16

Bipolar Disorders
Nicholas Lofthouse
Mary A. Fristad
Ohio State University

BACKGROUND AND
DEVELOPMENT
Over the past decade, bipolar disorder in children has
received increasing attention from the scientific community, media, and general public (see review by
Lofthouse & Fristad, 2004). Although interest has
grown, continued research is essential, as bipolar disorder in children often devastates family life, school functioning, and peer relationships. If left untreated, it may
have a prolonged, highly relapsing course; be less
responsive to treatment; and lead to legal difficulties,
multiple hospitalizations, and increased rates of substance abuse and suicide (Findling, Kowatch, & Post,
2003; Geller et al., 2003). Despite the detrimental
effects of bipolar disorder, few studies have examined
the specific effects it has on academic performance, school
behavior and peer functioning, clinicaleducational
implications, or treatment options. This chapter describes
the presentation of bipolar disorder in children, its development, specific problems in the school environment,
and interventions.

Definition of Key Concepts and Terms

Various terms have been used to describe bipolar disorder
in children, including pediatric, juvenile, early-onset,
childhood, and prepubescent bipolar disorder. However,
the singular term bipolar disorder is misleading, as there
appear to be a group of disorders (bipolar I [BP-I], bipolar II [BP-II], cyclothymia, and bipolar not otherwise
specified [BP-NOS]). A more fitting reference frequently
used in the adult literature is bipolar spectrum disorders
(Akiskal, 1983). Furthermore, because of differences
between adult-onset and childhood- or adolescent-onset
bipolar spectrum disorders (see discussion below), the

term early-onset bipolar spectrum disorder (EOBPSD) is

used when describing bipolar disorders that occur in persons younger than 18.
Although no epidemiological studies currently exist
for children, Lewinsohn, Klein, and Kleins (1995) community school survey of 14- to 18-year-olds found lifetime prevalence rates for BP-I to be about 0.12% and for
BP-II and cyclothymia to be about 1%. They reported
an additional 5.7% with subthreshold symptoms, multiple comorbidities, and associated psychosocial impairment, which may constitute a group of adolescents with
BP-NOS. By comparison, the cross-national lifetime
prevalence for adults with bipolar spectrum disorders
ranges from 3% to 6% (Weissman et al., 1996). A retrospective survey of 500 National Depressive and ManicDepressive Association group members self-identified
with bipolar illness found that nearly one-third (31%)
recalled a variety of depressive and manic symptoms during childhood. An additional 28% reported onset during
adolescence. Thus, over half of adults in this survey
reported that their symptoms began prior to adulthood
(Lish, Dime-Meenan, Whybrow, Price, & Hirschfeld,
1994).
According to the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV; American
Psychiatric Association, 1994), the four types of bipolar
disorder can be distinguished on the basis of the frequency and severity of manic and depressive symptoms.
An episode of mania involves a 1-week period or more
(no duration, if hospitalized) of persistently and excessively elevated mood (i.e., inappropriately happy) or irritable mood (i.e., temper tantrums and rages out of
proportion to events) that causes an observable change in
functioning. A less severe and durable episode of mania,
called hypomania, is characterized by a mood alteration
of at least 4 days but without any noticeable functional
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impairment. For both mania and hypomania, altered
mood is accompanied by three or more (four, if mood is
irritable and not elated) other symptoms. These symptoms include inflated self-esteem or grandiosity; decreased
need for sleep; rapid, loud, or uninterruptible speech; racing thoughts; increased distractibility; increased goaldirected activity or psychomotor agitation; and excessive
involvement in pleasurable or dangerous activities.
A major depressive episode involves a sad, empty, or
irritable mood or a loss of interest and pleasure in previously enjoyable activities that lasts most of the day, nearly
every day, for a 2-week period or longer. The depressed
mood and/or loss of interest or pleasure is accompanied
by three or four additional symptoms (for a total of five
symptoms). These symptoms include insomnia or hypersomnia, significant weight loss or gain, fatigue, psychomotor agitation or retardation, difficulty concentrating,
feelings of worthlessness or excessive guilt, and recurrent
thoughts of death or suicide.
With regard to the four DSM-IV types of EOBPSD,
BP-I is characterized by at least one manic episode, with
or without a major depressive episode. The diagnosis of
BP-I can be further specified by noting the nature
(manic, hypomanic, depressed, or mixed) of the current
and previous mood episodes. BP-II is typified by the
occurrence of one or more major depressive episodes and
one or more hypomanic episodes, without any history of
a manic or mixed episode. Cyclothymic disorder is not as
severe as either BP-I or BP-II, but the condition is more
chronic, lasting for 1 year or more in children and adolescents. In contrast, BP-NOS is a disorder with bipolar
features that does not meet the criteria for BP-I, BP-II,
or cyclothymic disorder.
Accurate diagnosis of children with EOBPSD
requires that bipolar symptoms be differentiated from
normal behaviors of childhood. For example, children
may become elated, giddy, and silly several days before a
trip to Disneyland. However, if this mood change is
extreme (e.g., described by parents as out of the blue
or way too high) in reaction to ongoing events, it may
be diagnostically significant. Similarly, children often
engage in imaginative play in which they assume many
roles, such as teacher, fireman, or superhero. This is typical in the context of play; however, this behavior becomes
problematic when the child continues to assume such
roles outside the context of play. For example, instead of
pretending to instruct an imaginary classroom full of students, a child with EOBPSD may stand up in class and
begin teaching her classmates because she believes she has
more knowledge than the teacher.
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EOBPSDs are some of the most difficult childhood

