The Ups and Downs of Serving Students with Bipolar Disorder PRESENTED BY: Diana Browning Wright, M.S., L.E.P. www.dianabrowningwright.com Educational Reform & Behavioral Consultant/School Psychologist LRP Education Consultant & National Convention Program Advisor -------------------------------------------------------- Initiative Director www.pent.ca.gov, statewide Initiative, sponsored by Ca. Dept. of Ed.- Diagnostic Center, Southern California, project manager: Deborah Holt AHAA and Principals Institutes, Statewide Initiatives-Arizona DIAL Project, Little Rock, Arkansas TAASA Project, Lodi, Ca. Social Skills Classes (ED) RtI Project, Calcasieu Parish, La. HELP-Secondary Inclusion Project San Jose, Ca. BICM competency Project, LAUSD, Ca. & San Joaquin, Ca. Other district initiatives dianawright@earthlink.net Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Legally Sound, Effective Guidelines for Responding to Student Threats of Violence 2007 Juvenile Bipolar Disorder Research Thanks to Ron Russell, Ph.D., clinical psychologist for his extensive research summaries and initial slides supporting this presentation! Ups and Downs of Serving Students with Bipolar Disorder, 2008 www.dianabrowningwright.com

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Areas We’ll Cover Is there a true increase now? Is it real? What is it? Is it different from adult Bipolar? Is the criteria changing? 3. Does this all equal “eligibility” and an IEP? (a) “Child Find” obligation? (b) What disabilities? (c) If eligible, eligible for what “specialized instruction”? And then what -- supplementary aids and supports? Related services? Ups and Downs of Serving Students with Bipolar Disorder, 2008

Areas We’ll Cover (cont.) 4. What about Sec. 504 for a Bipolar Disorder? 5. What if they already have eligibility (504 or IEP)? Should we add something to the IEP services for co-morbidity? 6. Research and websites for families and educators 7. Determining IEP components, if needed Ups and Downs of Serving Students with Bipolar Disorder, 2008

Ups and Downs of Serving Students with Bipolar Disorder, 2008 History of BP See History, Handout 7 Highlights: 400 BC mania and melancholia described as separate illnesses by Hippocratic physicians 150 AD First written account of JBPD 1949 benefits of lithium described to treat mania 1969 children as young as 6 treated with lithium in Sweden Late 1990s muti-site treatment and longitudinal studies funded by NIMH. More psychiatrists dx and rx for JBPD Ups and Downs of Serving Students with Bipolar Disorder, 2008

Is There a True Increase Now? Yes--Increased incidence since 1940s People are more mobile, making inter-marriage of two Bipolar adults more likely. High co-morbidity rate with alcoholism; women did not go to bars for drinking or finding mates until 1940s. Gene Penetrance increases inheritability when both parents have the disorder. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Triggers for Onset OFTEN APPEARS WITH NO IDENTIFIABLE CAUSE, HOWEVER: Puberty is a time of higher risk for males and females. Treatment with stimulants or antidepressants can trigger onset. Meth is a stimulant-some evidence of trigger effects reported Traumatic event or loss may trigger first episode of depression or mania. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 What is it and how is the childhood version different from the adult version? Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Four Versions of Typical Bipolar, a Mood Disorder from DSM IV-TR (only seen in 10% of non-adolescent children with dx of “Bipolar”) 1. Bipolar 1 Disorder 2. Bipolar 2 Disorder 3. Cyclothymia 4.Bipolar Disorder-Not Otherwise Specified (NOS) Review of Dx and Research Slides adapted from Ron Russell, Ph.D., Ca. Dept. of Ed.-Diagnostic Center-South, with permission, 2008 Bipolar is one of the MOOD DISORDERS from DSM4, which include depressive disorders, bipolar disorders, and two based on identifiable/external causes, i.e., medical condition or substance abuse. It involves the presence of Manic Episodes, Major Depression Episodes, and/or Mixed Episodes (Mania and Depression) in one of four combinations; episodes are not diagnoses in and of themselves; rather, they describes episodes that make up diagnosable conditions. The four combinations are: Bipolar I (One) Disorder = one or more Manic Episodes or Mixed Episodes (Mixed Episode = Mania and Major Depression nearly every day, with moods rapidly alternating between sadness, irritability, euphoria). Core features are elated/euphoric mood and grandiosity; and requires 3 additional symptoms of mania. Some individuals experience IRRITABILITY instead of euphoric/grandiose mania; in this case, 4 additional symptoms of mania are required. Usually accompanied by Major Depressive Episodes. Bipolar II (Two) Disorder = one or more Major Depressive Episodes with at least one Hypomanic (“low grade” Mania that is not as disabling) Episode. Some individuals experience heightened anxiety or irritability instead of euphoria. Cyclothymia = Hypomanic periods with symptoms that do no meet criteria for Manic Episode; and depressive periods with symptoms that do not meet criteria for a Major Depressive Episode. Absence of Manic or Mixed Episodes distinguishes it from Bipolar I Disorder. Bipolar Disorder-NOS These four “classic” presentations described in DSM4 are typically seen in adults, adolescents and a MINORITY of children (10%). A key component of this training is the differences between classic presentations and symptoms seen in the MAJORITY of children. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Adult/adolescent Type 1 of 4. Bipolar 1 Manic Focus History of one or more Manic Episodes or Mixed Episodes Mixed Episode: Mania and Major Depression nearly every day, with moods rapidly alternating between sadness, irritability, euphoria. Core features: elated/euphoric mood and grandiosity with 3 additional symptoms of mania. Alternate: IRRITABILITY instead of euphoric/grandiose mania; 4 additional symptoms of mania are required. Major Depressive Episodes usually accompany mania. Ups and Downs of Serving Students with Bipolar Disorder, 2008

Adult/adolescent Type 2 of 4: Bipolar 2 Major Depressive focus: History of one or more Major Depressive Episodes with at least one Hypomanic episode. Hypomanic = a “low grade” Mania that is not as disabling Variant: heightened anxiety or irritability instead of euphoria. Ups and Downs of Serving Students with Bipolar Disorder, 2008

Adult/adolescent Types 3 and 4 Cyclothymia: Hypomanic periods with symptoms that do not meet criteria for Manic Episode with depressive periods coupled with symptoms that do not meet criteria for a Major Depressive Episode. (Absence of full Manic or Mixed Episodes distinguishes it from Bipolar I Disorder). Bipolar Disorder-NOS Ups and Downs of Serving Students with Bipolar Disorder, 2008

