Bipolar Disorder:

Educational Implications
for Secondary Students
Bipolar disorder (BD) is a neurobiological disorder with cycling periods of mania and
depression that was historically recognized as occurring only in adulthood but can now
be diagnosed in children. lthough contro!ersy continues regarding the de"nition and
diagnosis of BD in children# it is chronic and can cause ma$or disruption in schooling for
children and adolescents.
%idely accepted estimates of the pre!alence of BD in adults range from &'()'
(merican *sychiatric ssociation
+*,# )---)# and incidence is
similar in adolescents (%olf . %agner#
)--/). BD is considered one of the most
heritable mental illnesses: children
of parents with BD are more li0ely to
de!elop a mood disorder. 1ther ris0
factors include rapid onset of depressi!e
symptoms with psychotic features
(e.g.# delusions)# family history of mood
depressi!e episode consists of loss
of interest in acti!ities or a low mood.
student ha!ing a depressi!e episode
may no longer be interested in a fa!orite
sub$ect and may show a signi"cant loss of
energy. 2e or she may be an3ious# argumentati!e#
or aggressi!e with teachers or
friends. 4eelings of worthlessness or guilt
and persistent thoughts of death or suicide
resulting in an inability to concentrate
also may be present (*# )---).
5riteria for the length of manic and
depressi!e episodes in adults are speci"c
(*# )---)6 the duration in children
and adolescents# howe!er# is not clear.
dolescents who ha!e BD may !acillate
between depressi!e and manic symptoms
on a wee0ly# daily# or hourly basis.
7his rapid cycling is a hallmar0 symptom
of BD in children and adolescents
(%olf . %agner# )--/).
8i3ed episodes cause e3treme
dysregulation of mood and energy. 7he
student might appear enraged# an3ious#
and upset all at once. 4re9uent mood
changes may produce se!ere irritability#
serious temper outbursts# rage reactions#
and beha!ior that is di:cult to
manage. Because of the cyclical nature
of the disorder# students ha!e periods
of calm during which their problems
seem miniscule and may not be apparent
in the classroom. It is important to note
patterns in students; beha!ior to better
predict when erratic beha!ior may occur.
5oe3isting Disorders
BD commonly o!erlaps with other
psychiatric disorders. Biederman# 8ic0#
and 4araone ()--<) found that =>' of
children with BD also had attention
de"cit?hyperacti!ity disorder (D2D)#
although only )-' of children with
D2D met criteria for BD. Symptoms
of grandiosity# ele!ated mood# @ight
of ideas# and decreased need for sleep
distinguish BD from D2D (*a!uluri#
Birmaher# . Aaylor# )--B). 7he combination
of D2D with BD often results
in se!ere impairment with increased
psychotic symptoms# need for hospitalization#
and school failure (%olf .
%agner# )--/) in addition to increased
impulsi!ity that may lead youth to act in
lethal ways# such as suicide (Biederman
et al.). 5hildren and adolescents with
BD often meet criteria for oppositional
de"ant# conduct# an3iety# and learning
disorders. ccurate diagnosis of BD is
complicated by the comple3ity of symptoms
and fre9uent coCoccurrence with
other disorders.
7reatment and Inter!ention
Because of the no!el recognition of pediatric
BD# treatment in children has been
an e3tension of adult treatment. 1nly recently
has inter!ention literature focused
on treatment options that are speci"cally
for children and adolescents with BD. 7o
stabilize the se!ere beha!iors often seen
in pediatric BD# psychotropic medications
are commonly used as "rstCline
treatment. %ithout mood stabilization
through medication# students may not
ade9uately bene"t from other inter!entions
(8cIntosh . 7rotter# )--D).
5urrent psychosocial treatment
guidelines for childhood BD are largely
based on clinical e3perience# with scant
empirical research establishing their
eEecti!eness. 5ogniti!eCbeha!ioral
therapy strategies and family psychoeducation
approaches are highlighted as
the most eEecti!e treatments (Fowatch
et al.# )--B6 8cIntosh . 7rotter# )--D).
Inter!entions are deli!ered at the
indi!idual or family le!el and include
cogniti!e restructuring for depressi!e
symptoms# problemCsol!ing strategies to
inter!ene with emotional dysregulation#
and beha!ior management techni9ues
to establish routine and consistency
(e.g.# *a!uluri et al.# )--<). 4amily psychoeducationG
pro!iding information
and guidance to families in a teaching
formatGhas also pro!en to decrease
symptom e3pression and increase
parental 0nowledge and positi!e family
interactions (4ristad# HoldbergCrnold
. Ha!azzi# )--/6 *a!uluri et al.# )--<).