disorders to assess, diagnose, and classify. Not only must
clinicians differentiate clinically significant grandiosity
and elation from normal temperamental differences in
childhood, such as recklessness and bragging, they need
to identify and discriminate EOBPSD symptoms from
symptoms of other psychological and behavioral disorders, such as Attention Deficit Hyperactivity Disorder
(ADHD), oppositional defiant disorder (ODD), and
conduct disorder (CD); learning disabilities and various
anxiety, psychotic, and pervasive developmental disorders; medical disorders; substance abuse; and poor childrearing (Kowatch et al., 2005). In addition, clinicians
must identify the presence of manic symptoms in terms
of a significant change from baseline, even if that baseline
is already disrupted by another condition such as
ADHD. In that case, the overlapping manic symptoms
of distractibility, psychomotor agitation, involvement in
dangerous activities, and pressure to keep talking must
increase, along with a change in mood, above and
beyond the baseline ADHD symptoms of inattention,
hyperactivity, and impulsivity.
Another problem with accurately diagnosing
EOBPSD is that manic symptoms in children may not
be clearly episodic. However, the child still must show
evidence of waxing and waning mood symptoms that frequently arise unexpectedly and are often unrelated to
environmental events. During the altered (expansive,
euphoric, or irritable) mood state, additional manic
symptoms (e.g., grandiosity, racing thoughts, and
decreased need for sleep) also must be present.
Additional areas to assess include a thorough family,
developmental, medical, social, and school history to
understand symptom manifestation in the larger context
of the childs life. Finally, a life chart should be developed
to clearly demarcate onset, duration, severity, impairment, and offset of mood symptoms during the childs
life to further distinguish the variety of EOBPSD subtype (BP-I, BP-II, cyclothymia, or BP-NOS). For a more
detailed review of key issues and methods related to the
assessment of EOBPSD, see Quinn and Fristad (2004).

Developmental Aspects of EOBPSD

Although the etiology of EOBPSD is not known, substantial evidence in the adult literature and more recent
research with children and adolescents suggest a biological basis involving genetics, various neurochemicals,
and certain affected brain regions (see review by Findling et al., 2003). Because EOBPSD appears to have

Chapter 16: Bipolar Disorders

biological origins that affect brain functioning, and as it
is not intentional or caused by bad parenting, it can be
considered a no-fault brain disorder. The initial manifestation of EOBPSD can be activated, and its developmental course exacerbated, by certain environmental factors,
such as family, teacher, or peer conflict; academic stress;
and disruption in the sleepwake cycle (see review by
Lofthouse & Fristad, 2004). Therefore, EOBPSD is best
conceptualized as a biopsychosocial disorder and, as such,
requires biopsychosocial interventions.
Regarding the onset of EOBPSD, Quinn,
Lofthouse, Fristad, and Dingus (2004) found that
parents reported their 8- to 11-year-old childrens manic
and depressive symptoms starting at 8.8 and 8.6 years,
respectively. In an interesting finding, the ages of onset
reported by their children were younger: at ages 8.3 and
7.8 for symptoms of mania and depression, respectively.
Currently, no studies exist charting the early development of EOBPSD from infancy to early childhood.
However, the clinical history of children with EOBPSD,
from toddler years or even infancy, often includes reports
of intense colic that evolves into ongoing extreme irritability, terrible twos that morph into terrifying threes,
and beyond. Many such children have preexisting problems with ADHD, ODD, CD, anxiety, and depression
long before they are actually diagnosed with EOBPSD
(McClellan, Werry, & Ham, 1993; Werry, McClellan, &
Chard, 1991). It is important to note, however, that
most children with colic and difficulties at ages 2 and 3
do not develop EOBPSD.
Retrospective research on 8- to 11-year-old children
with EOBPSD (Kljun, Lofthouse, Fristad, & Dingus,
2004) suggests that the majority (77%) of parents recalled their children experienced past behavior problems in
school and had previous special education services
(80%). More than half of the parents reported their children continue to have current behavior problem at
school (55%) and receive special education services
(64%). The only longitudinal study to date of children
with EOBPSD (Geller, Tillman, Craney, & Bolhofner,
2004) followed a sample of 86 7- to 16-year-olds diagnosed with BP-I for 4 years. Although most of these
youth were in treatment of some kind, at 6 months most
participants (86%) still met criteria for mania. Rates of
recovery (defined as 8 consecutive weeks without any
DSM-IV diagnoses of mania or hypomania) and of
relapse (defined as 2 consecutive weeks with DSM-IV
diagnoses of mania or hypomania) were reported at
6-month, 2-year, and 4-year follow-up. Although many
youth with EOBPSD recovered over time, the mean time