Criteria for Episode of Major Depression: What It Looks Like Depressed mood nearly every day. Crying spells or tearfulness. Sleeping too much or inability to sleep during depression (adults more likely; children sleep disturbance during mania likely). Withdrawal from previously enjoyed activities. Change in concentration, memory, thinking/decisions, word retrieval, verbal fluency Pervasive sadness or irritability. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Major Depression (cont.) Agitation or excessively quiet. Drop in work (or school) performance. Thoughts of death and/or suicide. Low energy.* Increase or decrease in appetite/weight.* Feelings of worthlessness or guilt.* Children may feel, but don’t have insight to report or discuss worthlessness or guilt Slow moving, e.g., difficulty getting out of bed. *more likely to occur in adults Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Criteria for Manic Episode (note: mania takes longer to develop in the disorder, children demonstrate depression usually first) Euphoric or elevated mood, lasting at least one week. Decreased need for sleep w/no daytime fatigue. Racing thoughts or flight of ideas. Pressured speech; pressure to keep talking. Grandiosity or inflated self-esteem. CRITERIA FOR MANIC EPISODE LIKELY TO SEE DEPRESSION FIRST, ESPECIALLY IN CHILDREN; MANIA TAKES LONGER TO DEVELOP. Elevated, expansive, elated or euphoric mood. Some children exhibit euphoria, but for a majority, the high energy or high arousal feature takes the form of giddiness, irritability/“affective storm” instead of euphoria. Decreased need for sleep without daytime fatigue. Unlike depressed or anxious insomniacs, would be out of bed and actively engaged in goal-directed activities. Racing thoughts: a significant change from baseline level, such that a familiar adult would have difficulty following the student’s train of thought. Pressured speech and/or pressure to keep talking; again, would require a distinct change from baseline level. Grandiosity or inflated self-esteem. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Grandiose Tales and Plans Legally Sound, Effective Guidelines for Responding to Student Threats of Violence 2007 Grandiose Tales and Plans Ups and Downs of Serving Students with Bipolar Disorder, 2008 www.dianabrowningwright.com

Criteria for Manic Episode (cont.) Involvement in pleasurable but risky activities. (KEY SYMPTOM-Geller studies) Hypersexuality: exhibition,kissing,flirting, dirty talk (different from abused children- no anxiety or compulsive qualities noted during talk) Distracted by irrelevant details. but not agitated as in depression Distinct increase in bizarre, disorganized goal-directed activities. Impairs social and/or occupational functioning; may require hospitalization if harm is present. Note: Psychosis, may occur with mania; but is not a diagnostic criterion. CRITERIA FOR MANIC EPISODE (continued) Involvement in pleasurable but risky activities. This is a key symptom according to Geller, who studies JBPD. For children, includes hyper-sexuality in the form of exhibition, kissing, flirting, or “dirty talk.,” Differentiate from sex abuse symptom: with JBPD, pleasure-seeking quality rather than anxious and compulsive qualities seen in sexually abused children. Distracted by irrelevant details (as opposed to agitation seen with depression). Increase in goal-directed activity (distinct increase over baseline level). Impairs social and/or occupational functioning; may require hospitalization if harm is present. Psychosis, impaired reality testing, may occur with mania; but is not a diagnostic criterion. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Criteria for HYPOMANIC Episode Less severe symptoms of Mania that do not impair social or occupational functioning or require hospital. Increase in multiple goal-directed activities, but organized and not bizarre. Unlike Mania, no psychosis. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Children Are Not Miniature Adults Adults, adolescents and a minority of children (10%) present the distinct episodes of mania, depression, and hypomania just described, and meet duration criteria; The majority of children with JBPD present chronic irritability instead of distinct episodes. CHILDHOOD PRESENTATION While adults, adolescents and a minority of children present the distinct episodes of mania, depression, and hypomania just described, and that meet duration criteria, the majority of children with JBPD present chronic irritability instead of distinct episodes of mania and depression. DSM4 describes Mania and Depression separately; therefore, many children do not meet the diagnostic criteria. Children do appear to experience mania and depression, but not as separate and distinct states. It may be that they are somehow combined to form chronic irritability, but this is not to be confused with MIXED STATES described in DSM4, in which patient rapidly alternates between mania and depression (criteria for each state).. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

The Controversy of It All See Handout 2 Summary: Children have been observed to have very rapid cycling Some have suggested that children have ultra-ultra-rapid cycling.   Ups and Downs of Serving Students with Bipolar Disorder, 2008

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Onset and Features Bipolar adults report first manic episode occurred before age of 21, with 20% occurring in childhood. Childhood onset (<13 years) usually begins with Major Depression (crankiness, sadness, loss of interest in play). Adolescent onset (13-17 years) more likely to begin with Manic Episode. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Recently Recent research is finding evidence that when onset is in childhood, the disorder becomes a more severe form of adult Bipolar Disorder. However, findings are inconclusive about what percentage of JBPD evolves into adult Bipolar Disorder. Ups and Downs of Serving Students with Bipolar Disorder, 2008

CLUE: CHILDREN EXPERIENCE MANIA DIFFERENTLY Adults typically enjoy Mania, or at least Hypomania, while children experience it as negative (irritable response?). High arousal (mood) is the core, subjective response can be either an emotional + or emtional -. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Critically Different Observable Behaviors Adults and adolescents typically experience euphoric mania (elation- yee haw!). Children’s mania, however, can appear as 1. chronic irritability if negative response to arousal. 2. giddy/goofy/silly if positive response to arousal. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 What Does NIMH Roundtable Propose About Types of Childhood Bipolar Disorder? Narrow: The minority who meet BP-1 or BP-2 Clear episodes elevated mood or grandiosity of 7+days for Mania or 4+ for hypomania, clear switches from other moods; irritability excluded Intermediate- Like Narrow, but includes irritable mania or hypomania with shorter duration of episodes Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 What Does NIMH Roundtable Propose About Types of Childhood Bipolar Disorder? Broad – describes the MAJORITY who do not meet DSM4 criteria for mania or hypomania (BPI or BPII). No hallmark symptoms of mania (elevated/expansive mood or grandiosity, or inflated self-esteem) but severe irritability present for at least 12 months without any symptom-free periods exceeding 2 months in duration. Symptoms are severe in one setting, and at least mild in a second setting (e.g., home/school). Presentation of non-episodic symptoms of severe irritability; hyperarousal, insomnia, flight of ideas or racing thoughts, difficulty concentrating, impulsivity, pressured speech, intrusiveness, pressured speech, and agitation); markedly increased reactivity to negative emotional stimuli, such as hearing “no” when they exceed established limits. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

