By: Elizabeth Coleman

& Kimberly Spence

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Bipolar disorder is a serious brain illness, also called manic-depressive illness.

Bipolar disorder influences mood, energy, thinking and behavior.

Unlike adults, who experience episodes of distinct “highs” and “lows,” children with the disorder have an ongoing, continuous mood disturbance that is a mix of mania and depression.

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Bipolar disorder does not affect every child and teen in the same way.

The frequency, intensity, and duration of a child’s symptoms and the child’s response to treatment vary dramatically. 

As the child grows up, bipolar disorder may affect the size, shape, and function of brain regions and networks.

Recent research suggests that pediatric bipolar disorder is a neurodevelopmental disorder. Parts of the brain mature at different rates and

times; brain maturation is not complete until an individual is 25 or so. Consequently, the symptoms and diagnosis of a psychiatric illness may change as the child grows.   

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The DSM-IV describes four types of bipolar disorder.2  Bipolar IBipolar I - individual experiences one or more

episodes of mania. Episodes of depression may also occur, but are not required to diagnose bipolar disorder. 

Bipolar IIBipolar II - The individual experiences recurrent periods of depression with episodes of normal mood or hypomania between episodes.  

Bipolar Disorder NOS (Not Otherwise Specified)Bipolar Disorder NOS (Not Otherwise Specified) - Doctors may make this diagnosis when there is severe mood dysregulation with serious impairment, but it is not clear which type of bipolar disorder, if any, is emerging.  Perhaps the child is experiencing the emergence of another neurodevelopmental illness and the symptoms of that disorder have not yet been fully expressed.   

CyclothymiaCyclothymia - This form of the disorder produces recurrent periods of less severe, but definite, mood swings that seriously impair the individual's life. Cyclothymia may progress into full bipolar disorder. 5

Anyone can develop bipolar disorder. However, most people with bipolar disorder develop it in their late teen or early adult years.

The illness lasts a lifetime.

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Factors that may contribute to bipolar disorder:

Genes – The illness is highly inheritable. If one parent has bipolar disorder, the risk

that his or her child will have bipolar disorder is 15% to 30%.

If both parents are affected, the risk increases to 50% to 75%.

If a sibling has bipolar disorder, the child's risk is 15% to 25%.

The risk in identical twins is approximately 85%.8

Abnormal brain structure and brain function.

Anxiety disorders 7

To properly transmit information from one neuron (nerve cell) to another within the central nervous system, neurotransmitters must be generated, dispatched, and delivered to the right destination cells. 

Scientists have pinpointed six primary brain chemicals that are implicated in bipolar disorder.  When the levels of these six substances are out of balance, the normal flow of information between neurons is disturbed, and a person’s normal activity, feelings, and thoughts cannot be processed in the usual way. 

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SerotoninSerotonin:  A neurotransmitter found in portions of the brain related to mood, anxiety, and cognition. 

DopamineDopamine:  Responsible for movement, attention, emotional response, and the ability to experience pleasure and pain.   

NoradrenalineNoradrenaline (also called norepinephrine):    Controls alertness and the sleep cycle, and regulates drive and motivation. 

Monoamine oxidaseMonoamine oxidase:  An enzyme that breaks down the brain chemicals noradrenaline, dopamine and serotonin.  The action of this enzyme affects the availability of these other chemicals to perform their respective functions. 

Gamma-aminobutyric acid Gamma-aminobutyric acid (GABA):  One GABA system is in the hippocampus and is involved in memory formation. 

GlutamateGlutamate:  Glutamate is an amino acid neurotransmitter that acts to excite neurons within the brain.  Glutamate stimulates N-methyl-D-asperate (NMDA) receptors that are actively involved in learning and memory activities.  9

Scientists are now able to identify physical differences in the brain that are associated with bipolar disorder. 

Prefrontal cortex:  Contains the skills needed to be successful in school are located.

Limbic system:  Essential in the regulation of visceral (instinctive) motor activity and emotional expression.

Amygdala:  Controls automatic, emotional and sexual behavior. 

Hippocampus:  The “filing cabinet” of the brain, it performs the central role in the formation of memories. 

Thalamus:  Helps make complex thought processes, emotions, and problem solving occur.

Basal nuclei (also known as basal anglia):    Organize motor behaviors.

