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.

National Children's Mental Health Awareness Day

Ohio Psychological Association Raises Awareness for Mental Health Awareness Month

Association focuses on Bullying for National Children’s Mental Health Day on May 9

The Ohio Psychological Association (OPA) is taking part in Mental Health Awareness Month to bring public awareness to the critical importance of mental health. This Thursday, the association is joining the Substance Abuse and Mental Health Services Administration (SAMHSA) in recognizing National Children’s Mental Health Day.

According to the American Psychological Association (APA), systematic international research has shown school bullying to be a frequent and serious public health problem.  Psychologists and other mental health professionals are using this research to develop bullying prevention programs that are being implemented in schools around the world.

Current OPA president, Dr. Jim Broyles launched a task force to examine how psychologists may become a part of the solution to prevent and respond to bullying.

Dr. Broyles said, “As a group, psychologists are very aware and concerned about this topic, and the ongoing issues which continue to spring to light associated with it. Many of us work with children and families who are affected by bullying. Our clients can be individuals who are the target of a bully or in some cases may be the bullies themselves, who have their own unique psychological issues and needs.”

Dr. Kimberly Burkhart chairs the Bullying Prevention Task Force whose mission it is to increase awareness about warning signs that bullying may be occurring and to connect families, as well as school staff with resources.

Children who bully may exhibit the following characteristics:

·         Getting into physical or verbal fights

·         Acquiring new belongings that are unexplainable

·         Increasing aggressiveness and competitiveness

·         Blaming others for his/her mistakes

Children who have been victimized may have some of the following characteristics:

·         Unexplainable injuries

·         Destroyed property

·         Changes in eating habits

·         Decline in academic performance

·         Decreased self-esteem

·         Avoidance of social situations

·         Engaging in self-destructive behavior

·         Frequent stomachaches or headaches

·         Sleep problems

Students who experience bullying may feel depressed or anxious. If your child or student is having trouble at school, problems with relationships, or displaying signs or symptoms listed above as a result of bullying, a mental health professional, such as a psychologist, can help your child develop coping skills to manage negative emotions and to respond to bullying.  Mental health professionals can also work with children who bully to help decrease behavioral problems and better manage anger.   

Located in Columbus, OH, The Ohio Psychological Association is a membership organization of approximately 1,600 Ohio psychologists. Its mission is to advance the creation, communication and application of psychological knowledge to benefit society and to improve people’s lives in Ohio. For more information, or for a psychologist referral, visit www.ohpsych.org.

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YMCA Healthy Kids Day -- Cleveland

OPA participated in the YMCA Healthy Kids Day in Cleveland, OH on Sunday, April 7th. 

OPA Members Nancy Duff-Boehm, Wendy Kellon, Cathy Gaw (pictured above) and Kathleen Ashton participated in the event. 

April is Child Abuse Prevention Month

April is Child Abuse Prevention Month. Child abuse is a national tragedy affecting more than three million children annually and causing the deaths of three children every day. Preventing and reporting child abuse is one of the most important things a community can do for the future of its children. Statistics vary, but for example, Franklin County Children Services receives more than 13,000 reports of child abuse each year and serves more than 28,000 children and their families (Franklin County Children's Services).Here are some resources that may be useful during this month. 

http://www.childwelfare.gov/preventing/preventionmonth/

http://www.apa.org/pi/e-card/child-abuse-prevention.aspx

http://actagainstviolence.apa.org/

http://www.preventchildabuse.org/publications/cap/index.shtml

http://jfs.ohio.gov/OCTF/CAPM.stm

Back to School Blues?

August marks the start of the school season and can be stressful for both kids and parents. Changes in routine, new sleep schedules, and coping with new people can be a challenge for kids and parents alike. Consider some of the following tips from the American Psychological Association:
1. Practice the first day of school routine: Getting into a sleep routine before the first week of school and organize lunches and bookbags the night before. Visit the school in advance to ease anxiety of the unknown.
2. Get to know your neighbors: If your child is starting a new school, walk around your block and get to know the neighborhood children
3. Talk to your child: Asking your children about their fears or worries about going back to school and also what they liked about their previous school or grade.
4. Empathize with your children: Nerves are normal, but highlight that not everything that is different is necessarily bad. Encourage your children to face their fears instead of falling in to the trap of encouraging avoidance.
Get involved and ask for help: Knowledge of the school and the community will better equip you to understand your child’s surroundings and the transition he or she is undergoing and seek expert advice from a mental health professional, such as a psychologist, if you are having trouble coping.

Links: http://www.apa.org/helpcenter/school-rush.aspx

April 2009 Awareness

Did You Know? April is....

Sexual Assault Awareness Month
The theme is Prevent Sexual Violence...in our workplaces, with the slogan Respect Works! April 8 is the SAAM Day of Action

National Minority Health Month
The theme is Ordinary Couples Don't Plan Their Pregnancies: Be Extraordinary! Preconception health is a family affair. Also be sure to visit the National Minority Health Month Foundation website.