An Alternate: Papolos’ Proposed “Core” Phenotype Episodic, abrupt transitions in mood states accompanied by rapid alteration in levels of arousal, emotional excitability, sensory sensitivity, and motor activity. Variable mood states of mania/hypomania and depression meet DSM4 symptom criteria, but not duration criteria, Mania/hypomania/or mixed state(required): mirthful, silly, goofy or giddy; elated, euphoric, or overly optimistic, and self-aggrandizing, grandiose or difficulty regulating self-esteem. Depression: withdrawn; bored or anhedonic; sad or dysphoric; overly pessimistic and self-critical. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

An Alternate: Papolos’ Proposed “Core” Phenotype Results in behaviors that are excessive or inappropriate for age and/or context, and the expression of aggressive behaviors in situations that elicit frustration; these are hallmark features of this phenotype that must be present most days for at least 12 months. Differs from Narrow-to-Broad Spectrum by eliminating episode duration criteria, and by specifying daily, abrupt mood fluctuations, as well as poor modulation of drive states as cardinal features. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

An Alternate: Papolos’ Proposed “Core” Phenotype PLUS Poor modulation of at least one of four drives that is excessive for age and/or context: 1.aggressive (fight/flight*), critical, sarcastic, demanding, oppositional, overbearing “bossiness,” easily enraged, prone to violent outbursts), and/or self-directed aggression (head-banging, skin-picking, cutting, suicide attempt), 2. sexual, appetitive (cravings) developmentally premature and intense sexual feelings and behaviors 3. Acquisition (have to have wanted item NOW). appetite dysregulation (binge eating, purging, anorexia) and poor control over acquisitive impulses (buying excessively, hoarding). Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Papolos’ Proposed “Core” Phenotype 4. Sleep/wake disturbances: Sleep discontinuity: Initial insomnia, middle insomnia, early morning awakening, hypersomnia. Sleep arousal disorders: REM dysregulation, night terrors/nightmares (often containing images of gore and mutilation, and themes of pursuit, bodily threat and parental abandonment), bruxism, sleep walking, enuresis, confusional arousal. Sleep/wake reversals: Tendency toward periodic lengthening or shortening of sleep duration associated with day-for-night reversals, often dependent of circannual changes in zeitgebers (external time cues), including light/dark duration, changes in temperature, and social zeitgebers (established routines, work shifts, etc.). Executive function deficits. Deficient habituation to sensory and environmental stimuli. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Of Interest: Non-specific Features Parents Report (not DSM4 Criteria) Irritability – Chronic for many children, a cardinal feature that causes others to “walk on eggshells” around them. Defiance of authority (typically related to grandiose delusion of believing they are right). Easily overwhelmed by emotions. Explosive reactions, often lengthy, with slow recovery, and often destructive. Can be triggered by “no.” Strong and frequent cravings, often for carbohydrates and/or sweets. Self-regulation difficulties (different from Tourette’s dysregulation). Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Non-Specific Features (cont.) Clingy/separation anxiety-extraordinarily so. Difficulty settling for sleep; sleep may be erratic. Poor school attendance. Anxiety and physical complaints. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Additional Facts & Feartures Adolescents and adults may experience periods of complete wellness/recovery between episodes or cycles; children are not as likely to do so, especially when there are no distinct episodes. Geller’s longitudinal study of 6-17 year olds with JBPD: 58/89 (65%) recovered (8 consecutive weeks without mania or hypomania). But then, the relapse (2 consecutive weeks of mania after a period of recovery) occurred for 32/58 (55%) approx. 29 weeks post recovery on average. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Kindling Effect Once the illness emerges, episodes tend to recur and increase in severity, especially without treatment. Referred to as kindling effect. Traumatic event or loss may trigger first episode of depression or mania. Later episodes may occur independently of obvious stressors, although they may worsen with stress. Once the illness emerges, episodes tend to recur and increase in severity, especially without treatment. Referred to as kindling effect, wherein successive episodes cause biological changes at genetic level that over time cause more frequent and spontaneous episodes. This is why early intervention is important. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Treatment Response Responds quickly to mood stabilizers, but this does not solve the problem. Mood and behavioral dysregulation, like a seizure, is the outward, observable manifestation of internal Central Nervous System pathology. Bipolar is not a simple mood disorder, it is a complex neurological condition with labile mood a prominent, but not only feature that handicaps. Responds quickly to mood stabilizers (see Appendix for Bipolar medications), but this does not mean the work is over. Mood and behavioral dysregulation, like a seizure, is the outward, observable manifestation of internal CNS pathology, like a seizure is outward manifestation. Both can be brought under control with similar medications, but this addresses only the “tip of the iceberg,” as the conditions include more than outward/observable features. Bipolar is more than just a mood disorder; it is a complex neurological condition, of which labile mood is a prominent feature, but not the only feature that handicaps. Medications used for children with Bipolar Disorder are used largely “off label.” Algorithms for prescribing are pretty straightforward for adults, but not for kids, because most require multiple medications, which requires: targeting symptom, and add medication for it; assessing symptom improvement; adjust or change just one medication at a time; maximize dose before discontinuing or adding additional medication; monitor side effects; discontinue drug of least benefit. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Geller’s 2005 Longitudinal Study Children with JBPD are twice as likely to recover when living in context of intact, nuclear family; Four times as likely to relapse in the context of low maternal warmth; these children demonstrate significant levels of low mother-child warmth, high mother-child tension, high father-child tension, and peer problems. Ups and Downs of Serving Students with Bipolar Disorder, 2008