Occipital lobe:  Responsible for sending and receiving visual messages and information. 10

Bipolar mood changes are called “mood episodes.”

Children may have manic episodes, depressive episodes, or “mixed” episodes.

Children and teens with bipolar disorder may have more mixed episodes than adults with the illness.

Mood episodes are intense. The feelings are strong and happen along with extreme changes in behavior and energy levels.

Bipolar children and teens have a difficult time developing and maintaining friendships.

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Talk really fast about a lot of different things

Have trouble staying focused Complain about pain a lot, like

stomachaches and headaches Feel guilty and worthless Eat too little or too much Extreme sadness or lack of interest in play

and fun activities Sleep disturbances, including gory

nightmares -or not sleeping very much Drawings or stories with extremely graphic

violence Experience short-term memory loss

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Severe and recurring depression Feel very happy or act silly in a way that’s

unusual Explosive, destructive or lengthy rages,

especially after the age of four Severe separation anxiety Talk of wanting to die or kill themselves or

others Dangerous behaviors, such as trying to

jump from a fast moving car or a roof, driving too fast

Grandiose belief in own abilities that defy the laws of logic (possessing ability to fly)

Sexualized behavior unusual for the child’s age

Impulsive aggression13

Delusional beliefs and hallucinations Extreme hostility Extreme or persistent irritability Telling teachers how to teach the class,

bossing adults around Creativity that seems driven or

compulsive Excessive involvement in multiple

projects and activities Compulsive craving for certain objects or

foods Hearing voices telling them to take

harmful action Racing thoughts, pressure to keep talking

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Just, as juvenile diabetes is generally a more severe disorder than adult-onset diabetes, pediatric bipolar disorder appears to be more perilous than adult-onset bipolar disorder.  

Common outcomes of pediatric bipolar disorder are school refusal, suspension, and dropping-out; impulsive acts of aggression; self-injury; substance abuse; and suicide attempts and completions.

Many teens with symptoms of untreated bipolar disorder are arrested and incarcerated. Suicide is the third leading cause of death among teens. Children as young as six have attempted to hang, shoot, stab or overdose themselves.   

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Substance abuse. Teens are at high risk of drinking or/and taking drugs.

Attention deficit/hyperactivity disorder (ADHD)

Anxiety Disorders. Separation anxiety, panic disorder, social phobia, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and generalized anxiety disorder (GAD)

Bipolar depression.

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Bipolar disorder is a chronic, lifelong condition.

An effective treatment plan for children and teens with bipolar disorder requires three essential elements:Medication Lifestyle and environmental

changes School accommodations

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Medication

Medications can help alleviate and reduce symptoms, smooth out mood fluctuations, reduce anxiety and distractibility, and increase frustration tolerance.

Children with bipolar disorder are treated with psychotropic medications many of which have side effects that may include physical discomfort and cognitive impairment.

Medicines most often used to treat bipolar disorder in children and adolescents include: Mood Stabilizers Antipsychotics Antidepressants 18

Lifestyle and Environmental Changes

Therapy - Therapy - Different kinds of psychotherapy, or “talk” therapy, can help children with bipolar disorder. Therapy can help children change their behavior and manage their routines. It can also help young people get along better with family and friends.

Stress is a trigger that intensifies bipolar symptoms and causes a decline in overall level of functioning, lifestyle and school changes should be made to reduce stress.

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Families need to understand and accept the illness as a chronic medical condition, participate in psychosocial therapies, and create effective family and community support networks.

Counseling services and psychoeducation help the child deal with the effects of the illness, and therapy for other family members can help the family cope and reduce tensions at home.

Keeping a consistent sleep schedule, getting regular exercise, and maintaining a healthy diet can be particularly important for an individual with bipolar disorder.

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School Accommodations

In school a child with bipolar disorder needs to be provided a consistent predictable schedule with advance notice of schedule changes as well as time to prepare for transitions throughout the day. 

Schools need to work with the parent to adjust homework requirements as needed to ensure that the child is able to get needed sleep and participate in psychoeducational programs/

A child struggling with a bipolar disorder is often highly gifted, but may have difficulty making transitions, and may have co-morbid syndromes that make him or her distractible, inattentive, anxious, or very perfectionistic.

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The differences in behaviors seen at home and at school can be dramatic. Because children react differently to the stresses of schoolwork, classroom noise, and transitions between classes and activities, some children show more severe symptoms at school, while others show more severe symptoms at home.

