1. EARLY ONSET BIPOLAR DISORDER: Epidemiology, Educational Implications, and Interventions Shelley Hart shelley_hart@charter.net

2. DIAGNOSIS

3. DSM-IV-TR DSM-IV-TR Five types of episodes Five types of episodes Four subtypes Four subtypes Four severity levels Four severity levels Three course specifiers Three course specifiers American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision. Washington, DC: Author.

4. Manic Episode Symptoms: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep 3. Pressured speech or more talkative than usual 4. Flight of ideas or racing thoughts 5. Distractibility 6. Psychomotor agitation or increase in goal- directed activity 7. Hedonistic interests

5. Hypomanic Episode Similarities with Manic Episode = Similarities with Manic Episode = Same symptoms Same symptoms Differences = Differences = Length of time Length of time Impairment not as severe Impairment not as severe

6. Major Depressive Episode Symptoms: 1. Depressed mood (in children can be irritable) 2. Diminished interest in activities 3. Significant weight loss or gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue/loss of energy 7. Feelings of worthlessness/inappropriate guilt 8. Diminished ability to think or concentrate/indecisiveness 9. Suicidal ideation or suicide attempt

7. Mixed Episode Both Manic and Major Depressive Episode criteria are met nearly every day for a least a one week period. Both Manic and Major Depressive Episode criteria are met nearly every day for a least a one week period.

8. Subtypes Bipolar Disorder I = more classic form; clear episodes of depression & mania Bipolar Disorder II = presents with less intense and often unrecognized manic phases Cyclothymia = chronic moods of hypomania & depression, often evolves into a more serious type Bipolar Disorder Not Otherwise Specified (NOS) = largest group of individuals

9. Children vs. Adults (or early vs. late onset ) Irritability Irritability Depression Depression Lack of mood reactivity Lack of mood reactivity Rejection sensitivity Rejection sensitivity Less evident are the classic symptoms of mania Less evident are the classic symptoms of mania

10. EPIDEMIOLOGY

11. Prevalence Estimated between 3-6% Estimated between 3-6% Subsyndromal bipolar disorder Subsyndromal bipolar disorder Equal distribution across gender variables Equal distribution across gender variables Average age @ onset = 20 years old Average age @ onset = 20 years old

12. Course Initial cycle typically major depressive episode Initial cycle typically major depressive episode Recovery Recovery Relapse Relapse Rapid Cycling Rapid Cycling Rapid cycling=4 episodes/year Rapid cycling=4 episodes/year Ultrarapid cycling=5-364 episodes/year Ultrarapid cycling=5-364 episodes/year Ultradian cycling=>365 episodes/year Ultradian cycling=>365 episodes/year

13. Age at Onset Pediatric, prepubertal, or early adolescent (prior to age 12) Pediatric, prepubertal, or early adolescent (prior to age 12) Adolescent (12 - 18 years) Adolescent (12 - 18 years) Adult onset (+ 18 years) Adult onset (+ 18 years)

14. IMPAIRMENTS

15. Comorbidity Attention Deficit Hyperactivity Disorder (ADHD) Attention Deficit Hyperactivity Disorder (ADHD) Between 60-80% Between 60-80%

16. Criteria Comparison Bipolar Disorder (mania) 1. More talkative than usual, or pressure to keep talking 2. Distractibility 3. Increase in goal directed activity or psychomotor agitation ADHD 1. Often talks excessively 2. Is often easily distracted by extraneous stimuli 3. Is often on the go or often acts as if driven by a motor Differentiation= elated mood, grandiosity, decreased need for sleep, hypersexuality, and irritable mood.

17. Comorbidity (cont.) Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD) Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD) 70-75% 70-75% Substance Abuse Substance Abuse 40-50% 40-50% Anxiety Disorders Anxiety Disorders 35-40% 35-40%

18. Suicidal Behaviors Prevalence of suicide attempts Prevalence of suicide attempts 40-45% 40-45% Age of first attempt Age of first attempt Multiple attempts Multiple attempts Severity of attempts Severity of attempts Suicidal ideation Suicidal ideation

19. Cognitive Deficits Executive Functions Executive Functions Attention Attention Memory Memory Sensory-Motor Integration Sensory-Motor Integration Nonverbal Problem-Solving Nonverbal Problem-Solving Academic Deficits Academic Deficits Mathematics Mathematics

20. Psychosocial Deficits Relationships Relationships Peers Peers Family members Family members Recognition and Regulation of Emotion Recognition and Regulation of Emotion Social Problem-Solving Social Problem-Solving Self-Esteem Self-Esteem Impulse Control Impulse Control