Additional Facts & Features (cont.) Co-occurring ADHD and Bipolar appears to be a genetically transmitted form associated with earlier onset and more severe features. Regular “social rhythms” and routines (esp. sleep/wake) may reduce risk. Much higher probability when one or both parents have BPD. Recovery more likely in context of nuclear family; and with “warmth” and reduced levels of tension in parent-child interactions. Co-occurring ADHD and Bipolar in childhood appears to be a genetically transmitted form with earlier onset and more severe features. Regular “social rhythms” and routines (esp. sleep/wake) may reduce risk. Much higher probability when one or both parents have BPD. More likely to recover in context of nuclear family; when there is “warmth” and reduced levels of tension in parent-child interactions. . * Geller’s 2005 longitudinal study (refer to previous slide) also found the following: Children with JBPD are twice as likely to recover when living in context of intact, nuclear family; four times as likely to relapse in the context of low maternal warmth; and demonstrate significant levels of low mother-child warmth, high mother-child tension, high father-child tension, and peer problems. * Gene Penetrance – defective gene sequences that cause a disorder grow longer each time they are inherited, increasing likelihood offspring will inherit the disorder. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Additional Facts & Features (cont.) Incidence rate is 3-6% equally distributed across both genders. Many teens with untreated Bipolar Disorder abuse alcohol and drugs Adolescents who appear normal until puberty, then experience sudden onset are thought to be especially vulnerable to substance abuse. Children with hypomania are very likely to develop mania; but are also likely to recover. Creativity and humor are common features. Incidence rate is 3-6% equally distributed across both genders. Many teens with untreated Bipolar Disorder abuse alcohol and drugs. Adolescents who appear normal until puberty then experience sudden onset of symptoms are thought to be especially vulnerable to substance abuse. Children with hypomania are very likely to develop mania; but are also likely to recover. Creativity and humor are common features. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Additional Facts & Features (cont.) Ethnic difference: African-American youths more likely to present with psychotic symptoms, and white youth present delusions (Patel et al, 2005). Culture of the clinician colors diagnosis of mania. Incidence of obesity is 68% (all ages). Borderline Personality Disorder is a common co-morbidity. Ethnic difference: African-American youths more likely to present with psychotic symptoms, and white youth present delusions (Patel et al, 2005). Culture of clinician colors diagnosis of mania. Incidence of obesity is 68% (all ages). Borderline Personality Disorder is a common co-morbidity. Patel, DelBello, Strakowski (2006). Ethnic differences in symptom presentation of youths with bipolar disorder, Bipolar Disorders 8 (1) , 95–99 doi:10.1111/j.1399-5618.2006.00279.x  at www.blackwell-synergy.com/doi/abs/10.1111/j.1399-5618.2006.00279.x?cookieSet=1&journalCode=bdi Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Borderline Adolescents Legally Sound, Effective Guidelines for Responding to Student Threats of Violence 2007 Borderline Adolescents Psychotic-like behaviors (drug-induced psychosis, quasi-delusional statements). Unstable moods (anxiety, inability to be alone, anger, depression and suicidal behavior). Self-damaging behavior (drug use, recklessness, wrist cutting, sexual promiscuity, shoplifting, eating disorders). Unstable relationships (idealization and devaluation, splitting, manipulativeness). Identity problems (uncertainty about self, feel like different persons; problems with gender identity, values, loyalty, career goals; sense of emptiness and unreality). Ups and Downs of Serving Students with Bipolar Disorder, 2008 www.dianabrowningwright.com

Medication Side Effects Medications for treating JBPD may cause further complications, report if observed Impaired memory Reduced organizational skills Altered concentration Complications—physician will monitor: Nausea, diabetes, weight gain, liver toxicity, poly-cystic ovary disease In addition to the disabling symptoms of JBPD, medications for treating it have side effects that cause further complications: Impaired memory Reduced organizational skills Altered concentration Some have been known to cause nausea, diabetes, weight gain, liver toxicity, poly-cystic ovary disease. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Importance of Early & Accurate Diagnosis Prevent “kindling effect.” Prevent suicide and substance abuse. 33% attempt suicide within the first 6 years after onset; 15-19% succeed. 1% of youth attempt suicide by age 18, 22% with major depression and 44% with JBPD With co-morbid PDD, can prevent further impairment of functioning caused by JBPD. Stabilizing mood with medication and providing evidence-based psycho-social interventions can prevent: Kindling effect Suicide and substance abuse. For students with co-morbid disorders such as a PDD, can prevent further impairment of functioning caused by JBPD. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Characteristics of Suicide Attempts DATA ON SUICIDE - - JBPD CAN BE LETHAL: 33% attempt suicide (across all ages). Older children more vulnerable, and especially as depressive episodes subside. 11% had most extreme degree of intent, while 16% had moderate-to-high probability. JBPD CAN BE A LETHAL ILLNESS: 33% attempt suicide. Older children more vulnerable. More vulnerable as depressive episodes subside. Recall that mania mixed with depression causes risky behaviors, in general. 11% had most extreme degree of intent. 16% had moderate-to-high probability of lethality based on method, probability of rescue, and amount of medical treatment needed. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