At school, children with bipolar disorder may be affected by some or all of the following symptoms.

Fluctuations in cognitive abilities; alertness, processing speed, and concentration. 23

Impaired ability to plan, organize, concentrate, and use abstract reasoning. This can affect behavior and academic performance.

Heightened sensitivity to perceived criticism. These children also are far more easily frustrated than a typical child.

Hostility or defiance at small provocations, as their moods dominate how they "hear" directions from a teacher

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At school – cont’d

Crying for no apparent reason, appearing upset out of proportion to actual events, or seeming inconsolable when distressed. School staff may notice how "irrational" these children seem to be, and that trying to reason with them often doesn't work. Most of these children suffer from extremely high levels of anxiety that interfere with their ability to logically assess a situation.

Side effects from medications. Medications may have cognitive effects or physically uncomfortable side effects that interfere with school performance.

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Once diagnosed with bipolar disorder, a child can become eligible for accommodations.

A child is protected by two federal laws: Section 504 of the Rehabilitation Act of 1973; and the more powerful statute known as the Individuals with Disabilities Education Act (IDEA).

Section 504 Section 504 mandates that individuals with impairments that substantially limit a major life activity, such as learning, are entitled to academic adjustments and auxiliary aids and services, so that courses, examinations, and services will be accessible to them.

A Section 504 is intended primarily for use in the mainstream classroom.

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However, bipolar disorder is by nature an episodic illness which may become acute at times. A student with this illness typically needs more services outside the classroom and may need accommodations such as time spent in a resource room, an aide, or a later start to the school day which are available only if the student has an Individual Education PlanIndividual Education Plan.

In deciding between a 504 plan and an IEP, each child is an individual with different social, emotional, and academic strengths and weaknesses. Educational needs may vary from one season or school year to the next. 27

Depending on the decision of a 504 or an IEP, the accommodations for each child may be simple or extensive. Some of the most common are:Extending time to take testsReducing homework and allowing flexible

due datesProviding the student with a place to go to

regain composure or take a breakAllowing unlimited access to water and

unrestricted bathroom breaks

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Today’s teachers face many stressors that teachers as recently as 10 years ago did not.

At-risk learners included in mainstream classrooms create more responsibilities for teachers.

Parents need to assist in the education process by advocating for their child.

Parents can help the staff to understand the disorder, what works best for their child, changes in medications, or behavioral strategies that work at home.

Communication is the key. 29

A school principal needs to be an instructional leader but some are simply building managers, hopefully s/he is both.

The school principal can be an important ally, particularly in regards to discipline.

IEP’s & 504’s should discuss the disciplining of students with bipolar disorder. The circumstances behind the behavior, the environment in which the problem occurred, and the events leading up to the undesirable behavior must be addressed.

Often, problematic behavior occurs when a child does not have the appropriate tools to cope with a situation.

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The school psychologist is responsible for completing the educational assessments.

The school psychologist has the potential to be an effective ally for the parent and advocate for the child if they are well-informed about bipolar disorder and current treatment practices.  However, they can also be a difficult roadblock for a parent if they are not informed about pediatric bipolar disorder or if they do not believe in or discount the child’s diagnosis.

The school psychologist should collaborate with others to insure that a child succeeds academically, socially and emotionally;

The school psychologist should work with individual students and teachers to help develop techniques to manage behavior in the classroom, develop effective teaching and learning strategies as well as prevent or manage crises. 31

The school adjustment counselor and a child’s guidance counselor are part of the child’s study team.

The school adjustment counselor and a child’s guidance counselor are responsible for Collaborating with others to ensure that a

child succeeds academically, socially and emotionally

Completing assessments, observations and review of outside reports and data.  These are usually related to the emotional and behavioral component.

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Working with students and teachers to help develop techniques to manage behavior in the classroom, develop effective teaching and learning strategies, as well as prevent or manage crises.

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Providing individual and group therapy as identified on a student’s IEP, as well as assessing crises situations for students on their caseload

Rylan is an eighth-grade student with early onset bipolar disorder (BD), attention deficit/hyperactivity disorder (ADHD), oppositional tendencies, social problems, and writing difficulties. Rylan’s behavior results in classroom disruptions, peer conflicts, teacher frustration, and poor academic performance. Rylan’s educators are struggling with how to best support his needs.