for recovery became longer between the 2- and 4-year

assessments. After recovery, they relapsed at an increasingly higher rate over time, but the mean time to relapse
after recovery also lengthened. For instance, at 6 months
after baseline, recovery rates were low (14%), but they
rose quite dramatically 1, 2, and 4 years later (37%,
65%, and 87%, respectively). Relapse rates after recovery
followed a similar pattern, starting low at 6 months
(16.7%), then increasing at 1, 2, and 4 years follow-up
(38%, 55%, and 64%, respectively). Furthermore, polarity switches, from mania and hypomania to MDD and
minor depression, occurred on average 1.1 times every
year.
Geller et al. (2004) also found low maternalchild
warmth predicted relapse at the 2- and 4-year follow-up
interviews, similar to research in the adult literature on
the deleterious effect of high expressed emotion
(which, in this case, refers to an intrusive, critical, or
overinvolved style of interacting within a family) on the
course of bipolar disorder in adults. Although the Geller
study requires replication, no other characteristics of
baseline symptoms that were assessed (e.g., MDD, ODD
or CD, psychosis, mixed mania, continuous cycling, or
global functioning) predicted relapse. However, the presence of psychosis at baseline did predict longer manic
and hypomanic episodes.
Very little research has examined how EOBPSD may
manifest differently with age. In comparison to adults,
who are more likely to present with discrete cycles of
mania and depression, children with EOBPSD may
exhibit both manic and depressive symptoms at the same
time or within the same day (Kowatch et al., 2005).
Mood shifts in children are characterized by mixed states
(i.e., simultaneous manic and depressive symptoms) and
by rapid cycling (i.e., four or more mood episodes per
year) and short duration (e.g., several hours, several times
daily for several days in a row). Whereas mood states in
adults with bipolar disorder are often expressed as
euphoric or sad, manic and depressive moods in children
often manifest as intense irritability. For children, this
atypical presentation of symptoms often fails to meet the
diagnostic criteria associated with BP-I, BP-II, or cyclothymia. Therefore, many children with EOBPSD are
given the catchall diagnosis BP-NOS.
With respect to prognosis, as previously described,
EOBPSD may include a prolonged and highly relapsing
course; significant impairments in home, school, and
peer functioning; legal difficulties; multiple hospitalizations; and increased rates of substance abuse and suicide.
In short, children with EOBPSD have a chronic brain
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disorder that is biopsychosocial in nature and, at this current time, cannot be cured or grown out of. However,
children and their families can buffer themselves against
further impairment by learning to manage dysfunctional
mood, related comorbid symptoms, and environmental
stressors. Means to do so are described later in this chapter. The more families can minimize symptoms and stressors, the closer children can come to experiencing
normal developmental functioning.

PROBLEMS AND IMPLICATIONS

Problems Caused by the Core Manic and
Depressive Symptoms
Mood symptoms wax and wane and may or may not be
related to environmental triggers. They represent a significant change from the childs typical functioning. A child
with EOBPSD can experience extremely intense emotions of sadness, tearfulness, rage, or elation and mixed
states of simultaneously occurring manic and depressive
symptoms.
Manic and depressive symptoms may express themselves in a variety of ways in the school environment (see
Tables 1 and 2, respectively). Manic or depressive symptoms also can escalate and become potentially harmful to
the child (e.g., engaging in suicidal behaviors or dangerous activities) or others (e.g., hitting the teacher or fellow
pupils, destroying property, or making sexually inappropriate advances to classmates). Furthermore, severe
mania or depression may lead to psychotic symptoms
such as paranoia (e.g., a child truly believes someone is
spying on him), delusions (e.g., a child believes a war in
another country was his fault), and auditory or visual
hallucinations (e.g., a child hears voices telling her to do
bad things or sees skeletons playing basketball). Psychotic
symptoms in the presence of manic or depressive symptoms do not mean the child has schizophrenia or a
related psychotic disorder. Typically, these psychotic
symptoms disappear when mood symptoms improve.

Stressors Associated With EOBPSD

In addition to the impairment of school functioning
caused by core manic and depressive symptoms, children with EOBPSD may have additional problems in
school as a result of a combination of various stressors.
One of these stressors is comorbidity. Children and adolescents diagnosed with EOBPSD typically have a large
214

number of co-occurring conditions, including ADHD

(57%98%), ODD or CD (41%76%), and various
anxiety disorders (13%78%; see review by Lofhouse &
Fristad, 2004). Substance abuse is less commonly an
issue for children with EOBPSD, but Findling et al.
(2003) suggested 50% to 70% of diagnosed adolescents
will use and occasionally abuse various substances.
School professionals need to be aware of the signs of
substance abuse in youth with EOBPSD, as it can
trigger further episodes of mania or be used to selfmedicate symptoms in place of more safe and effective
pharmacology.
Although children with EOBPSD have a high rate of
ADHD, there are significant differences between these
two disorders. Geller, Zimmerman, et al. (2000) compared a group of children and adolescents diagnosed with
EOBPSD, with or without ADHD, to a group with
ADHD alone. They found five DSM-IV mania-specific
symptoms provided the best discrimination between the
EOBPSD/ADHD and ADHD-only groups: Elated
mood (89% and 14%, respectively), grandiosity (86%
and 5%, respectively), flight of ideas/racing thoughts
(71% and 10%, respectively), decreased need for sleep
(40% and 6%, respectively), and hypersexuality (43%
and 6%, respectively).
The presence of multiple disorders in adolescents
with EOBPSD has also been associated with greater psychosocial impairment (Lewinsohn et al., 1995). Among
children diagnosed with both ADHD and CD, those who
also had manic episodes showed far greater impairment
(Biederman et al., 1997). Of those children with mania,
ADHD, and CD, 38% were retained in school, 86%
needed extra help, and 71% were in a special education
class. In contrast, only 18% of children with ADHD and
CD, without mania, were retained, 35% needed extra
help, and 3% were in a special education class.
Comorbid conditions might act as stressors, triggering future episodes of mania or depression (e.g., an
increase in separation anxiety disorder symptoms and
poor-quality sleep related to moving to a new middle
school could prompt a manic episode). Additionally, these
co-occurring conditions often warrant clinical attention
in their own right because of their debilitating effects on
academic, behavioral, and peer dysfunction. Therefore, as
a result of the prevalence and impairments associated with
comorbidity, the evaluation, accurate identification, and
effective treatment of comorbid conditions in children
and adolescents with EOBPSD are essential.
In addition, other factors that may contribute to the
above problems include teacher, parent, and sibling

Chapter 16: Bipolar Disorders

Table 1

Manic Symptoms and Their Expression in the School Environment

Symptom and Definition

Example

Euphoria: Elevated (too happy, silly, giddy) and expansive

(about everything) mood, out of the blue or as an
inappropriate reaction to external events for an extended
period of time.