PREDICTORS OF SUICIDE ATTEMPTS Mixed Episodes. Psychosis. Physical/Sexual Abuse. History of Psychiatric Hospitalization. Substance Use Disorder. Co-morbid Panic Disorder. Less likely if child/adolescent has ADHD and SIBs. PREDICTORS OF SUICIDE ATTEMPTS Mixed Episodes. Psychosis. Physical/Sexual Abuse. History of Psychiatric Hospitalization. Substance Use Disorder. Co-morbid Panic Disorder. Less likely if child/adolescent has ADHD and SIBs. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Features That Impact School Performance Difficulties recognizing facial expressions of emotions. Easily overwhelmed by emotions. Impulse control difficulties and poor judgment result in risky behaviors. Can appear defiant. AT THIS POINT, WE SHIFT TO HOW JBPD IMPACTS SCHOOL PERFORMANCE, AND WHAT SCHOOLS SHOULD DO TO HELP. Difficulties recognizing facial expressions of emotions. Easily overwhelmed by emotions (their own and others). Impulse control difficulties and poor judgment result in risky behaviors (substance abuse, unsafe sex, etc.). Can appear defiant, but due to grandiose belief that they are right. Teachers are initially surprised by students’ (whose Bipolar condition is yet undiagnosed) challenging their authority. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Implications for School (cont.) Impose rules on peers that they may have difficulty following. Difficulties with concentration and sustained attention. Disorganization; reduced task completion. Handwriting difficulties. Psychotic delusions. IMPACT ON SCHOOL PERFORMANCE (CONTINUED) Impose rules on peers that they may have difficulty following (also related grandiose belief that they are right). Difficulties with concentration and sustained attention. Disorganization and difficulty completing tasks Handwriting difficulties. Psychotic delusions. More likely for adolescents. Can cause claims of grandeur that peers find very odd and disruptive. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Verbal Memory Impairment Verbal memory impairment found with Bipolar Disorder: Recall impaired (high “forgetting” rates). Recognition impaired due to poor encoding rather than rapid forgetting. May contribute to impaired daily functioning. Reported in Psych Res 2006; 142: 139-150 Bipolar disorder and Unipolar Major Depression associated with similar degrees of verbal memory impairment on CVLT-2. Medial temporal dysfunction underlies both. Recall impaired. Recognition impaired due to poor encoding rather than rapid forgetting. May contribute to impaired daily functioning. Reported in Psych Res 2006; 142: 139-150 Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Assessment Best Practices Parent rating scales most accurate. Look for cognitive and neuropsychological impairments associated with JBPD. Rule out adaptive performance deficit associated with depression. Differentiate from ADHD, Asperger’s, ODD/CD. ASSESSMENT BEST PRACTICES Parent rating scales are more accurate than teacher’s, student’s, or combination of teacher’s/parent’s/student’s. Recall that behaviors are more problematic at home, so parent ratings more likely to capture the severity. Also recall that one or both parents likely to have BPD; which can either enhance parent awareness of indicators; or denial of symptoms, hoping they have not passed Bipolar Disorder on to their child. In cognitive assessment, look for known neuropsychological impairments associated with JBPD. In adaptive behaviors assessment, rule out performance deficit (versus skill deficit) associated with depression. Differentiate from ADHD, Asperger’s, ODD/CD; or, assess whether these are comorbid disorders (see next slide). Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Co-morbid Conditions More Common: ADHD (60-80%); ODD (70-75%); Substance Abuse (40-50%); Anxiety (35-40%); OCD. Less Common But Significant: PDD/ASD (21% meet criteria for JBPD); Tourette’s. Co-occurring ADHD and Bipolar in childhood appears to be a genetically transmitted form with earlier onset and more severe features. Differentiate from, or determine whether it is a co-morbid condition. More Common: ADHD (60-80%); ODD (70-75%); Substance Abuse (40-50%); Anxiety (35-40%); OCD. Less Common: PDD (Pervasive Developmental Disorders or Autism Spectrum Disorders – of which 21% meet criteria for JBPD)); Tourette’s Syndrome. Many parents of students with ASDs have Bipolar. “Meltdowns” are described by parents of students with ASDs and JBPD. Co-occurring ADHD and Bipolar in childhood appears to be a genetically transmitted form with earlier onset and more severe features. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Differentiating ADHD from JBPD SIMILARITIES: Talkative, Distractible, Overly Active KEY DIFFERENCES: [delineated in Handout 1] Very common for co-occurring conditions to be diagnosed first, causing long latencies between emergence of JBPD symptoms and a clinical diagnosis. SIMILARITIES: Talkative, Distractible, Overly Active KEY DIFFERENCES [delineated in handout] Very common for co-occurring conditions to be diagnosed first, causing long latencies between emergence of JBPD symptoms and a clinical diagnosis. ADHD and Major Depression are examples; children with both are at risk for JBPD, especially very-early-onset Major Depression. Best practice is to treat JBPD with mood stabilizers before treating depression with antidepressants or ADHD with stimulants; this is because these medications can cause “manic induction” (switching from unipolar depression to bipolar); increased cycling; psychosis; and violent or suicidal ideation. EXAMPLES IN HANDOUTS: DIFFERENTIATING BIPOLAR DISORDER FROM ADHD AND NONVERBAL LEARNING DISORDER IN A 10 YEAR OLD MALE STUDENT FINDINGS AND RECOMMENDATIONS FROM ASSESSMENT OF STUDENT WITH ASPERGER’S DISORDER AND CO-MORBID JUVENILE BIPOLAR DISORDER Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Co-morbid PDD Children with PDDs are 2 to 6 times more likely to develop co-morbid psychiatric condition. Possible genetic link between Bipolar and PDD. Mood disorders can further impair PDD. More mood disorders in children with NVLD, which is similar to Asperger’s. Children with PDDs are 2 to 6 times more likely to develop co-morbid psychiatric condition; and they often go untreated in spite of frequent medical attention. There is a possible genetic link between Bipolar Disorder and PDDs. Early identification of mood disorders is crucial to reduce problematic behaviors than can further impair functioning. Rourke found significantly more mood disorders in children with NVLD, which is similar to, or a variant of Asperger’s. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Co-morbid PDD (cont.) Persons with MR and DD have different clinical presentations of mood disorder due to: Intellectual distortion Psychosocial masking Cognitive disintegration Baseline exaggeration Sovner (1986) found that persons with mental retardation and developmental disabilities have different clinical presentations of mood disorder symptoms due to: Intellectual distortion - limited ability to label or accurately describe complicated internal experiences. Psychosocial masking - mood disorder further impoverishes reduced social skills. Cognitive disintegration - affective episodes impair information processing, causing patient to appear more mood-disordered or psychotic. Baseline exaggeration – affective disorder exacerbates preexisting cognitive deficits and maladaptive behaviors, making it difficult to recognize that increased symptoms are due to psychiatric illness rather than the developmental disorder. The factors impact accuracy of findings by interviewing persons with MR and DD for DSM4 criteria/symptoms. Sovner proposed a better approach (next slide). Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Better Indicators of Mood Disorder for MR/DD Students Depression: Increased self-injurious behaviors, apathy, loss of adaptive skills (e.g., onset of urinary incontinence). Mania: Increased verbalization (rate or frequency), overactivity, distractibility, noncompliance. SOVNER (1986) RECOMMENDED USE OF THE FOLLOWING INDICATORS OF CO-MORBID MOOD DISORDER FOR STUDENTS WITH MENTAL RETARDATION AND OTHER DEVELOPMENTAL DISABILITIES: Depression: Increased self-injurious behaviors, apathy, loss of adaptive skills (e.g., onset of urinary incontinence). Mania: Increased verbalization (rate or frequency), overactivity, distractibility, noncompliance. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 If We Suspect Bipolar? Conundrum: Refer to physician “for diagnostic purposes”? And/or Provide data to assist diagnoses. NIMH publishes screening instruments for symptoms of Bipolar Disorder, which are available at: www.nimh.nih.gov/publicat/manic.cfm. Structured Interview for Childhood Affective Disorders (Kiddie SADS) available at: www.wpic.pitt.edu/ksads/default.htm. Papolos has published a screening instrument, the Child Bipolar Questionnaire (CBQ), as well as a follow-up diagnostic interview protocol; both areavailable at: www.jbrf.org/library.   Ups and Downs of Serving Students with Bipolar Disorder, 2008

False + and False - ? YES Co-morbitity Possible? YES Post Traumatic Stress Disorder Reactive Attachment Disorder Intermittent Rage Disorder Literature describes several examples, false +, - ____________________________ Autism Spectrum Disorders AD/HD Psychotic Episode Literature describes False + and false -, Co-morbidity Ups and Downs of Serving Students with Bipolar Disorder, 2008