21. TREATMENT APPROACHES

22. PsychopharmacologicalDEPRESSION Mood Stabilizers Mood Stabilizers Lamictal Lamictal Anti-Obsessional Anti-Obsessional Paxil Paxil Anti-Depressant Anti-Depressant Wellbutrin Wellbutrin Atypical Antipsychotics Atypical Antipsychotics Zyprexa ZyprexaMANIA Mood Stabillizers Lithium, Depakote, Depacon, Tegretol Aypical Antipsychotics Zyprexa, Seroquel, Risperdal, Geodon, Abilify Anti-Anxiety Benzodiazepines Klonopin, Ativan

23. Therapy Psychoeducation Psychoeducation Family Interventions Family Interventions Cognitive-Behavioral Therapy Cognitive-Behavioral Therapy RAINBOW Program RAINBOW Program Interpersonal and Social Rhythm Therapy Interpersonal and Social Rhythm Therapy Schema-focused Therapy Schema-focused Therapy

24. EDUCATIONAL IMPLICATIONS

25. IDEA Classification Emotional Disturbance (ED) vs. Other Health Impaired (OHI) Emotional Disturbance (ED) vs. Other Health Impaired (OHI)

26. Considerations Rapidly changing moods of depression, irritability, grandiosity, pressured speech, racing thoughts, etc. Rapidly changing moods of depression, irritability, grandiosity, pressured speech, racing thoughts, etc. Need for movement Need for movement Poor relationships Poor relationships Difficulties with concentration and focus Difficulties with concentration and focus Difficulties with task completion Difficulties with task completion Impaired judgment and imulsivity Impaired judgment and imulsivity Disorganization Disorganization Becoming overwhelmed with stressful situations Becoming overwhelmed with stressful situations

27. Possible Accommodations/Modifications Provide student with a safe place and person to go to when feeling overwhelmed or stressed Provide student with a safe place and person to go to when feeling overwhelmed or stressed Shortened day (permit late start as needed) Shortened day (permit late start as needed) Prior notice of transitions Prior notice of transitions Consistent schedule Consistent schedule Scheduling the students most challenging tasks at a time of day when the child is best able to perform Scheduling the students most challenging tasks at a time of day when the child is best able to perform Modified or shortened assignments Modified or shortened assignments Plan for unstructured times of the day Plan for unstructured times of the day Adjust for medication needs, dispensing, as well as plans for addressing side effects (e.g., sedation) Adjust for medication needs, dispensing, as well as plans for addressing side effects (e.g., sedation)

28. Other Considerations Educating staff Educating staff Communication Communication Hospitalization Hospitalization

29. RESOURCES BOOKS/BOOKLETS: Mondimore, F. (1999). Bipolar disorder: A guide for patients and families. City: Johns Hopkins Press. Mondimore, F. (1999). Bipolar disorder: A guide for patients and families. City: Johns Hopkins Press. Geller, B., & DelBello, M. P. (Eds.). (2003). Bipolar disorder in childhood and early adolescence. New York: Guilford Press. Geller, B., & DelBello, M. P. (Eds.). (2003). Bipolar disorder in childhood and early adolescence. New York: Guilford Press. Educating the child with bipolar disorder. Available from: www.bpkids.org Educating the child with bipolar disorder. Available from: www.bpkids.org Anderson, M., Kubisak, J.B., Field, R., & Vogelstein, S. (2003). Understanding and educating children and adolescents with bipolar disorder: A guide for educators. Anderson, M., Kubisak, J.B., Field, R., & Vogelstein, S. (2003). Understanding and educating children and adolescents with bipolar disorder: A guide for educators.

30. RESOURCES WEBSITES: The Child and Adolescent Bipolar Foundation The Child and Adolescent Bipolar Foundation www.bpkids.org www.bpkids.org www.bpkids.org Depression and Bipolar Support Alliance Depression and Bipolar Support Alliance www.dbsalliance.org www.dbsalliance.org www.dbsalliance.org The Bipolar Child The Bipolar Child www.bipolarchild.com www.bipolarchild.com www.bipolarchild.com Parents of Bipolar Children Parents of Bipolar Children www.bpparent.org www.bpparent.org www.bpparent.org The Gray Center for Social Learning and Understanding The Gray Center for Social Learning and Understanding www.thegraycenter.org/Social_Stories.htm www.thegraycenter.org/Social_Stories.htm www.thegraycenter.org/Social_Stories.htm National Institute of Mental Health (NIMH) National Institute of Mental Health (NIMH) www.nimh.org www.nimh.org www.nimh.org