A child laughs hysterically for 30 minutes after a mildly funny

comment by a peer and despite other students staring at him.

Irritability: Energized, angry, raging, or intensely irritable

mood, out of the blue or as an inappropriate reaction to
external events for an extended period of time.

In reaction to meeting a substitute teacher, a child flies into a

violent 20-minute rage.

Inflated Self-Esteem or Grandiosity: Believing, talking, or

acting as if he is considerably better at something or has
special powers or abilities despite clear evidence to the
contrary.

A child believes and tells others she is able to fly from the top
of the school building.

Decreased Need for Sleep: Unable to fall or stay asleep or

waking up too early because of increased energy, leading to a
significant reduction in sleep yet feeling well rested.

Despite only sleeping 3 hours the night before, a child is still

energized throughout the day.

Increased Speech: Dramatically amplified volume,

uninterruptible rate, or pressure to keep talking.

A child suddenly begins to talk extremely loudly, more

rapidly, and cannot be interrupted by the teacher.

Flight of Ideas or Racing Thoughts: Report or observation

(via speech/writing) of speeded-up, tangential, or
circumstantial thoughts.

A teacher cannot follow a childs rambling speech that is out

of character for the child (i.e., not related to any cognitive or
language impairment the child might have).

Distractibility: Increased inattentiveness beyond childs

baseline attentional capacity.

A child is distracted by sounds in the hallway, which would

typically not bother her.

Increase in Goal-Directed Activity or Psychomotor

Agitation: Hyper-focused on making friends, engaging in
multiple school projects or hobbies or in sexual encounters,
or a striking increase in and duration of energy.

A child starts to rearrange the school library or clean

everyones desks, or plans to build an elaborate fort in the
playground, but never finishes any of these projects.

Excessive Involvement in Pleasurable or Dangerous

Activities: Sudden unrestrained participation in an action
that is likely to lead to painful or very negative consequences.

A previously mild-mannered child may write dirty notes to

other children in class or attempt to jump out of a moving
school bus.

stress; sleep disruptions; and time spent out of school

related to an escalation of symptoms, treatment, and
school-mandated suspensions or expulsions. As resources
only recently have become available to educate and train
teachers about EOBPSD and how to manage it in the
classroom (see Recommended Resources), it is likely that

teachers and other school professionals feel doubly frustrated, as they are dealing with significant and acute
problems, often while lacking knowledge and training in
how to handle these situations.
Two potential sources of stress that occur within the
homethe effects of which may extend to the school
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Table 2

Depressive Symptoms and Their Expression in the School Environment

Symptom and Definition

Example

Depressed Mood: Feels or looks sad or irritable (low energy)

for an extended period of time.

A child appears down or flat or is cranky or grouchy in class

and on the playground.

Markedly Diminished Interest or Pleasures in All

Activities: Complains of feeling bored or finding nothing fun
anymore.

A child reports feeling empty or bored and shows no interest

in previously enjoyable school or peer activities.

Significant Weight Lost/Gain or Appetite Increase/

Decrease: Weight change of >5% in 1 month or significant
change in appetite.

A child looks much thinner and drawn or a great deal heavier,

or has no appetite or an excessive appetite at lunchtime.

Insomnia or Hypersomnia: Difficulty falling asleep, staying

asleep, waking up too early or sleeping longer and still feeling
tired.

A child looks worn out, is often groggy or tardy, or reports

sleeping through alarm despite getting 12 hours of sleep.

Psychomotor Agitation/Retardation: Looks restless or

slowed down.

A child is extremely fidgety or cant stay seated. His speech or

movement is sluggish or he avoids physical activities.

Fatigue or Loss of Energy: Complains of feeling tired all the

time.

Child looks or complains of constantly feeling tired even with

adequate sleep.

Low Self-Esteem, Feelings of Worthlessness or Excessive

Guilt: Thinking and saying more negative than positive
things about self or feeling extremely bad about things one
has done or not done.

A child frequently tells herself or others Im no good, I hate

myself, no one likes me, I cant do anything. She feels bad
about and dwells on accidentally bumping into someone in
the corridor or having not said hello to a friend.

Diminished Ability to Think or Concentrate, or

Indecisiveness: Increased inattentiveness, beyond childs
baseline attentional capacity; difficulty stringing thoughts
together or making choices.

A child cant seem to focus in class, complete work, or choose

unstructured class activities.

Hopelessness: Negative thoughts or statements about the

future.

A child frequently thinks or says nothing will change or will

ever be good for me.

Recurrent Thoughts of Death or Suicidality: Obsession

with morbid thoughts or events, or suicidal ideation,
planning, or attempts to kill self.

A child talks or draws pictures about death, war casualties,

natural disasters, or famine. He reports wanting to be dead,
not wanting to live anymore, wishing hed never been born;
he draws pictures of someone shooting or stabbing him,
writes a suicide note, gives possessions away or tries to kill
self.