BEHAVIORAL RESPONSE RATINGS FOR PHYSICIAN STUDENT: DATE: Complains of fatigue. 1 2 3 4 5 Never Infrequent Some Often Frequent Moods change quickly. 1 2 3 4 5 Easily irritated. 1 2 3 4 5 Never Infrequent Some Often Frequent Defiant or challenges adults. Completes assigned tasks. 1 2 3 4 5 Complies with redirection plan. 1 2 3 4 5 . Collaboration with prescribing physician is critical. Mood stabilizers are often a primary component of treatment; after mood is stabilized, may add antidepressant or ADHD medication. Combinations of medications are common, and requires adjusting as new medications are added. Efforts at objectively measuring responses to medication changes are crucial, but not always done. This form is printed in a larger format in the handouts section, and can be duplicated for your use in collaborating with physician. The dimensions or behaviors listed are target symptoms being addressed through medication changes; they can be changed as needed. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Should Children Be Taking Mood Stabilizing Drugs? Bipolar medications reduce brain injury from the disorder HYPERCORTISOLEMIA—damages the brain With Major Depression and Bipolar, increased levels of Cortisol (Hyper-cortisolemia) cause damage to various areas of the brain. For example, it causes structural damage to the hippocampus, which results in poor regulation of emotions as well as learning disabilities. Some medications reduce Cortisol toxicity by turning on a naturally occurring protective protein, Brain-derived Neurotropic Factor (BDNF), which helps repair nerve cells. BDNF latches onto Cortisol molecules, rendering them less toxic.   Ups and Downs of Serving Students with Bipolar Disorder, 2008

Should Children Be Taking Mood Stabilizing Drugs? Bipolar medications reduce brain injury from the disorder HYPERCORTISOLEMIA—damages the brain (cont.) The gene that turns on BDNF is disabled when an individual has Bipolar or Major Depression. Lithium and antidepressants are able to turn on BDNF, reducing the likelihood of brain injury caused by Cortisol.   Ups and Downs of Serving Students with Bipolar Disorder, 2008 58

Should Children Be Taking Mood Stabilizing Drugs? Bipolar medications reduce brain injury from the disorder   UNREGULATED APOPTOSIS—damages the brain Lithium and other mood stabilizers prevents unregulated Apoptosis (neural pruning). This is a naturally occurring type of “neural pruning” is turned on genetically at specific stages of development to optimize neural functioning. Bipolar affects the gene that switches it off, resulting in unregulated pruning or loss of neural cells. Ups and Downs of Serving Students with Bipolar Disorder, 2008

But Do They All Need IEPs? Core question: Do the symptoms come under control and remain under control with medical intervention? Yes? Eligibility would then be in question, effective differentiated instruction in the least restrictive environment may suffice. Ups and Downs of Serving Students with Bipolar Disorder, 2008

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Do They All Need IEPs? Two-prong eligibility determination applies 1. “Child Find” for Handicapping Condition LD or, ED or, OHI ? TBI (co morbidity? head injury occurred during dangerous behaviors?) 2. If criterion is met, does the student need “specialized instruction” due to the unique nature of the disability? Yes? IEP description of specialized instruction Ups and Downs of Serving Students with Bipolar Disorder, 2008

Famous People Reported to Have Bipolar Disorder: Winston Churchill Abraham Lincoln Theodore Roosevelt Virginia Woolf Ernest Hemingway Tolstoy Schumann Goethe Handel Patty Duke Did they need specialized instruction? Examples of creativity and achievement in persons with Bipolar Disorder. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

LD: Suggestions for Validity Assess the processing areas most commonly reported for JBPD. Do NOT assess cognitive or adaptive functioning when in a depressed state; be cautious when in a manic state. Carefully assess academics, use short sessions, structured with “winning” prizes. Ups and Downs of Serving Students with Bipolar Disorder, 2008

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Neuropsychological Impairments Persist After Mood Is Stabilized: May be a “processing disorder” in LD determination Verbal and visual memory Visual-motor skills for writing Planning and problem-solving Attention & Executive functions Misinterpretation of facial expressions (often result in attribution errors-hostile intent from neutral stimuli) In addition to fluctuating/unstable affective states, Bipolar involves a constellation of symptoms including impulsivity, neuro-vegetative changes (sleep, appetite, energy), and specific cognitive processing deficits in the areas bulleted, that persist even after mood is stabilized: Verbal memory Sustained attention Executive functions Visual memory Visual-motor skills for writing Planning and problem-solving; some claims of particular difficulty with nonverbal problem solving. Misinterpretation of facial expressions Inhibition of pre-potent responses (e.g., Stroop Color Word Interference Tasks) No single, localized area affected. Rather, Bipolar affects multiple areas and the pathways connecting them (refer to handout on Neuropsychological Implications). Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Neuropsychological Impairments Persist After Mood Is Stabilized: Executive functioning deficits demonstrated in assessment Difficulty inhibiting previously learned or “intuitive” responses when a new rule is introduced (pre-potent responses). Decreased ability to adapt to changing rules or contingencies, ability to switch between multiple sources in problem solving (cognitive flexibility deficits. Planning and problem-solving (Examine project time line skills, word problems in math, etc. In addition to fluctuating/unstable affective states, Bipolar involves a constellation of symptoms including impulsivity, neuro-vegetative changes (sleep, appetite, energy), and specific cognitive processing deficits in the areas bulleted, that persist even after mood is stabilized: Verbal memory Sustained attention Executive functions Visual memory Visual-motor skills for writing Planning and problem-solving; some claims of particular difficulty with nonverbal problem solving. Misinterpretation of facial expressions Inhibition of pre-potent responses (e.g., Stroop Color Word Interference Tasks) No single, localized area affected. Rather, Bipolar affects multiple areas and the pathways connecting them (refer to handout on Neuropsychological Implications). Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

ED Eligibility? Suggestions …a condition (BP) exhibiting one or more of the following characteristics over a long period of time (6 months or more?) and to a marked degree (well beyond typical children) that adversely affects a child’s educational performance (look at class performance, achievement of educational and social/emotional milestones that has not responded to RtI: including well designed behavior and accommodation plans, implemented with fidelity) Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

ED, A through E, Requires One or More An inability to learn that cannot be explained by intellectual, sensory or health factors. (manic/depressed states ?) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers. (chronic irritability?) Inappropriate types of behavior or feelings under normal circumstances. (fears? High anxiety? Attribution theory deficits-hostile intentions from neutral stimuli?) Ups and Downs of Serving Students with Bipolar Disorder, 2008

