Educating the Child with Bipolar Disorder: Child and Adolescent Bipolar Foundation (page 3)

What is Pediatric Bipolar Disorder?

Bipolar disorder is a biological brain disorder causing severe fluctuations in mood, energy, thinking and behavior. It was previously known as manic depression, as it causes moods to shift between mania and depression. Children—whose symptoms present differently than those of adults—can experience severe and sudden mood changes many times a day. Symptoms of mania and depression can also occur simultaneously. Young people with this disorder are frequently anxious and have very low frustration tolerance.

At least three quarters of a million American children and teenagers struggle with bipolar disorder, most of them undiagnosed and untreated. Children with bipolar disorder are at risk for school failure, substance abuse, and suicide. The lifetime mortality rate for bipolar disorder (from suicide) is higher than some childhood cancers. Yet children who are stable and have the right support can thrive in school and develop satisfying peer relationships.

Commonly Seen Behaviors:

• Crying for no apparent reason
• An expansive or irritable mood
• Depression
• Rapidly changing moods lasting a few minutes to a few days
• Explosive, lengthy, and often destructive rages
• Separation anxiety
• Defiance of authority
• Hyperactivity, agitation, and distractibility
• Sleeping too little or too much
• Night terrors
• Strong and frequent cravings, often for carbohydrates and sweets
• Excessive involvement in multiple projects and activities
• Impaired judgment, impulsivity, racing thoughts, and pressure to keep talking
• Dare devil behaviors
• Inappropriate or precocious sexual behavior
• Delusions and hallucinations
• Grandiose belief in personal abilities that defy the laws of logic (ability to fly, knows more than the teacher or principal)
• Extreme irritability

Depressed children may not appear to be sad. Instead they may withdraw, not want to play, need more sleep than usual, display chronic irritability, or cry for no obvious reason. Children may also talk of wishing to die and may need to be hospitalized for harm to themselves or others.

Symptoms of mania may include elation, grandiose thinking, racing thoughts, pressured speech, hypersexuality, and decreased need for sleep. Since hyperactivity can be seen in both bipolar disorder and ADHD, a growing number of researchers believe that many children who are diagnosed with "severe ADHD" may actually have undiagnosed bipolar disorder.

Bipolar disorder is a chronic, lifetime condition that can be managed, but not cured, with medication and lifestyle changes. Because the symptoms wax and wane on their own, and children’s bodies change as they grow, managing medication to ensure continued stability is a complex and ongoing challenge.

How Bipolar Disorder Affects Cognition and Learning

Recent brain imaging studies show biological differences in patients with bipolar disorder. The disorder affects learning in a number of ways, ranging from difficulties with sleep, energy, school attendance, concentration, executive function, and cognition. Side effects from medications can affect the child’s learning and energy. Moreover, while many of these children are uncommonly bright or creative, they often have co-occurring learning disabilities.

Even when moods are stable, the condition often causes cognitive deficits, including the ability to:

• Pay attention
• Remember and recall information
• Think critically, categorize, and organize information
• Employ problem-solving skills
• Quickly coordinate eye-hand movements

In addition, bipolar disorder can cause a child to be at times impulsive, talkative, distractible, withdrawn, unmotivated, or difficult to engage. Medications to manage the illness can cause cognitive dulling, sleepiness, slurring of speech, memory recall difficulties, and physical discomfort such as nausea and excessive thirst.

Despite all these challenges, a student with bipolar disorder can succeed in the classroom with the right supports and accommodations.

Strategies for Teaching a Child with Bipolar Disorder

The teaching skills that make a classroom teacher successful with typical students are essential when working with children who have bipolar disorder:

Flexibility to adapt assignments, curriculum and presentation style as needed.

Patience to ignore minor negative behaviors, encourage positive behaviors, and provide positive behavioral choices. Most important is the ability to stay calm and be a model of desired behavior.

Good conflict management skills to resolve conflicts in a non-confrontational, non-combative, safe, and positive manner.

Receptivity to change and to working collaboratively with the child’s parents, doctors, and other professionals to best meet the needs of the child.

The ability to laugh at oneself and at situations. Teachers who can laugh at their own mistakes, and bring fun and humor into the classroom reduce the level of stress that students feel.

