Epidemiology, Educational Implications, and Interventions

DSM-IV-TR

Five types of episodes

Four subtypesFour severity levelsThree course

specifiers

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision. Washington, DC: Author.

Manic Episode

Symptoms:1. Inflated self-esteem or grandiosity2. Decreased need for sleep 3. Pressured speech or more talkative than

usual4. Flight of ideas or racing thoughts5. Distractibility6. Psychomotor agitation or increase in

goal-directed activity7. Hedonistic interests

Hypomanic EpisodeSimilarities with Manic Episode =

Same symptoms

Differences = Length of timeImpairment not as severe

Major Depressive EpisodeSymptoms:1. Depressed mood (in children can be irritable)2. Diminished interest in activities3. Significant weight loss or gain4. Insomnia or hypersomnia5. Psychomotor agitation or retardation6. Fatigue/loss of energy7. Feelings of worthlessness/inappropriate guilt8. Diminished ability to think or

concentrate/indecisiveness9. Suicidal ideation or suicide attempt

Mixed Episode

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

SubtypesBipolar 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

Children vs. Adults (or early vs. late onset ) IrritabilityDepression Lack of mood

reactivity Rejection

sensitivityLess evident are

the “classic” symptoms of mania

PrevalenceEstimated between 3-6%Subsyndromal bipolar disorderEqual distribution across gender variablesAverage age @ onset = 20 years old

CourseInitial cycle typically major depressive episodeRecoveryRelapseRapid Cycling

Rapid cycling=4 episodes/yearUltrarapid cycling=5-364 episodes/yearUltradian cycling=>365 episodes/year

Age at OnsetPediatric, prepubertal, or early adolescent

(prior to age 12)Adolescent (12 - 18 years)Adult onset (+ 18 years)

ComorbidityAttention Deficit Hyperactivity Disorder

(ADHD)Between 60-80%

Criteria ComparisonBipolar Disorder (mania)1. More talkative than

usual, or pressure to keep talking

2. Distractibility3. Increase in goal

directed activity or psychomotor agitation

ADHD1. Often talks

excessively2. 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.

Comorbidity(cont.)

Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD)70-75%

Substance Abuse40-50%

Anxiety Disorders35-40%

Suicidal BehaviorsPrevalence of suicide attempts

40-45%Age of first attemptMultiple attemptsSeverity of attemptsSuicidal ideation

Cognitive DeficitsExecutive FunctionsAttentionMemorySensory-Motor IntegrationNonverbal Problem-SolvingAcademic Deficits

Mathematics

Psychosocial DeficitsRelationships

PeersFamily members

Recognition and Regulation of EmotionSocial Problem-SolvingSelf-EsteemImpulse Control

Psychopharmacological

DEPRESSIONMood Stabilizers

Lamictal

Anti-Obsessional Paxil

Anti-Depressant Wellbutrin

Atypical Antipsychotics Zyprexa

MANIAMood Stabillizers

Lithium, Depakote, Depacon, Tegretol

Aypical Antipsychotics Zyprexa, Seroquel,

Risperdal, Geodon, Abilify

Anti-Anxiety Benzodiazepines

Klonopin, Ativan

TherapyPsychoeducationFamily InterventionsCognitive-Behavioral TherapyRAINBOW Program Interpersonal and Social Rhythm TherapySchema-focused Therapy

EDUCATIONAL IMPLICATIONS

IDEA ClassificationEmotional Disturbance (ED) vs. Other Health

Impaired (OHI)

ConsiderationsRapidly changing moods of depression,

irritability, grandiosity, pressured speech, racing thoughts, etc.

Need for movementPoor relationshipsDifficulties with concentration and focusDifficulties with task completionImpaired judgment and imulsivityDisorganizationBecoming overwhelmed with stressful

situations

Possible Accommodations/ModificationsProvide student with a safe place and person to

go to when feeling overwhelmed or stressedShortened day (permit late start as needed)Prior notice of transitions Consistent scheduleScheduling the student’s most challenging tasks

at a time of day when the child is best able to perform

Modified or shortened assignmentsPlan for unstructured times of the dayAdjust for medication needs, dispensing, as well

as plans for addressing side effects (e.g., sedation)

Other ConsiderationsEducating staffCommunicationHospitalization

RESOURCESBOOKS/BOOKLETS:

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.

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.

RESOURCESWEBSITES:

The Child and Adolescent Bipolar Foundation www.bpkids.org

Depression and Bipolar Support Alliance www.dbsalliance.org

The Bipolar Child www.bipolarchild.com

Parents of Bipolar Children www.bpparent.org

The Gray Center for Social Learning and Understanding www.thegraycenter.org/Social_Stories.htm

National Institute of Mental Health (NIMH) www.nimh.org