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Chapter 16: Bipolar Disorders

environmentare childsibling and childparent conflict. Being the sibling or a parent of a child with
EOBPSD is associated with a high level of stress (e.g.,
coping with unpredictable and severe outbursts, which
often draw support away from other family members),
physical demands (e.g., dealing with extreme and
extended bouts of aggression, high energy, insomnia, and
dangerous behaviors), and financial pressures (e.g., multiple and long-term treatments and time off work), some
of which may intensify intrafamily conflicts. Given these
multiple sources of stress, interventions designed to
reduce sibling and parent stress should contribute to
improved outcomes for the child at home that might
carry over to improved school functioning.
Although a reduced need for sleep has been identified as a cardinal symptom of EOBPSD, very little
research has explored sleep difficulties in this population,
and no research we are aware of has examined sleep problems in children with EOBPSD that are associated with
their depressive or comorbid psychopathology. However,
preliminary results from an ongoing study of 104 8- to
11-year-olds with EOBPSD suggest that 94% of children
with EOBPSD have sleep problems associated with
either their manic, depressive, or comorbid psychopathology (Lofthouse, Fristad, Splaingard, & Kelleher,
2004). Presumably, sleep disruptions in children with
EOBPSD will deleteriously affect academic, behavioral,
and social functioning at school.
Taking the necessary time out of school for escalating
and debilitating symptoms or for inpatient or outpatient
treatment can further set back the already delayed child
with EOBPSD in terms of developing the essential skills to
function academically, behaviorally, and socially. Similarly,
school-enforced suspensions and expulsions, often used for
disciplining behaviors that may well be beyond the control
of the mood-disordered child, not only can disrupt the
learning and socialization process but also can lead to failing
grades and increased dropout rates. Contemplating the
transition back to school also can be a potent stressor for a
child with EOBPSD. Furthermore, parents, children, and
teachers often report the child with EOBPSD has great difficulty with simple classroom transitions.

Educational Implications of EOBPSD

Although research is limited on academic functioning of
children with EOBPSD, studies reported that 24% of
children with EOBPSD repeated a grade, 13% had
learning disabilities, 43% had special education placements, 58% received tutoring (Biederman, Faraone,

Chu, & Wozniak, 1999), and 30% and 42% had math
and reading disabilities, respectively (Wozniak, et al.,
1995). Compared with children with MDD or dysthymic disorder, children with EOBPSD evidence a trend
toward more placements in special education classrooms
(Fristad, Goldberg-Arnold, & Gavazzi, 2002).
As discussed earlier, in the retrospective study of 8to 11-year-old children with EOBPSD, the majority of
parents reported past and current special education services (Kljun et al., 2004). A related study that used similar
participants reported that most parents (79%) and teachers (72%) and many children (46%) reported current
difficulties with academics at school (Griffith, Lofthouse,
Fristad, & Dingus, 2004).
Adolescents with EOBPSD also experience significant impairments in academic functioning.
Quackenbush, Kutcher, Robertson, Boulos, and Chaban
(1996) examined 44 adolescents with EOBPSD and
found that prior to onset of their illness, 71% had goodto-excellent work effort, 58% were identified as having
specific academic strengths, and 83% were taking college
preparatory classes. After the onset of the disorder, however, teachers reported adolescents work effort had
diminished drastically; 67% had significant difficulties in
math, and only 38% of the 37 students who were of age
had graduated from high school.
Others have reported that children and adolescents
with EOBPSD score higher on verbal measures of IQ
than on visualspatial measures of IQ (Shear, DelBello,
Rosenberg, & Strakowski, 2002). This discrepancy may
contribute to the difficulties children with EOBPSD
often have with math achievement and decoding of
nonverbal social cues, both of which require good visual
spatial abilities. Children with EOBPSD also have
functional deficits on measures of attentional set-shifting
and visualspatial memory (Dickstein et al., 2004),
whereas adolescents with EOBPSD have demonstrated
impairment on tasks requiring executive functioning,
such as systematic problem-solving and self-monitoring
behavior (Shear et al.). Retrospective data on adolescents
with EOBPSD also reveal developmental histories with
significantly more language and motor delays than adolescents with unipolar depression (Sigurdsson,
Fombonne, Sayal, & Checkley, 1999).

Social Implications of EOBPSD

Very little research exists on the social problems of children and adolescents with EOBPSD in the school environment. However, difficulties with social skills and
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having few or no friends have been reported (Geller,
Bolhofner, et al., 2000), and these children may show
higher levels of aggression than their peers (Geller,
Warner, Williams, & Zimmerman, 1998). For 8- to 11year-olds with EOBPSD, the majority of parents and
children report difficulties with peers; over half of the
children report having no friends, and over half of the
parents report their child does not have a best friend
(Kljun et al., 2004). Similarly, teachers report 8- to
11-year-olds with EOBPSD have moderate to severe
difficulties with antisocial behavior, social competence,
withdrawn behavior, interpersonal skills, and selfmanagement skills (Griffith et al., 2004).