Suggested Accommodations

Students with bipolar disorder benefit enormously from stress-reducing accommodations such as:

• Consistent scheduling that includes planned and unplanned breaks
• Seating with few distractions, providing buffer space and model children
• Shortened assignments and homework focusing on quality, not quantity
• Prior notice of transitions or changes in routine—minimizing surprises
• A plan for unstructured time or lulls in the day
• Scheduling the student’s most challenging tasks at a time of day when the child is best able to perform (allowing for medication related tiredness, hunger, etc.)

Managing Challenging Behavior

Bipolar disorder affects the areas of the brain that regulate memory, speech, thought, emotions, personality, planning, anxiety, frustration, aggression, and impulse control. It’s no surprise, then, that these children have difficulty behaving appropriately in all situations. Although medication helps the children control their behavior, they are highly influenced by their impulses and surroundings even when moods are stable.

Children with bipolar disorder need adults around them who are positive, calm, firm, patient, consistent, loving, and who encourage them to behave appropriately. Praise and key words elicit positive behaviors, while negativity helps the child spin out of control. In fact, experts recommend some praise at least once every 5 minutes, or 12 positive comments to every negative comment.

In addition, the child’s team should have a behavior intervention plan. When a child is stable, the team needs to build the child’s skills that lead to appropriate reactions and behavior, including emotion labeling, empathy, anger management, social rules, nonverbal communication, and making amends. Those who work with the child need training in nonviolent crisis prevention, focusing on verbal de-escalation techniques, to avoid crises.

Reward positive behavior with praise and privileges but don’t set up a reward system in advance. Programs that reward the child for positive behavior, while punishing negative behaviors set the child up for failure, raising stress. Punishing a child with bipolar disorder for a fit of anger is akin to punishing an asthmatic child for an asthma attack.

A child with bipolar disorder often feels overwhelmed by the intensity of their emotions. Experts recommend some praise at least once every 5 minutes, or 12 positive comments to every one negative comment.

Modifying the Physical Environment

Children with bipolar disorder generally need an environment that reduces distractions and improves their ability to focus and behave appropriately. They benefit from accommodations like those made for students with ADHD, and in fact many of these children have ADHD in addition to bipolar disorder. Preferential seating near model students, with few nearby distractions, is critical. Some students do better near the teacher so that the teacher can unobtrusively check in and keep them on task, while others need extra space to pace or move around.

Noise is an issue for some children with bipolar disorder, as sensory integration problems are not uncommon. Earplugs for loud events, headphones that screen out noise, or even calming music can help a child focus. If music is more distracting than helpful, try a tape with a background noise such as ocean sounds to filter out random classroom noises.

Discomfort from heat and light can be distracting. If you don’t have control over the temperature in your classroom, suggest the child dress in layers to ensure comfort. Children who are tired or depressed may fall sleep if it’s too dark in the room. Others, if they’re sensitive to bright light, can be made more comfortable by sitting in carrels or away from bright sunlight.

Other Accommodations for Comfort

Students with bipolar disorder need an established "safe" person—an adult to go to when feeling overwhelmed—and a safe place. This safe place should be a private location used for regaining composure or collecting one’s thoughts, away from peers or other staff. Sometimes the student simply needs to take a walk. Make arrangements in advance that do not call undue attention to the student, but also consider policies on safety.

Many children experience side effects from medication, including sleepiness, thirst, frequent urination, or constant hunger. Work out a plan to keep these issues from affecting the child’s success.

Some students, particularly younger ones, may need one-on-one adult supervision, not only in the classroom, but at times of transition or unstructured activities full of peer interaction, such as recess or lunch time.

Consider extending education about diversity to include learning differences and how individual minds can work differently. This information can increase peer acceptance and reduce stigma for these students.

Dealing with Changing Moods

In a manic mood, children may exhibit distractibility, increased energy, grandiose thinking, rapid speech, and a strong goal orientation. Help them direct all that energy productively with hands-on projects and increased activity. The child will need help to set realistic goals. During lulls in the classroom, give the child an OT break, send the child on errands, or assign tasks involving motor activity, such as washing the board or moving items. Provide opportunities for the student to move around during class, work on computers, or use manipulatives and encourage him/her to get involved in other interactive activities. You might even set up games and intervention strategy that allow the children to become more conscious of and better able to control their need for movement.

When children are sad or depressed, exhibiting low energy, shorten their assignments and check in frequently to help them stay on track. Sometimes, simply asking what is wrong and how you can help is enough to get the child back on track. Children in a depressed state can find it extremely hard to wake up in time for school, particularly at certain times of the year. They should not be penalized for tardiness that is biologically based. Any talk of suicide must be taken seriously and reported to the child’s parents.

