Abstract
This article examines the individual components of bipolar disorder in children and the behaviors that can escalate as a result of misdiagnosis and treatment. The brain/behavior relationship in bipolar disorders can be affected by genetics, developmental failure, or environmental influences, which can cause an onset of dramatic mood swings and dysfunctional behavior. School is often the site where mental health disorders are observed when comparing behaviors with other children. Assessing the emotional, academic, and health needs of a student with a bipolar disorder is a critical step in designing effective interventions and school accommodations. Without appropriate medical, psychological, pharmaceutical, and academic interventions, a child is at risk for uncontrolled mania, depression, substance abuse, or suicide. The school nurse is part of the multidisciplinary team and plays a key role in facilitating case management to potentially reverse this possible negative trajectory. Successful case management provides children with bipolar disorder the opportunity to reach their academic potential.
Keywords
INTRODUCTION
Children with bipolar disorder (BPD) can be misunderstood, misdiagnosed, and treated incorrectly. Children who are diagnosed with this disorder are like pieces of a puzzle with jagged edges. They lack the tools to fit the pieces into the puzzle, causing significant impairment in academic, social, and emotional development. Without proper diagnosis, treatment, and case management, these students are at risk for dysfunctional relationships, educational failure, and an inability to function within their environment. Children with classic symptoms of inattention, hyperactivity, and impulsivity can be quickly diagnosed with attention deficit hyperactivity disorder (ADHD) without considering the clinical characteristics of BPD, which has similar symptoms. School nurses play a significant role in identifying at-risk behaviors, educating parents and teachers, facilitating appropriate care, and coordinating resources that will link families to outside services.
BIPOLAR DISORDER
Etiology
Bipolar disorder is a cyclical mood disorder that is attributed to genetic factors as well as environmental influences. Research supports a strong genetic component, in that a child who has bipolar parents is at greater risk for developing BPD (Chang, Blasey, Ketter, & Steiner, 2001). A child who has one bipolar parent has a risk factor of 15% to 30% of developing a mood disorder. If both parents have BPD, that child’s risk increases from 50% to 75% (Koplewicz, 1996; Papolos & Papolos, 2002). Genetic transmission, developmental failure, and an early traumatic brain injury can contribute to the onset of a mood disorder, resulting in BPD (Blackwood & Muir, 2001).
Environmental factors have a powerful influence on a child’s development. For example, the presence of a bipolar parent who is absent, neglectful, or dysfunctional can increase the chances of a child developing BPD. If a child experiences a traumatic event, such as a premature parental loss or a recent stressful event, a mood disorder can be triggered (Chang and colleagues, 2001). The brain is the center for all meaningful functions, sensations, and perceptions and has the innate ability to interpret life experiences that involve interpersonal, social, and cultural factors (Papolos & Papolos, 2002). Table 1 identifies the brain/behavior relationships that may be associated with functional abnormalities affecting human behavior.
The brain weighs approximately 0.66 pounds at birth and fully develops in 20 to 29 years, by which time it weighs 2.6 to 3.3 pounds. During that time, a single gene or a variety of genes that increase the risk of developing BPD can be triggered by a life event, resulting in significant behavioral change (Hyman, 2003). Human behavior is determined not only by the brain and by life experiences, but also by neurotransmitters, which trigger electrical signals, producing thoughts, emotions, memories, and sleep patterns (Koplewicz, 1996). Table 2 describes the neurotransmitters dopamine, norepinephrine, serotonin, and acetylcholine, which regulate the brain’s chemistry (Manderscheid, Atay, Brown, & Henderson, 2003; Memory Disorders Project, 2001).
In addition to patterns of inherited behavior and environmental influences, substance abuse can contribute to an increased risk of BPD (Blackwood & Muir, 2001). Substance abuse has a profound effect in altering the brain. Alcohol and marijuana can delay the development of memory, whereas the use of psychoactive drugs can change the function and development of the brain (Williamsgroup, 2003). Abuse of alcohol or psychoactive drugs may precipitate the initial episode of BPD (Salloum & Thase, 2000). Continual alcohol and psychoactive substance abuse can complicate the diagnosis of BPD and can adversely affect the duration, progression, and treatment of the disorder (Salloum & Thase).
Prevalence
The actual number of bipolar cases in children is unknown, because diagnosing a child with BPD is very challenging. Experts estimate that 1 million children suffer from BPD, and 2.3 million adults in the United States live with the disorder (Papolos & Papolos, 2002). BPD is a recurrent mood disorder in which one cycles through episodes of mania, depression, and mixed moods (known as rapid cycling). Mixed moods can occur when a child experiences high energy simultaneously with a depressed mood (Child and Adolescent Bipolar Foundation [CABF], 2004). A child can be trapped in a specific mood state for weeks at a time or can escalate to rapid cycling, in which a child shifts from one mood to another in quick succession within a single day (CABF, 2004). Table 3 lists the most common symptoms of bipolar disorder in children.
