onset bipolar disorder tends to be different from adult bipolar disorder in that the manic episodes are characterized more by irritability or aggressive behavior than by the “euphoria” that adults report when experiencing a manic episode (Wozniak, Biederman, Kiely, et al., 1995). Research also shows that children with bipolar do not exhibit the “intense mission-driven efforts” to complete tasks or the seemingly obsessive behaviors that characterize adult bipolar disorder (Blader & Carlson, 2007). Therefore, teachers will not necessarily notice students becoming overly absorbed in something and more likely to witness “vigorous and hurried activity...without much goal direction,” (Blader & Carlson, 2007, p. 107).
One of the main age-related issues in childhood bipolar disorder is the role that puberty plays in behavior and symptom expression. Research shows that prepubertal children with bipolar disorder are “more hyperactive” than their postpubertal counterparts and therefore more likely to receive a comorbid diagnosis of ADHD (Geller, Zimerman, Williams, et al., 2000). Moreover, postpubertal adolescents exhibit different manic symptoms than their younger counterparts, including hypersexuality without any significant differences related to gender (Geller, Zimerman, Williams, et al., 2000).
Bipolar disorder in children and adolescence does have a bearing on behavior, social interactions, and also on cognitive and academic performance. However, the disorder will affect each child differently. Due to the nature of bipolar disorder, the symptoms may also affect the child’s performance differently at different times depending on whether the child is currently experiencing a depressive or a manic stage. As with children with ADHD, children with bipolar disorder have higher rates of learning disabilities versus their peers without these diagnoses (Wozniak, Biederman, Kiely, et al., 1995). Scores on standardized tests, and assessment of learning scores may be lower than their peers or versus prior performance. Specific instruments such as vocabulary and literacy tests for cognitive performance show that students with bipolar disorder score lower than their peers regardless of age cohort (Wozniak, Biederman, Kiely, et al., 1995). These cognitive features of bipolar disorder imply the need for structural supports and accommodations to the general educational curricula. Physical aggression is one of the behavioral characteristics of students with bipolar disorders, with implications for classroom design and classroom management techniques.
As with students diagnosed with ADHD, students with bipolar disorder have as one of their chief symptoms affective dysregulation: the inability to self-monitor and control their own emotions (Blader & Carlson, 2007). Age of onset of symptoms or of diagnosis is likely linked to external or environmental variables, most notably abuse. Physical, emotional, and verbal abuse is associated with an earlier age of onset of bipolar disorder in young people (Post, Altshuler, Kupka, et al., 2014). Special education teachers and general education teachers alike therefore need a holistic approach to working with students with bipolar disorder. Teachers need to work not just within the realm of instructional strategy and content adaptations, but also collaborate with school counselors, psychologists, and social workers to advocate for students. Involving the family is a crucial component of helping children with bipolar disorder.
Educational Accommodations and Best Practices Interventions
Some of the educational accommodations and instructional strategies used with children with BPSD will be strikingly similar to those used when working with children with ADHD, given the symptom overlap with mania. Also as with students with ADHD, those with bipolar disorder may be taking medications that mitigate symptoms: educators need to know about these medications and how their side-effects may be impacting student performance, behaviors, or symptom development (Goodwin, Haddad, Ferrier, et al., 2016). Evidence-based interventions used in psychotherapy can be adapted to suit the classroom environment, too. For example, research reveals the efficacy of dialectical behavior therapy specifically when working with youth with bipolar disorder (Goldstein, Ferseh-Podrat, Rivera, et al., 2015). Family interventions, including psychoeducation and methods of enhancing intra-family communications to reduce verbal abuse patterns in the home, can and should be initiated by special education teachers in conjunction with school counselors (Post, Altshuler, Kupka, et al., 2014). Pavuluri, Graczyk, Henry, et al., 2004) found that child and family-focused cognitive behavioral therapy is also effective for addressing the environmental factors that exacerbate risk or symptoms in children with bipolar disorder.
As with dialectical behavioral therapy and psychoeducation, child and family-focused cognitive behavioral therapy is a method that special educators can use to provide “direct assistance to parents in addressing their frustrations,” while also helping general education teachers with the same (Pavuluri, Graczyk, Henry, et al., 2004, p. 529). Special education teachers can also learn more about the neurobiology of bipolar disorder to understand that children with the diagnosis may need specialized assistance with metacognition, higher-order cognitive functioning, and sophisticated problem solving, particularly among adolescents (Pavuluri, Graxzyk, Henry, et al., 2004). Special education teachers also need to collaborate with parents on strategies for modifying the child’s responses to adverse stimuli to promote resilience and self-regulation.
The student with bipolar disorder can and should be included in the general education classroom and learns according to the general education curriculum. However, modifications and changes to instructional strategy may be warranted. Evidence-based practices include the inclusion of sex education early in the curriculum due to the tendency for postpubescent students with bipolar disorder to exhibit hypersexuality and a propensity for risk taking (Geller, Zimerman, Williams, et al., 2000). Specific skill-building activities can also be incorporated into the instructional strategies in accordance with research on how the bipolar brain functions and what activities help mitigate symptoms. For example, communications skill-building exercises can help students of all ages with bipolar disorder as well as their fellow classmates who have been diagnosed with other mental health disorders like autism spectrum disorders or ADHD (Kowatch, Fristad, Birmaher, et al., 2005). Because students with bipolar disorder can struggle with problem solving and many have specific learning disabilities, special education teachers can also incorporate additional problem-solving strategies in instructional design.
What differentiates students with bipolar disorder from those with ADHD has major implications for instructional design. Students with bipolar disorder exhibit internalizing behaviors shared in common with those who have depressive disorders, and these are behaviors that are not disruptive to the classroom. As such, internalizing behaviors often go unnoticed by general education teachers and even parents. Special education teachers can, however, recognize the presence of internalizing symptoms in students with bipolar disorder, help general education teachers also to recognize them, and create a supportive learning environment that supports student self-expression. Creating a “positive learning climate” includes continuing to hold the student to high standards, providing them with high-quality learning experiences and opportunities to strengthen social relationships in the classroom (Johnson, Eva & Johnson, 2010, p. 12). Specific tips for teachers working with students with bipolar disorder include strong, clear, and flexible communications strategies that are age appropriate and culturally sensitive, and personalizing content to make it more meaningful to the student (Johnson, Eva & Johnson, 2010). Teachers may want to incorporate creative activities using art, music, or creative writing to stimulate student self-expression, or team-based collaborative learning experiences pairing the student with supportive peers. Fostering a respectful environment in the classroom, minimizing both distractions and adverse triggers like bullying, and improving student self-efficacy are also crucial components of an evidence-based approach to empowering students with bipolar disorder (Johnson, Eva & Johnson, 2010).
Resources for Parents and Teachers
Education and awareness are the key to helping students with bipolar disorder. Parents and teachers are therefore urged to learn more about child onset or adolescent bipolar disorder by visiting the website of the Juvenile Bipolar Research Foundation (2018). Additional resources include the American Academy of Child and Adolescent Psychiatry (2018), which maintains the Bipolar Resource Center. The National Alliance on Mental Illness (2018) also offers helpful resources for parents and teachers including a hotline. Educators may want to make use of access to professional and academic databases to find recent evidence-based practice models. Educators and administrators are also urged to locate community-based resources that can help both students and their caregivers.




References
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