Understanding the Effects of Misinterpretation of Facial Expressions Students with bipolar disorder tend to misinterpret neutral facial expressions as hostile. Over-identification of anger on neutral faces can stimulate aggression and irritability, which impacts social interactions. Reported in an advance online publication by the Proceedings of the National Academy of Sciences Proc Natl Acad Sci 2006; 103: Advance online publication Students with bipolar disorder tend to misinterpret neutral facial expressions as hostile. Over-identification of anger on neutral faces can stimulate aggression and irritability, which impacts social interactions. Associated with increased activation in the amygdala and ventral striatum. Reported in an advance online publication by the Proceedings of the National Academy of Sciences Proc Natl Acad Sci 2006; 103: Advance online publication Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 ED, A thru E (cont.) D. A general pervasive mood of unhappiness or depression (check period of time?) E. A tendency to develop physical symptoms or fears associated with personal or school problems (state fluctuation anxieties and fears; psychosomatic complaints; on going separation anxiety?) . Ups and Downs of Serving Students with Bipolar Disorder, 2008

ED Additional Criteria ii. The term includes schizophrenia. (Psychosis sometimes associated?) The term does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance. (Consider group affiliations, but assess for all items above to rule out ED eligibility. It is possible to be gang affiliated AND BP !) Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 OHI or ED? OHI limits strength, vitality, energy, and cognitive functions, impacting alertness to instruction. Some claim EBD programs worsen JBPD. Biased view? EBD Quality Program Components are appropriate. OHI signifies limited strength, vitality, or alertness, including altered response to environmental stimuli, that impacts alertness to instruction. Energy levels as well as several cognitive functions are impacted. Some claim that programs for EBD worsen this condition. Is this due to biased view of ED? Parents are becoming increasingly aware of the dismal data on demographics and outcomes for students with EBD. Exception: Kindergarten student with not problems at all at school; significant problems at home and being treated with mood stabilizers; IEP Team opted for OHI eligibility basis since criteria for ED not met at school. EBD Quality Program Components are appropriate (see next slide). Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 EBD Quality Program Indicators (see article at ccbd.net/beyondbehavior Spring 2003) Environmental Management Affective Education Behavior Management Internalize Affective Education Engaging, Quality Instruction Connect Instruction to Adult Living Environmental Management: organization of resources and physical layout; emotional climate; scheduling and systems for communicating expectations for learning and behavior. Affective Education: social skills training as well as disability awareness. Refer to “The Storm in My Brain,” a social story for children with JBPD available at www.bpkids.org. Behavior management: individual, classroom and school wide systems that teach and encourage appropriate behaviors. Activities that help individualize and internalize instruction in affective education. Engaging, quality academic instruction. Connecting academic instruction with transition to career and adult living. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

EBD Quality Program Indicators Strongly recommended additions: CONSTANT SUPERVISION while symptomatic, especially when prone to destructive rage. Avoid struggles for control. Collaboration with prescribing physician. Appropriate accommodations. Strongly recommended additions to this list: CONSTANT SUPERVISION while symptomatic, especially when prone to destructive rage. Avoid struggles for control. Collaboration with prescribing physician. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 OHI vs. ED Limited strength, vitality or alertness, including altered responses to environmental stimuli, that impacts alertness to instruction. Energy levels AND other cognitive functions are impacted by JBPD, BUT … … JBPD primarily impacts mood and behavior. JBPD is a mental illness. Services and Placement are the real issues, not category. Ups and Downs of Serving Students with Bipolar Disorder, 2008

Ups and Downs of Serving Students with Bipolar Disorder, 2008 504? A condition. Substantially affecting a major life activity. Learning Results in a need for accommodations. If “specialized instruction” and related services are required, special education will be delivered under an IEP (funding). Ups and Downs of Serving Students with Bipolar Disorder, 2008

Case Management for Bipolar Disorder Share strategies that work, and don’t work with all teachers and staff Make safety a top priority. Assure consistent accommodations across all settings (document and share). Collaborate with home and physician on response to medication changes. COLLABORATION: SCHOOL PSYCHOLOGIST’S ROLE AS CASE MANAGER Strategies that work should be practiced across all settings. Safety is the top priority; all other collaborative efforts are useless unless student is safe from harming self or others. Young children (3-6 years) are at risk for hurting others, even though they fear their rage. Older children (6-11) are at risk for hurting themselves. Collaboration should establish safety precautions and routines as a first step. Consistent provision of accommodations by adults working with student - - across all settings. Document what works for the student, and share with IEP Team. Response to medication changes (see next slide). FAST FACTS (refer to handout) was developed as a collaboration tool. Refer to the handout entitled FAST FACTS FOR PLANNIN INSTRUCTION. NOTE: EDUCATIONAL PRIORITIES section has been added at the top of the form since this document was developed, and lists critical needs for educational programming. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 IEP Content Academic goals aligned to state standards. Determine any Supplementary Aids and Supports. 1. “Special Factors” consideration. Does behavior “Impede Learning of Student or Peers?” Positive Behavior Supports Can include a function-based behavior plan 2. Accommodation Plan and Behavior Plan to Maintain LRE. Determine any Related Services to benefit from special education. Ups and Downs of Serving Students with Bipolar Disorder, 2008