The assistant principal who deals with Rylan’s misbehavior has noticed escalating concerns since earlier this school year. Rylan has only recently been sent to the office because of his short temper, refusal to write in most classes, argumentative interactions with teachers, and fights with peers. Upon reviewing Rylan’s record and discovering his diagnoses, the assistant principal immediately puts a plan together to support Rylan.

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The assistant principal created a plan of action for Rylan when problems first began. A proactive meeting was held with his parents and teachers. Medical providers were contacted immediately for consultation. School counseling efforts began while medication changes were being completed. Learning issues were assessed and teachers were given support to deal with Rylan in the classroom via the development and implementation of a 504 plan.

These collaborative prevention measures allowed the assistant principal to manage the situation and support Rylan and his teachers.

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Sources:American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders-text revision (4th ed.). Washington, DC: Author.

Sophia was a 15 year old freshman when she walked into the assistant principals office on the first day of her very first mid-term and told him she was high and needed help. Up to this point, she had been labeled an “uncooperative” student who wandered the halls, cut class, acted weird, and talked back to teachers.

The school adjustment counsel was very concerned and believed Sophia was crying out for help and suggested an out-patient treatment program. As Sophia had been in an out-patient program the previous year for cutting, her mother agreed with the school adjustment counselor. The same hospital was called and as space was available, Sophia was placed in the program that day.

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Since Sophia’s previous hospitalization, her mother had put her into weekly therapy but no medication had been recommended.

By the end of Sophia’s first day in the out- patient center her doctor’s strongly recommended that she be sent to in-patient care due to her suicidal thoughts, unprovoked outbursts, and uncontrollable sexual behavior.

Within 48 hours, Sophia was diagnosed with Bipolar Disorder NOS and placed on medication. Ten days later she was released from the hospital with a plan for medication, therapy and for school.37

Over the past year, Sophia has been hospitalized again for severe bipolar depression and had her medication changed twice and dosages increased 3 times.

She struggles in school even with her 504 plan as her classroom teachers don’t seem to remember that she cannot always control her actions, but instead see her as willful, obstinate and uncooperative.

Sophia’s mother has advocated for her with her guidance counselor and school adjustment counselor and thus, she will be placed in a smaller and more creative based learning environment for the next school year.

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Early-onset BD severely impairs all areas of a child/student’s life.

Parents should learn as much as possible about the disorder and be prepared to advocate for their child.

Administrators and counselors need to provide guidance to various staff members who work directly with students with BD by seeking information about BD, helping and supporting teachers and other school staff members in identifying and devising appropriate intervention techniques for problem behaviors, consult with parents to support their needs in dealing with educational issues of students with BD, and forge positive relationships with the student’s entire treatment team. 39

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"About Pediatric Bipolar Disorder | Child & Adolescent Bipolar Foundation." Home | Child & Adolescent Bipolar Foundation. Child & Adolescent Bipolar Foundation, 25 May 2011. Web. 10 June 2011. <http://www.bpkids.org/learn/library/about-pediatric-bipolar-disorder>.

"Bipolar Disorder (Manic Depression) in Children and Teens." Massachusetts General Hospital Home. Massachusetts General Hospital. Web. 12 June 2011. <http://www2.massgeneral.org/schoolpsychiatry/info_bipolar.asp>.

Effectively Manage Bipolar Symptoms. Web. 12 June 2011. <http://www.bipolar-lives.com/index.html>.

"NIMH · Bipolar Disorder in Children and Teens (Easy to Read)." NIMH · Home. National Institute of Mental Health, 29 Apr. 2011. Web. 10 June 2011. <http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-teens-easy-to-read/index.shtml>.

"Understanding What Bipolar Disorder Is and How to Diagnose If You Have It." Advancements in Meta Psychology. Web. 12 June 2011. <http://advancedcognitivepsychology.blogspot.com/2011/04/dr-drew-pinksy-helps-you-understand.html>.

"What Is Bipolar Disorder in Children and Teens? - New Solutions to Bipolar Disorder - Health.com." Health.com: Health News, Wellness, and Medical Information. Healhwise, Inc., 8 May 2009. Web. 12 June 2011. <http://www.health.com/health/condition-article/0,,20275107,00.html>.

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