Treating Pediatric Bipolar Disorder

by Kelsey Ross, M.A., Guest Blogger

In the United States, at least 750,000 children and adolescents are diagnosed with pediatric bipolar disorder (PBPD) (Killu & Crundwell, 2008). PBPD is a biological brain disorder that causes fluctuations in a youth’s mood, energy, and ability to function (Killu & Crundwell, 2008). PBPD is characterized by a slightly different presentation than the adult presentation of bipolar disorder, yet the adult criteria are used to diagnose children (American Psychological Association [APA], 2013; Grier, Wilkins, & Szadek, 2005). This is one reason why PBPD remains one of the most difficult disorders to diagnose and treat in youth, and under-detection, misdiagnosis, and inappropriate treatment are serious problems (Lofthouse & Fristad, 2004; McDonnell, 2010).

Evidence-Based Treatments

Lofthouse, Mackinaw-Koons, and Fristad (2004) found that pharmacological treatment is often the first step for children and adolescents with PBPD, and it is not uncommon for youth with PBPD to take several medications. Youth are often given a mood stabilizer, followed by a low dose anti-depressant to reduce depressive and anxiety symptoms and/or psychostimulants to reduce ADHD symptoms of inattention, impulsivity, and hyperactivity. These medications may be supplemented by anti-psychotic medications to reduce aggressive or psychotic symptoms and/or anti-hypertensive medications to improve the sleep-wake cycle.

To address the significant impairment in family life, social relationships, academics, and behavior, psychotherapy is often needed (Lofthouse et al., 2004). Psychoeducation, which teaches parents and youth about the disorder, its treatment, and the signs of relapse so that they can seek treatment early, can be an important component of psychotherapy (NIMH, 2012). The major psychotherapy options for PBPD include cognitive behavior therapy (CBT), which helps the youth change harmful thought patterns and behaviors; family-focused therapy (FFT), which teaches the family coping strategies, communication skills, and problem-solving skills; and interpersonal and social rhythm therapy, which aims to improve peer relationships and manage daily routines and sleep schedules (NIMH, 2012). Psychotherapy that combines these approaches can also be effective: one study found promising results for an FFT and CBT combined treatment for PBPD (Pavuluri et al., 2004).

School-Based Interventions

There are currently no research-supported school-based interventions for PBPD (Lofthouse et al., 2004). The pharmacotherapy and psychotherapy discussed do not primarily involve school professionals and would not be appropriate if administered solely in school settings. However, school professionals still play an instrumental role in treating youth with PBPD.

In terms of pharmacotherapy, school psychologists and school nurses can create a behavioral intervention plan that schedules a youth’s medication to be taken during the school day (Grier et al., 2005). This plan increases medication compliance, which can be an issue for youth with PBPD (Grier et al., 2005). School psychologists should also be aware of common side effects of PBPD medications (Grier et al., 2005). Then, school psychologists can include accommodations and modifications that address these side effects in a youth’s Individualized Education Program (IEP) or 504 plan (Grier et al., 2005). For example, one common side effect is frequent urination (Casey, 2006). A school psychologist could suggest an accommodation that allows the child to have unlimited access to the bathroom.

Regarding psychotherapy, school psychologists can supplement the community-based therapy with additional skills training sessions. For example, perhaps a child with PBPD receives Child and Family Focused Cognitive-Behavioral Treatment (CFF-CBT) in the community. Phase three of CFF-CBT teaches the child social and problem-solving skills (Casey, 2006). The school psychologist can collaborate with the community mental health professional to provide a school-based social skills intervention that reinforces the CFF-CBT social skills training (Grier et al., 2005).

Though pediatric bipolar disorder affects 2.2% of U.S. adolescents ages 13 to 18, it is not yet entirely understood (Merikangas et al., 2012). Researchers debate almost everything about the disorder, including the label, age range, prevalence, and risk factors. However, what is not debated is that PBPD can negatively impact students’ academic, social, and psychological functioning. Fortunately, evidence-based treatments exist; however, additional school-based interventions are needed to provide comprehensive support for youth with PBPD.

References:

1. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
2. Casey, K. (2006). Effective interventions for students with bipolar disorder. In C. Franklin, M. B. Harris, & P. Allen-Meares (Eds.), The school services sourcebook: A guide for school-based professionals (119-127). New York: Oxford University Press.
3. Grier, E. C., Wilkins, M. L., Szadek, L. (2005). Bipolar disorder in children: Treatment and intervention, part II. NASP Communique, 34(3), 1-7.
4. Killu, K., & Crundwell, R. A. (2008). Understanding and developing academic and behavioral interventions for students with bipolar disorder. Intervention In School & Clinic, 43(4), 244-251.
5. Lofthouse, N., & Fristad, M. A. (2004). Psychosocial interventions for children with early-onset bipolar spectrum disorder. Clinical Child And Family Psychology Review, 7(2), 71-88. doi:1096-4037/04/0600-0071/0
6. Lofthouse, N., Mackinaw-Koons, B., & Fristad, M. A. (2004). Bipolar spectrum disorders: Early onset. Retrieved from http://www.nasponline.org/communications/spawareness/bipolar_ho.pdf
7. McDonnell, M. A. (2010). Race, gender and age effects on the assessment of bipolar disorder in youth (Doctoral dissertation). Retrieved from Nursing dissertations. (d20000351)
8. Merikangas, K., Cui, L., Kattan, G., Carlson, G., Youngstrom, E., & Angst, J. (2012). Mania with and without depression in a community sample of US adolescents. Archives of General Psychiatry, 69(9), 943-951. doi:10.1001/archgenpsychiatry.2012.38
9. National Institute of Mental Health (NIMH). (2012). Bipolar disorder in children and adolescents. Retrieved from http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-adolescents/Bipolar_Children_Adolescents_CL508_144277.pdf
10. Pavuluri, M. N., Graczyk, P. A., Henry, D. B., Carbray, J. A., Heidenreich, J., & Miklowitz, D. J. (2004). Child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: Development and preliminary results. Journal of the American Academy of Child and Adolescent Psychiatry, 43(5), 528-537. doi:10.1097/01.chi.0000116743.71662.f8

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Kelsey Ross, M.A., is a third year doctoral student in school psychology at The Ohio State University (OSU). She received a B.A. with Honors Research Distinction in psychology and English from OSU. She currently serves as the Social Justice Chair for OSU's Student Affiliates in School Psychology (SASP). Kelsey's research interests include reading instruction and interventions.