Schools; Iesponse
Each student with BD has a uni9ue
symptom pattern# which ma0es the
de!elopment and use of inter!ention
plans in the school setting challenging.
collaborati!e approach that uses
problemCsol!ing strategies and includes
families# school staE members# and
medical and mental health pro!iders is
necessary to pro!ide appropriate school
inter!ention for students with BD.
SchoolCbased inter!entions for these
students can include diEerent le!els
of special education ser!ices# speci"c
classroom modi"cations# and direct
ser!ices pro!ided by school counselors
and psychologists. Students diagnosed
with BD can be ser!ed in general education
or special education classrooms or
a combination of both.
Students who ha!e lessCse!ere symptoms
but who show limited academic
progress because of BD may bene"t
from a Section B-< plan# which might
include speci"c classroom accommodations
and schoolCbased counseling.
n IE* is often created under the
JEmotional DisabilityK or J1ther 2ealth
ImpairedK (12I) category of disability#
but for students to 9ualify for these
ser!ices# their symptoms must ad!ersely
aEect learning.
Iylan is an eighthCgrade student with early onset bipolar disorder (BD)# attention
de"cit?hyperacti!ity
disorder (D2D)# oppositional tendencies# social problems# and writing di:culties. Iylan;s
beha!ior results in classroom disruptions# peer con@icts# teacher frustration# and poor
academic
performance. Iylan;s educators are struggling with how to best support his needs.
7he assistant principal who deals with Iylan;s misbeha!ior has noticed escalating concerns
since earlier this school year. Iylan has only recently been sent to the o:ce because of his
short
temper# refusal to write in most classes# argumentati!e interactions with teachers# and "ghts
with peers. Lpon re!iewing Iylan;s record and disco!ering his diagnoses# the assistant
principal
immediately puts a plan together to support Iylan.
7he assistant principal created a plan of action for Iylan when problems "rst began.
proacti!e meeting was held with his parents and teachers. 8edical pro!iders were contacted
immediately for consultation. School counseling eEorts began while medication changes were
being completed. Mearning issues were assessed and teachers were gi!en support to deal
with
Iylan in the classroom !ia the de!elopment and implementation of a B-< plan. 7hese
collaborati!e
pre!ention measures allowed the assistant principal to manage the situation and support
Iylan and his teachers.
Symptoms and E3pression of Depressi!e and 8anic Episodes in 5hildren and
dolescents
Depressive Episode
&. Depressed 8ood and?or
). Moss of Interest and
Four Other Symptoms Possible Expression in Children and Adolescents
/. %eight loss?gain Lninterested in eating and?or o!ereats.
<. Insomnia or hypersomnia Di:culty falling and staying asleep. Sleeps more than usual.
B. *sychomotor agitation or retardation 2yperacti!e# di:culty sitting still# and?or impulsi!e. Mess
acti!e and interacti!e.
D. 4atigue or loss of energy Aeeds more rest# complains when pushed to do acti!ities# and?or
pretends to
be sic0.
>. 4eelings of worthlessness or inappropriate guilt 8a0es negati!e selfCcomments# such as JI am
stupidK and JAo one li0es me.K
=. Diminished ability to thin0 or concentrate 2as poor concentration# is disorganized# and?or
distractible.
N. Iecurrent thoughts of death# suicidal ideation?attempt. 7al0s about dying or has themes of death
in con!ersation# play# or artwor0.
Manic Episode
&. Ele!ated and?or e3pansi!e mood and?or
). Irritable mood and
Three (our i mood is only irritable! Other Symptoms" Possible Expression in Children
and Adolescents
/. In@ated selfCesteem or grandiosity Demands to be center of attention or o!ercommits to
pro$ects?acti!ities. 2as
hallucinations (e.g.# hears?sees things) or tells eccentric stories.
<. Decreased need for sleep 4ull of energy and re9uires little sleep (e.g.# wanders around house
nightly
loo0ing for things to do). Hets !ery little sleep but is full of energy ne3t day
with no tiredness.
B. 8ore tal0ati!e than usual 7al0s rapidly# loudly# and incessantly without allowing others to enter
con!ersation.
D. 4light of ideas?racing thoughts In absence of language problems# does not ma0e sense when
they tal0.
5omments they can;t get things done because their thoughts are interrupting
them.
>. Distractibility 8ore than typical# has di:culty paying attention and?or is disorganized.
=. *sychomotor agitation?increase in goal directed acti!ity 1!erly acti!e# spends more time playing
and completing a speci"c acti!ity
than usual# and?or displays impulsi!e beha!iors.
N. E3cessi!e in!ol!ement in pleasurable acti!ities that ha!e high potential for
painful conse9uences (i.e.# poor $udgment).
Shows hyperse3ual beha!iors (in the absence of se3ual abuse) or ma0es
inappropriate displays of aEection. Engages in ris0Cta0ing beha!iors and ta0es
dares easily from others.