BPD is a recurrent mood disorder in which one cycles through episodes of mania, depression, and mixed moods (known as rapid cycling).
Typically, a child who has BPD will present with hallmark symptoms of rapid cycling, irritability, and destructive behaviors. For example, a child can become explosive, with violent rages triggered by a simple “no” from a parent or teacher. A child may believe that he or she has an incredible mind and is beyond classroom rules and expectations. Grandiose ideas may cause a child to jump out of a moving car or fly from the rooftop of a building. In each case, the child’s actions defy the laws of logic. These children are unable to regulate their emotions or judge their actions rationally, because their moods are racing out of control with mania. Jamison (1996) describes mania as “gliding through star fields and dancing around the rings of Saturn” (p. 211). This intoxicating state can shift to the darkness of depression, which has unforgettable images of violence, madness, and death.
Many parents do not recognize the red flags of irrational, raging behavior because of the wide parameters that have been established for normal childhood behavior. As a result, most parents do not rush to the emergency room or seek mental health guidance during the initial phase of the disorder. Periods of calmness are eventually replaced by periods of rapid cycling, causing havoc and confusion to parents, teachers, and friends. As the bipolar moods continue to cycle from depression to mania with increasing intensity and frequency, the child may feel trapped in both poles of mania and depression. The child not only becomes a victim of the disorder, but experiences great pain, distress, and low self-esteem (Koplewicz, 1996). School becomes increasingly challenging as the child becomes unable to organize, plan, solve problems, and develop social relationships (Leibenluft, Charney, Towbin, Bhangoo, & Pine, 2003). As friendships deteriorate, the child becomes more isolated and withdrawn and can plummet into an agitated state of hopelessness and despair. This despair can lead to suicide ideation, suicide attempts, or suicide. Suicide is the most tragic consequence for a child with BPD and may be disguised as an accident or an attempt to gain attention. Suicide in adolescents is the third leading cause of death and represents 12% of all deaths in this age group (Weller & Weller, 2001).
School becomes increasingly challenging as the child becomes unable to organize, plan, solve problems, and develop social relationships.
Diagnosis and Treatment
There is no blood test or brain scan that can identify BPD. Skilled clinicians can diagnose the clinical phenotypes of Bipolar I, Bipolar II, Cyclothymia, and Bipolar Not Otherwise Specified through the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association [APA], 2000). It is recommended that parents seek medical intervention if their child has four or more of the symptoms described in Table 3 over a 2-week period (CABF, 2004).
There is no cure for BPD, but early diagnosis and treatment are important in helping stabilize the child’s moods. Without appropriate treatment, each bipolar episode can increase in intensity and duration. Nightmares can progress into night terrors, which are characterized by bodily threat, dismemberment, and death induced by a delusional or paranoid state (Papolos & Papolos, 2002).
Without appropriate treatment, each bipolar episode can increase in intensity and duration.
If BPD is misdiagnosed, inappropriately treated, or overlooked, rapid cycling, mixed moods, psychosis, or even suicide can occur. For example, an early onset of BPD in children can be masked by the classic symptoms of ADHD, which include hyperactivity, inattention, and impulsivity. Approximately one third of children in the United States who are diagnosed with ADHD are actually experiencing an early onset of mania (Papolos & Papolos, 2002). An inaccurate diagnosis of ADHD and subsequent treatment with a prescribed stimulant can precipitate an early onset of BPD, leading to an increase in irritability, mood swings, aggression, suicide ideation, and possible psychosis (Dubovsky, Brooks, & Dubovsky, 2002). On the other hand, if a child with BPD is treated for depression with an antidepressant, the adverse effects of the medication could cause hypomania, rapid cycling, and aggressive or violent behavior (Papolos & Papolos, 2002). Severe depression can emerge as the first bipolar episode in a child and can present as symptoms of chronic irritability and sadness. Without treatment, a severely depressed child under the age of 15 is at risk for developing mania by age 20 (CABF, 2004).
Stabilizing the mood disorder with medication is the initial plan in treating BPD (CABF, 2004). However, monotherapy is often inadequate. Combination drug regimens and psychotherapy with the child and family are recommended (Bowden, 2003). Other adjunct psychosocial interventions include education, stress reduction, proper nutrition, and regular sleep and exercise patterns (CABF, 2004). Incorporating these interventions and participating in support groups can help children and their parents to cope with this disorder (Papolos & Papolos, 2002).