Although studies on the offspring of adults with bipolar

disorders are in progress (see Chang & Steiner, 2003),
currently no evidence-based prevention programs, strategies, or techniques exist for promoting healthy development and preventing negative outcomes in predisposed
children. However, many of the strategies and techniques
described below may be helpful for preventing continued
impairment in children diagnosed with EOBPSD. Given
the chronic nature of EOBPSD, efforts should be made
to increase resiliency and recovery using a combination
of effective pharmacological, psychosocial, and school
interventions.

depression, and co-occurring conditions. Although

medications have not been adequately studied in children with EOBPSD, clinical practice indicates their
potential utility. Because most school professionals will
be informed about the brand rather than chemical
names of medications children take, the following section notes brand names only.
Mood stabilizers (e.g., Depakote, Lithium, Gabitril,
Lamictal, Tegretol, Trileptal, and Topamax) are considered the first line of pharmacological intervention.
Antipsychotic medications (e.g., Abilify, Clozaril,
Geodon, Risperdal, Seroquel, and Zyprexa) may help
reduce aggressive or psychotic symptoms, and antihypertensive medications (e.g., Clonidine and Tenex) are
sometimes used to improve the sleepwake cycle. After
a childs mood has been stabilized with a mood stabilizer, low-dose adjunctive antidepressant medications
(e.g., Celexa, Lexapro, Luvox, Prozac, Remeron,
Serzone, Wellbutrin, and Zoloft) may reduce depressive
and anxiety symptoms, and adjunctive psychostimulants
(e.g., Adderal, Concerta, Dexedrine, Focalin, Metadate,
and Ritalin) and norepinephrine reuptake inhibitors
(e.g., Strattera) may reduce ADHD symptoms of inattention, impulsivity, and hyperactivity. However, both
antidepressants and psychostimulants pose a risk of activating manic symptoms, so they must be carefully
monitored. Furthermore, school professionals should be
aware of the major side effects students medications
may have in the school environment (e.g., chronic
thirst, increased urination, and drowsiness) and should
know how to help their students cope with them (e.g.,
more frequent bathroom breaks or changes in school
schedule). For a more detailed review of the findings
and issues in pharmacotherapy of EOBPSD, see
Findling et al. (2003).
Finally, although dietary interventions such as
Omega-3 fatty acids and high-intensity vitamin
mineral complexes have been tried in children, their
efficacy is still being tested, and only case series data are
available (Kaplan, Crawford, Gardner, & Farrelly, 2002).
As evidence for efficacy in some of the medicines being
used for EOBPSD is currently stronger, families are
encouraged to begin treatment with those agents first.

Pharmacological Treatments

Psychological Treatments

Pharmacological intervention is the foundation of effective treatment for EOBPSD. Research and clinical practice indicate that most children require multiple
medications to alleviate symptoms of mania,

Whereas pharmacological interventions are viewed as the

foundation for effective treatment for EOBPSD, psychological interventions can be seen as the real-world building blocks of resiliency and recovery. Psychological

Problems and ImplicationsSummary

Despite the scarcity of studies, research suggests children
and adolescents with EOBPSD have numerous, severe,
and durable problems with manic and depressive symptoms with serious developmental, educational, and social
implications. The high level of comorbidity associated
with EOBPSD; teacher, parent, and sibling stress; sleep
disruptions; and time spent out of school may all contribute to these problems.

ALTERNATIVE ACTIONS FOR

PREVENTION AND
INTERVENTION

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Chapter 16: Bipolar Disorders

interventions might include some combination of family
therapy, individual therapy, parental guidance, group
therapy, school-based intervention, home-based treatment, respite, out-of-home placement, or web-based
support.
As recently as 1999, no evidence-based guidelines
existed for psychosocial interventions with children who
have EOBPSD (Fristad et al., 2002). Since then, three
groups have developed interventions for children
(Fristad, Gavazzi, & Mackinaw-Koons, 2003), children
and adolescents (Pavuluri, Graczyk et al., 2004), and
adolescents (Miklowitz et al., 2004). To date, only the
multifamily psychoeducational groups (MFPG) and
individualfamily psychoeducation (IFP) developed by
Fristad et al. (2003) have been tested in randomized
clinical trials. MFPG and IFP teach parents and children
about mood disorders, symptoms, and co-occurring disorders; pharmacological, mental health, and school- and
community-focused interventions; and coping and selfpreservation skills. Interventions are time limited, with
the expectation that ongoing work of a similar nature
will be required to maintain treatment gains over time
for this chronic illness. Participation is expected to
increase parents and childrens knowledge of EOBPSD
and its treatment and to expand their repertoire of individual and family coping skills, which it is hoped will
lead to more effective and efficient use of existing and
future treatments. For a more detailed description of the
MFPGs session contents and clinical tools, see Fristad
and Goldberg-Arnold (2003) and Goldberg-Arnold and
Fristad (2003).
Originally, MFPG consisted of a 6-week, 75-minute
group treatment. It has since expanded to an 8-week, 90minute format. MFPG has separate parent and child
groups with combined check-in and check-out sessions
at the beginning and end of each group. In the first study,
families were randomized into immediate treatment or a
6-month wait-list prior to receiving treatment. All families continued to receive treatment as usual, which
included medication management, as MFPG is an
adjunctive intervention. Results from 35 participating
8- to 11-year-old children and their 47 participating
parents indicate parents knowledge about childhood
mood disorders increased; parentchild relationships, as
rated by parents, improved; childrens ratings of perceived social support from parents increased (Fristad
et al., 2002); and parents consumer skills (i.e., their
ability to obtain appropriate services) improved
(Goldberg-Arnold, Fristad, & Gavazzi, 1999). A fullscale, randomized study (N = 165) of the expanded