Rage Is Cardinal Feature Stories abound: Stab, bite others, usually mother. Parents become fearful of them; younger siblings at risk of harm. Parents lock doors to prevent raging child eloping and doing harm; keep child away from knives, sharp objects, even pencils. Sometimes triggered by antidepressants or stimulants. Child FEARFUL OF HIS/HER RAGE. RAGE IS CARDINAL FEATURE Stab, bit others, usually mother. Parents become fearful of them; younger siblings at risk of harm. Parents lock doors to prevent raging child eloping and doing harm; keep child away from knives, sharp objects, even pencils. Sometimes triggered by antidepressants or stimulants. Child FEARFUL OF HIS/HER RAGE. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Reacting to Challenging Behaviors Help student channel manic energy productively. Use non-violent crisis prevention verbal de-escalation techniques. In handling defiance, recognize it is often rooted in manic grandiosity, which can be delusional. MANAGING CHALLENGING BEHAVIORS Help student channel manic energy productively. Use non-violent crisis prevention verbal de-escalation techniques. In handling defiance, recognize it is often rooted in manic grandiosity, which can be delusional. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Accommoations Easy access to nurse, counselor, etc. Cues and prompts Organization strategies Consistent schedule Visual checklists Flexible grading Safe haven Easy access to nurse for medication and to deal with medication side effects. Cues and prompts to assist concentration, retrieval, memory. Organization strategies for remembering assignments, such as agenda and second set of books for home. Consistent schedule; prior notice of changes or transitions. Visual checklists of required steps for problem solving. Flexible grading, expectations, and possibly modifications for assignments when energy levels fluctuate. Safe haven when emotions are overwhelming; access to counselor. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Accommoations (cont.) Extra time or individual assistance Modify demands that elicit anxiety Modify P.E. instruction Carefully select courses Schedule challenging tasks during times student performs optimally Extra time or individual assistance when concentration and organization are reduced or unreliable. Modify demands that elicit anxiety. Modify P.E. instruction or excuse absence when energy level takes downturn. Most students will NOT be in APE; so spell this out in IEP, perhaps by school nurse as health accommodation. Carefully select courses, even if student is cognitively able. Schedule challenging tasks during times student performs optimally. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Behavior Supports Individual, classroom and school wide systems that teach and encourage appropriate behaviors. Individual interventions to monitor antecedents of escalation to rage. Individual, classroom and school wide systems that teach and encourage appropriate behaviors. THREE EXAMPLES OF INDIVIDUAL BEHAVIOR MANAGEMENT PLANS ARE INCLUDED IN HANDOUTS : BEHAVIOR SUPPORTS for 12 YEAR OLD MIDDLE SCHOOL STUDENT WITH BIPOLAR DISORDERFAST; includes FACTS FOR PLANNING INSTRUCTION RECOMMENDATIONS FOR PROCESSING DIFFICULTIES for a 15 YEAR OLD FEMALE STUDENT WITH BIPOLAR DISORDER STRATEGIES FOR IMPROVING SELF-MONITORING AND IMPULSIVITY for A 14 YEAR OLD STUDENT WITH BIPOLAR DISORDER AND CO-MORBID ADHD Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Related Services as Needed to Benefit from Special Education Consider “Related Services” to benefit from the special education Cognitive Behavior Therapy to address Internalizing behavior Externalizing behavior Ups and Downs of Serving Students with Bipolar Disorder, 2008

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Evidence-based Psychotherapy Approaches (Consider for Related Services) Cognitive Behavioral Therapy Affective Education Disability awareness and social skills training Social Rhythm Therapy-- Frank (2005) Lack of stable sleep patterns increased social problems Family Therapy See Handouts for description See websites See: Empirically-Supported Interventions in School Mental Health EVIDENCED-BASED PSYCHOTHERAPY/COUNSELING SERVICES Cognitive Behavioral Therapy (CBT) Affective Education: Also known as Patient Education (Medical/Psychiatric Model); includes disability awareness and social skills training. Social Rhythm Therapy: Strategies to regularize daily routines and sleep schedules, which can stabilize mood; and strategies to stabilize interpersonal relationships. Frank (2005) found two factors that impact the course of Bipolar Illness: support for maintaining consistent daily routines, especially sleep-wake cycles; supports for maintaining social relationships. Sleep is critical for the production of neurotransmitters that help regulate mood. Family Therapy: Emphasis on reducing the tremendous level of stress caused by the illness; and grieving or mourning the loss of the healthy child (more common in families who have experience with the disorder). CAUTION: Forcing a child into therapy will negatively impact outcome future receptivity to treatment. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Parent Support Behaviors at home are often more intense and problematic than at school. Parents are likely to have Bipolar Disorder, given strong inheritability, and this can complicate grieving “loss of healthy child.” Recovery more likely in an intact nuclear family; additional factors of parental warmth, low tension between parent and child, and flexibility also affect outcome. PARENT SUPPORT Behaviors at home are often more intense and problematic than at school, because affect and associated behaviors are more intense in close interpersonal relationships. Parents are likely to have Bipolar Disorder, given strong inheritability; while “inside knowledge” of this disorder may be helpful, it also increases awareness of disabling implications, and this can result in earlier and more intense grieving. Recovery more likely in an intact nuclear family; additional factors of parental warmth, low tension between parent and child, and flexibility also affect outcome. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

Dx: Take-home Messages Juvenile BP dx is on the rise. Criterion is in flux. Adult and Juvenile phenotype differ depending on emotional response to heightened arousal changed by the disorder. BP is not simply a mood disorder. Ups and Downs of Serving Students with Bipolar Disorder, 2008

Dx: Take-home Messages There are false positive and false negative dx. Research is demonstrating BP is one of the most heritable of psychiatric disorders. Comorbity can occur with other disorders compounding the service needs. Medication does not fully address the problem. Ups and Downs of Serving Students with Bipolar Disorder, 2008

Eligibility: Take-home Messages BP dx triggers a “child find” obligation-service needs will vary. Most with BP will require accommodations for mood effects on learning. Many with BP will require behavior support. Many with BP will require IEP or 504. Some with BP will require no “specialized instruction” and therefore, no IEP. Some with BP will require neither IEP nor 504. Ups and Downs of Serving Students with Bipolar Disorder, 2008

Services: Take-home Message All require adult understanding, supervision and a disability perspective. Most require accommodation plans. Many to most require behavior plans. Most with special education eligibility benefit from related services. For All--Safety is a primary concern. Beware increased probability of risky behavior, including suicide risk. Ups and Downs of Serving Students with Bipolar Disorder, 2008

Ups and Downs of Serving Students with Bipolar Disorder, 2008 Online Resources Bipolar and Juvenile BiPolar Disorder: www.bpkids.org www.bipolarchild.com www.bpchildren.com www.jbrf.org www.bpinfo.net MENTAL HEALTH IN SCHOOLS: see handouts www.dmh.ca.gov/mhsa ONLINE RESOURCES: Web sites published by various organizations that support individuals with Bipolar Disorder, especially families of children with JBPD; and offer information useful to instructional teams. Ups and Downs of Serving Students with Bipolar Disorder, 2008 Ron Russell, Ph.D./DIAGNOSTIC CENTER-SOUTH

A.R.M.S. JBPD Summary--HANDLE WITH CARE ASSESS- needs Legally Sound, Effective Guidelines for Responding to Student Threats of Violence JBPD Summary--HANDLE WITH CARE 2007 A.R.M.S. REFER-therapy & information sources MONITOR-Safety ASSESS- needs SUPPORT-behavior & accommodations THANK YOU For Your Time Today! www.dianabrowningwright.com