Alcohol Awareness Month
April 9th is National Alcohol Screening Day

National Child Abuse Prevention Month
Contains a resource guide and community resource materials.

National Autism Awareness Month
April 2 is World Autism Day

Reach Out and Read

If you are attending the OPA Convention, please consider bringing "gently used" books for children. This is a community outreach project by the OPA staff. There will be a collection box at the registration table for the books.

The books are donated to Operation Reach Out and Read. Reach Out and Read is a national organization that makes literacy promotion a standard part of pediatric care so that children grow up with books and a love of reading. Reach Out and Read trains doctors and nurses to advise parents about the importance of reading aloud and to give books to children at pediatric check-ups from six months to five years of age. A special focus is placed on children growing up in poverty. By building on the unique relationship between parents and medical providers, Reach Out and Read helps families and communities cultivate early literacy skills so that children enter school prepared to succeed at reading.

For more information, please visit the "Reach out and Read" website.

Did You Know? June 21st is National ASK Day

ASK Day is a national day of focus on the lifesaving message of the ASK (Asking Saves Kids) campaign. ASK Day will take place on Saturday, June 21, 2008, the first day of summer, a time of year when children play more often in other homes.

Parents ask all sorts of questions to protect their children when they go play at the home of a friend, neighbor or relative. But there is one important question that more than half of parents say it never even occurred to them to ask: "Is there a gun where my child plays?"

Forty percent of homes with children have guns, and the ASK campaign offers free materials for professionals to encourage parents to ASK if there are guns where their children play. You can download the ASK Day Kit which contains details, ideas and materials to organize an ASK Day event. Please visit the Real Solutions to Gun Violence website for more details about this day.

Did You Know? National Children's Mental Health Awareness Day

National Children's Mental Health Awareness Day is a day for SAMHSA (Substance Abuse & Mental Health Services Administration) and the initiatives and communities it supports to promote positive youth development, resilience, recovery, and the transformation of mental health services delivery for children and youth with serious mental health needs and their families. Awareness Day will be held on Thursday, May 8th, 2008.

Awareness Day raises awareness of effective programs for children's mental health needs, demonstrates how children's mental health initiatives promote positive youth development, recovery and resilience, and shows how children with mental health needs thrive in their communities. The theme for this year's national event is Thriving in the Community, with a special emphasis on high school youth who receive the services they need are more likely to have positive outcomes such as better grades and higher rates of education and less likely to have negative outcomes such as involvement with the juvenile and criminal justice systems.

For more information, please visit SAMHSA's website.

Autism Awareness Month

April is Autism Awareness Month. If you are concerned that your child may have autism, speak to a psychologist. Psychologists are uniquely trained to assess children’s behavioral and social development, and will be able to diagnose your child.

Listen to the following podcast for more information about the symptoms of autism.

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Did You Know? April is Child Abuse and Neglect Prevention Month

From the Wilmington News Journal:

"This month, child welfare advocates across Ohio are coming together to shed light on the impact of abuse and neglect and encourage all Ohioans to do their part to prevent it. Efforts range from public displays representing the number of abuse and neglect cases in a given county to a two-day conference at the end of the month for child welfare professionals.

According to the Ohio Department of Job and Family Services (ODJFS), there were 73,156 reports of abuse and neglect in Ohio for 2006, up from 71,762 in 2005. Efforts to protect the children affected by these reports must go beyond those of government agencies to succeed. "

To read the rest of the article, click here.

April is Autism Awareness Month

In 2007, the CDC estimated the prevalence of autism to be as high as 1 in 150 children; as many as 560,000 children may be affected. Given this recent increase in prevalence, psychologists need to be aware of the clinical issues in autism. The American Academy of Pediatrics recently released materials to help pediatricians identify autism, and useful information for parents.

Psychologists play a critical role as one of the key professionals who are able to diagnose autism. Children with autism are often first identified by their language delay; children also demonstrate echolalia (repeating words and phrases). Autism is also characterized by deficits in socialization, such as difficulties in making direct eye contact, demonstrating joint attention (looking at an object that another person refers to), and sustaining reciprocal conversations. Finally, children with autism often demonstrate excesses in repetitive behavior or restricted interests; these include self-stimulatory behavior (e.g. rocking back and forth, flapping their hands), insistence on routines, lining up objects such as cars, unusual interests such as ceiling fans, vacuum cleaners, headlights, or excessive interests in typical things, such as only talking about trains or dinosaurs.

Best practices in treatment in autism is controversial, but most agree on early, intensive interventions, typically behavioral in nature, but also stemming from developmental approaches, that include reinforcement for learning new tasks, visual supports, efforts to improve language, socialization, adaptive behavior and decrease disruptive behaviors. For more information on autism, go to http://www.aap.org/healthtopics/Autism.cfm .

Information by: Nabil Hassan El-Ghoroury, Ph.D.