8-week, 90-minute format is now under way to further

establish efficacy of the MFPG program.
In an uncontrolled pilot study of 34 participating
5- to 17-year-olds with EOBPSD, Pavuluri, Graczyk,
Henry et al. (2004) assessed the impact of their child- and
family-focused cognitivebehavioral therapy program
(CFF-CBT or Rainbow Program). After all children
were initially prescribed medication according to a specific
algorithm (Pavuluri, Henry et al., 2004), CFF-CBT was
delivered through 12 individual parent-and-child sessions. Parent-and-child treatment components included
psychoeducation regarding the neuropsychiatric basis of
bipolar disorder and the importance of routines; and skill
building to improve affect regulation and anger control,
increase positive self-statements, restructure negative
thinking for living in the now, promote a balanced lifestyle (for parents), increase interpersonal and situational
problem-solving, and develop support systems. Additionally, the childs school received a work folder of the individual sessions, and the school staff had a teleconference
with the treatment therapist. Participants showed reductions in symptoms of ADHD, aggression, mania, psychosis, depression, and sleep disturbance; increases in global
functioning; and high levels of treatment adherence and
satisfaction (Pavuluri, Graczyk et al.).
Finally, Miklowitz et al. (2004) tested an adolescent
version of Functional Family Therapy for Adolescents
(FFT-A) combined with mood-stabilizing medications in
an open trial of twenty 13- to 17-year-olds with BP-I.
Treatment components, delivered by a standardized manual, included psychoeducation, family problem-solving,
communication, crisis management, and the rehearsal of
coping strategies for future relapses. Adolescents who
received a combination of FFT-A and mood stabilizers
experienced improvements in depressive, mania, and
behavioral symptoms 1 year later. Although psychosocial
treatment for families of children and adolescents with
EOBPSD is a relatively new area, these new studies offer
some hopeful and exciting future possibilities.

School-Based Treatments
Unfortunately no research-supported, school-based interventions currently exist for EOBPSD. However, a number of potentially beneficial clinical and educational
recommendations for school difficulties are available
from several sources:
 The website of the Child and Adolescent Bipolar
Foundation (CABF), at http://www.bpkids.org.
219

Childrens Needs III

 The Juvenile Bipolar Research Foundation (JBRF) at
http:// www.jbrf.org.
 The Josselyn Centers Understanding and Educating
Children and Adolescents with Bipolar Disorder: A
Guide for Educators (Anderson, Kubisak, Field, &
Vogelstein, (2003).
 Fristad and Goldberg-Arnolds 2004 book, Raising a
Moody Child: How to Cope with Depression and Bipolar
Disorder.
The seven fundamental recommendations that
appear below are adapted from these four sources.
1. Build, maintain, and educate the school-based team. It
is critical for the child, family, and school personnel
to work together. Working in isolation or at crosspurposes with other team members can be highly
ineffective, frustrating, and potentially devastating.
The first step involves thinking broadly about who
might be included on an education team. Qualified
persons could be anyone in the school environment
(e.g., secretary or custodian) or childs life (e.g., Cub
Scout leader or rabbi) who can provide consistent
and effective support in assisting the child to cope
with and recover from symptoms and related impairments. Second, successful maintenance of an education team rests on communication among its
members and the setting and monitoring of observable goals. Third, it is important for the education
team to have a firm foundation of knowledge about
EOBPSD to be able to identify, understand, and
flexibly work with the kinds of educational challenges EOBPSDs present.
2. Prioritize individualized education plan (IEP) goals.
The Josselyn Centers Guide for Educators presents a
hierarchy of basic priorities for educating children
with EOBPSD. These include attendance, emotional stability and physical safety, knowledge
acquisition, relationship building, and work
production.
3. Provide a predictable, positive, and flexible classroom
environment. Although predictability in the classroom
environment is no doubt good for all students, it
appears to be exponentially more important for children with EOBPSD, perhaps because of their unpredictable mood cycles. School professionals can
increase predictability by providing organized classrooms, daily routines that are structured and consistent, and clear expectations coupled with a positive
discipline strategy.
220

Negative consequences, such as ignoring attentiongetting behaviors, giving time-outs, removing privileges, assigning remedial work, and using suspension
and expulsion, are often used to reduce unwanted
behaviors. However, if the behavior (e.g., a euphoric
or irritable mood) is not one the child has the cognitive, emotional, or behavioral skills to control, negative consequences may not only be ineffective in
reducing that behavior, they could actually increase it.
As symptoms of EOBPSD wax and wane within
the developing child, maintaining flexibility is critical. It may be necessary to modify expectations
regarding the amount, content of, and time allowed
for activities, assignments, and tests, based on the
childs fluctuations in mood, attention, energy, and
motivation.
4. Be aware of and manage medication side effects.
Children with EOBPSD are frequently prescribed
multiple medications. It is important for school professionals to be kept up-to-date with the childs medications and any related side effects (e.g., increased
thirst and urination, drowsiness, or sluggishness).
Common classroom interventions include unlimited
access to fluids and the restroom, and rescheduling of
the most challenging activities to times when side
effects are less pronounced (e.g., after lunch).
5. Develop social skills. Many children with EOBPSD
have socialemotional skills deficits. They may misinterpret jokes, act shy, be bossy or bully, or become a
victim of bullying. Providing support from the guidance counselor, psychologist, or social worker; allowing the child to participate in a social skills group;
and increasing playground supervision to avert bullying can all help the child with EOBPSD function better at school.
6. Be prepared for episodes of intense emotion. Because a
child with EOPBSD may experience dramatic, unexpected, and intense shifts of mood and emotion during the school day, a functional behavior assessment
can help identify triggers that may precede losses of
control and can guide the development of a behavior
plan to help the child and school professional prevent
or cope with stressors and frustrations. For instance, if
episodes are triggered by boredom, school professionals can provide enrichment activities; if episodes are
due to hunger or low blood sugar, the child should
eat mid-morning and afternoon snacks; or if episodes
occur during particularly difficult activities, temporarily reducing demands to a level the child can manage
will reduce stressors. An important intervention for