Lithium has been billed as the “miracle drug” in treating BPD because it has been very successful in mood stabilization and in reducing the risk of suicide (Goodwin, Fireman, Hunkeler, Lee, & Revicki, 2003). However, it is contraindicated in children who are nonresponsive to the drug or find the side effects intolerable (Silva, Matzner, Diaz, & Singh, 1999). The most serious side effects include tremors, headaches, impaired memory, and fatigue. Lithium can also cause depressed motor reactions, weight gain, acne, gastric bloating, and nausea. Although the symptoms of BPD may be stabilized with lithium, the side effects have the potential to alter a child’s physical appearance, placing him or her at greater risk of social ridicule and isolation. Table 4 describes other classes of medications prescribed for stabilizing mood disorders. Convincing the child to take medication can be one of the most difficult obstacles to overcome in the treatment modality.
Diagnostic Tools
The DSM-IV-TR (APA, 2000) lists the diagnostic criteria for BPD and is the primary tool in diagnosing children with mental illness. Another assessment tool that is widely used in schools is the Behavior Assessment System for Children (BASC) (Reynolds & Kamphaus, 1998). The BASC uses a multimethod approach that identifies the behaviors and self-perceptions of children. The Bipolar Child Questionnaire (Papolos & Papolos, 2002) is an assessment completed by parents to identify behavioral symptoms of BPD, family history of mental illness, and the history and effectiveness of medical and pharmaceutical interventions. Although these tools are useful in identifying behavioral patterns, a thorough assessment by a physician or mental health provider is essential in making a definitive diagnosis.
IMPLICATIONS FOR SCHOOL NURSING PRACTICE
The school nurse is an integral part of the school multidisciplinary team. Although teachers are often the first to recognize that a child is having difficulty functioning in the classroom, they are not qualified to diagnose a child or recommend medication. They are, however, in a position to provide valuable information to the school nurse, who can help facilitate the evaluation process. The school nurse can observe the child in the classroom setting and interview the parents about their child’s behavior at home. Many times parents will report that their child has “no problems” and will blame their child’s difficulty on transitions, violent behavior, poor social skills, teachers, or other students. Feelings of guilt, embarrassment, and confusion about their child’s erratic behavior at home and school can cause parents to be reluctant to share information with an “outsider.” To overcome these barriers, it is essential for the school nurse to build rapport with parents by developing trust and understanding.
Through case management, the school nurse can be instrumental in coordinating the medical and social needs of the student, as well as implementing school accommodations described in Table 5. By initiating team meetings with parents, administration, and staff, the school nurse can communicate concerns regarding the child’s behavior. A critical step in early intervention is emphasizing the importance of a medical evaluation. Concrete examples of specific behaviors, rather than biased statements, are valued by mental health providers and help facilitate an accurate diagnosis and treatment plan (Brunner, 2002). After a bipolar diagnosis is made, a key role of the nurse is to educate staff and families about the symptoms of BPD and its social, emotional, and academic impact on the child and family. If a child is suicidal, homicidal, or delusional, Emergency Medical Services should be consulted. School nurses can also refer families to outside resources that will provide information about the disorder and support for families of individuals with BPD.
CONCLUSION
BPD is a very complex mental illness with serious consequences that can have an impact on a child’s academic, social, and emotional functioning. The brain takes up to 29 years to reach maturity and must be able to receive and process cognitive and emotional stimuli during that time for optimal development. If BPD is present during the critical periods of rapid growth, the brain can be adversely affected, causing long-term physiologic changes and psychosocial deficiencies. Learning delays, academic failure, substance abuse, misconduct, and suicide are just a few of the educational and societal concerns that can result from BPD. Children can benefit from the combined interventions of medication, psychotherapy, and school accommodations (Table 5), which can potentially reverse this negative trajectory and enhance a child’s ability to function. Every child has the right to receive an education regardless of his or her disability, and every child deserves the opportunity to be productive and to function at the highest possible level. School nurses are a valuable resource for students, parents, and school staff. As members of the school’s multidisciplinary team, they play an important role in case management by promoting the well-being of students with BPD at school, at home, and in the community.
Children can benefit from the combined interventions of medication, psychotherapy, and school accommodations, which can potentially reverse this negative trajectory and enhance a child’s ability to function.
Footnotes
This article was conducted as a requirement for the final project in the master’s degree program for both authors at Nova Southeastern University, Ft. Lauderdale, FL.