You might not be able to discern clearly defined episodes of mania or depression because children with bipolar disorder often experience both states at once, producing chronic agitation and irritability. Defiance and aggression are probably the most challenging moods to manage. The best strategy for addressing these behaviors is to not take it personally, keep your composure, and do not get involved in power struggles. Remain a positive model. Prompt children who are rude to rephrase statements politely and try again. Be firm and consistent, and give the child acceptable, positive choices. An ultimatum or threat can easily force the child to make poor choices.

At times all students are more demanding or just need a lot of attention. Greet them when they enter the classroom, seat them near where you teach, give them opportunities to work with other students, use their names in spelling sentences, math problems, etc, and acknowledge them when they stay on task. Try to ignore inappropriate, attention-getting behaviors as much as possible. Use "bossiness" to everyone’s advantage by making the child a leader or teacher.

Using Social Stories to Rehearse New Situations

Like children with other neurologically-based disorders, children with bipolar disorder often have difficulty in novel situations and don’t know how to behave appropriately. When given some sort of structure or script, however, they are far more successful. Social stories, which have been used by children with autism spectrum disorders, prepare the child in advance for a given situation so he can respond appropriately when that situation occurs.

Social stories can be simple, such as talking through and role-playing how to perceive that someone else doesn’t want to be splashed. They can also be longer, such as a 20-page book on going to a new camp or school. It’s important to not only give the child information on the situation, but also to reassure the child that he is capable of handling it. The story can also be a jumping off point for discussing "what if” scenarios, so the child has a chance to practice appropriate reactions for different outcomes. Involving the child in creating the story, either by coming up with what the child might say or by illustrating it, is a great way to capture the child’s interest.

Carol Gray, noted expert on social stories, provides the following guidelines* for writing your own social stories:

• Picture the goal
• Gather information
• Tailor the text
• Teach with the title

*Additional Resources:

www.thegraycenter.org/Social_Stories.htm, http://education-resources.cant.ac.uk

Adjusting the Schedule

Many factors affect the way children with bipolar disorder experience time, including difficulties with sleep, concentration, memory, and moods, plus medication side effects and a tendency to hyper focus. Students with bipolar disorder may need several or all of the following schedule accommodations:

• Permission to arrive later when necessary
• A shorter school day
• Scheduling difficult tasks for a time of day when the student is best able to perform
• Warnings before a change in activities
• More time for turning in homework or large projects
• Extra time for tests
• Breaking tests or assignments into shorter segments with breaks
• Scheduling stimulating courses early in the day to get interest flowing
• Periodic checks on progress during an assignment to ensure the student is on schedule

Optimizing Testing Situations

Brain imaging shows that people with bipolar disorder have differences in their brains in the areas that controlmemory. With help, however, such as the following testing accommodations, students with bipolar disorder can succeed in demonstrating their knowledge more effectively:

• Modified time constraints
• Altered or simpler instructions
• Oral testing or the use of a scribe
• An altered environment (such as a room with few or no other students)
• Multiple-choice or matching rather than open-ended questions
• Tools such as a calculator or word bank
• Offering an alternative type of assignment to reduce the stress of testing

Special Education Classification

When developing an IEP for a child with bipolar disorder, educators are sometimes unsure of the most appropriate way to classify the student’s special education needs. CABF advocates the classification Other Health Impaired (OHI). This classification acknowledges the biological nature of the illness. An OHI classification recognizes that:

• Bipolar disorder impairs a child’s ability to function effectively in school due to impairment in cognitive, emotional, and physical functioning.
• The behavioral and emotional problems of the student are symptoms of a biological brain disorder requiring pharmacological and psychosocial intervention, not primarily behavior modification.
• Behavioral outbursts, negative peer relationships, and an inability to interpret social situations are symptoms of neurological instability. These symptoms are not always within the child’s control, although proper medication can help.
• Repeated episodes of bipolar disorder cause deficits in social, vocational, and academic skills. Without proper accommodations within the academic program, these deficits lead to a high dropout and school failure rate.
• An OHI classification clearly defines the child’s heightened levels of impulsivity, distractibility, sensory integration deficiencies, and poor decision-making skills as being due to this neurological disorder.

With appropriate program supports, pharmacological treatment, and environmental support, students with bipolar disorder are more likely to successfully complete school and become productive citizens