Chapter 16: Bipolar Disorders

children with EOBPSD is to have available the use of
a safe or private place the child can visit to regain control (e.g., guidance office or resource room) and to
establish a secret signal for the child and teacher to
covertly communicate the need to take a brief timeout during class.
Preparation for episodes of intense emotion also
may include the development of a crisis management
plan that involves crisis prevention strategies. This crisis management plan should include the following:
 Explicit instructions to manage unsafe behaviors
(i.e., who does what, when, and where).
 Details regarding the location, supervision of, and
expectations surrounding safe and private places
(e.g., designating the guidance counselors office as
a safe place and making sure the child gets there
and returns to the classroom as soon as possible
after calming down).
 The development and practice of a specific communication system to implement procedures
quickly (e.g., a child could give a T hand signal
to communicate the need to go to his or her safe
place).
 Alternative backup plans (e.g., walking around the
gym with an adult if time in the safe place didnt
work).
 Recovery procedure for all involved following the
crisis (e.g., destress and debrief as a class, with
the child included, in order not to ostracize the
child).
Following hospitalization or after an upsurge in
symptoms that precludes success in negotiating an
entire school day, it is critical that the education team
prepare for the childs transition back to school to
prevent further disruption. The team might arrange
for temporary homebound instruction, followed by a
gradual transition back to school, if needed, or the
team might arrange for partial days at school.
7. Consider alternatives to regular classrooms. If symptoms
escalate and become potentially harmful to the child
and others in the regular classroom, the education
team may need to consider the temporary or even permanent support of more restrictive educational environments. These may include (in order of least to most
restrictive) regular classroom with a one-to-one aide,
special education teacher or resource room support,
self-contained classroom, home schooling, therapeutic
day school, hospital day treatment program, residential
treatment center, or therapeutic boarding school. The

website for the National Association of Therapeutic

Schools and Programs (http://www.natsap.org) can be
helpful in locating programs suited to a childs particular needs. Though no research to date has evaluated these alternatives to standard educational
placements, it can be assumed their effectiveness
will be enhanced if their staff have accurate and
up-to-date knowledge of EOBPSD and its manifestations in school settings.

SUMMARY
Early-onset bipolar spectrum disorders (EOBPSD) are
severe, highly comorbid, chronic, cyclical, and frequently
relapsing biopsychosocial mood disorders of childhood
and adolescence. The core symptoms of manic and
depressive symptoms can be further exacerbated by the
secondary problems of comorbidity; teacher, parent, and
sibling stress; sleep disruptions; and time spent out of
school. Interacting in a dynamic, caustic, debilitating
cycle, this constellation of problems can lead to a further
escalation of core symptoms, secondary problems, and
devastating effects on developmental, home, school, and
peer functioning.
Although EOBPSD cannot currently be cured or
grown out of, children, their families, and school professionals can help to increase resiliency and recovery by
the combined use of effective medications, psychoeducation, and psychosocial and school interventions
designed to manage dysfunctional mood, related comorbid symptoms, and environmental stressors. Despite the
recent development and testing of family-based psychosocial treatments for EOBPSD, no empirically supported school-based programs currently exist. One of
the main challenges facing researchers of treatment outcomes is how to scientifically examine school interventions for a group of disorders that are relatively
infrequent.
Despite the lack of research on school interventions,
a number of potentially beneficial clinical and educational recommendations are available. Seven fundamental recommendations were described in this chapter. In
conclusion, although EOBPSD is often chronic, variable,
and damaging to family life, school functioning, and
peer relationships, it is important not to lose hope.
Several effective treatment tools currently exist, and with
the increasing professional and public interest EOBPSD
has received in recent years, additional treatments are
likely to become available in the future.
221

Childrens Needs III

RECOMMENDED RESOURCES
Books and Other Printed Material
Anderson, M., Kubisak-Boyd, J., Field, R., & Vogelstein,
S. (2003). Understanding and educating children and
adolescents with bipolar disorder: A guide for educators.
Northfield, IL: The Josselyn Center.
This manual for educators provides ideas and principles to guide the assessment and intervention of children and adolescents with EOBPSD in educational
settings.
Fristad, M., & Arnold, J. G. (2004). Raising a moody
child: How to cope with depression and bipolar disorder. New York: Guilford Press.
This book for parents offers direct, easy-to-follow
information and recommendations for families with
children who suffer from mood disorders.
Incorporating real-life examples, practical suggestions,
and answers to frequently asked questions, this book
covers important issues, including knowing when a
child needs help, how parents can get a good evaluation, medical and psychological treatment options, crisis management, coping tools for the whole family,
and how parents can help their child cope in school.

Websites
http://www.bpkids.org
The Child & Adolescent Bipolar Foundation is a
parent-led, not-for-profit, Internet-based organization of families raising children diagnosed with
EOBPSD. The ResourcesPrinted Materials section of the website includes a brochure for educators
called Educating the Child with Bipolar Disorder.
The Learning Center page has information on educational issues of pediatric bipolar disorder. In its
bookstore, the CABF also sells an interactive CD for
school personnel, What is Pediatric Bipolar
Disorder? A Resource for Educators.
http://www.jbrf.org
The Juvenile Bipolar Research Foundation (JBRF)
is a web-based charitable organization of parents,
clinicians, and researchers dedicated to the support
of research on EOBPSD. The Discussion Forums
section of the website provides information on the
educational issues of students with bipolar disorder.
Also in this section, the JBRF sells a DVD of a
Janice Papolos presentation, Educating and
Nurturing the Bipolar Child.
222

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