Bipolar Disorder (BD) in Pediatrics

OT Dude Academy’s Free NBCOT® Exam Prep Course Pediatric Psychosocial Disorders Bipolar Disorder (BD) in Pediatrics
Contents Hide
1 Prevalence
2 Causes
3 Symptoms
3.1 Manic Episode
3.2 Depressive Episode
3.3 Mixed Episode
3.4 Rapid Cycling
4 Co-occurring Conditions and Disorders
5 Impact on Occupations
6 Outcome Measures
7 Treatment
8 Occupational Therapy Considerations
8.1 Don’ts
8.2 Parent Education

Children and adolescents often experience mood swings as part of their normal growth and development. However, when this interferes with their ability to function in daily life, they may have bipolar disorder (BD). BD is also known as manic-depression, is a mood disorder that is characterized by extreme changes in moods, energy levels, and behavior.1 

Prevalence

BD is more common in adults, can occur in teens, and is less common during childhood. BD affects males and females equally.2  BD can affect anyone. If one or both parents have BD, there is an increased risk of their children developing BD.3 

Causes

  • Genetics
  • Brain structure and function
  • Stress – modifiable2 

Symptoms

Manic Episode

Involves a period of elevated (overly happy) mood, expansion, and irritability with increased energy at the same time.

  • Unrealistic highs in self-esteem
  • Increase in energy
  • Hyperverbosity (talking too much)
  • Increased distractibility and poor attention
  • Rapid thought process
  • Repeated high risk-taking behavior: alcohol, drugs, reckless driving, sexual promiscuity

Depressive Episode

Involves experiencing periods of depression with low, depressed, or irritable mood.

  • Decreased enjoyment in favorite or meaningful activities
  • Low energy level; fatigue
  • Changes in sleeping patterns – oversleeping or difficulty falling asleep
  • Poor concentration
  • Complaints of boredom
  • Changes in eating habits, weight changes
  • Complaints of physical illnesses, e.g., headaches, stomach aches
  • Suicide ideation

Mixed Episode

  • Clients simultaneously meet criteria for both mania and depression that co-occur for at least 1 week.
  • Women are more likely to experience mixed episodes.
  • Associated with a poor prognosis due to a high risk of suicide.4 

Rapid Cycling

  • Clients experiencing more than 4 episodes per year have the rapid-cycling subtype of BD.
  • Associated with an increased chance of treatment resistance and poorer prognosis.5 

Co-occurring Conditions and Disorders

  • Drug abuse
  • ADHD
  • Major depressive disorder
  • Schizophrenia3 
  • Anxiety disorders6 

Impact on Occupations

Symptoms from BD may impact sleep, communication, academic performance, and family functioning.7 8  Pediatric BD may involve neurocognitive deficits that disrupt school behavior. Socially, pediatrics may have affected peer networks, be victimized, and have poor social skills.9 10  In family relationships, pediatric BD may cause frequent sibling and parental conflict, lower levels of warmth, and chronic stress in family life.11  These difficulties with social and family relationships may extend broadly to other interactions and pediatrics may experience low self-esteem, hopelessness, and maladaptive coping strategies.12  Research on adults with BD found an impact on the occupations of self-care, productivity, leisure, and roles (e.g., family member, friend, student).13 

Outcome Measures

  • Role Checklist (Oakley, 1982)
  • Occupational Performance Questionnaire
  • Canadian Occupational Performance Measure (COPM) 13 
  • Goal Attainment Scale (GAS) 14 
  • Assessment of Motor and Process Skills (AMPS)
  • Global Assessment of Functioning15 
  • Trail Making A and B: clients with BD are more likely to have impaired visual-motor sequencing, memory, and attention (cognitive impairments) 16 

Treatment

  • Individual or group therapy
  • Cognitive Behavioral Therapy (CBT)
    • Child- focused and family-focused (CFF-CBT) 17 18 
    • The RAINBOW CFF-CBT program centers on (1) Routine: establishing routines, (2) Affect Regulation: education about affective dysfunction and coping skills to manage triggers (3) I can do it: improving self-esteem and self-efficacy, (4) No negative thoughts and Live in the now, (5) Be a good friend and Balance lifestyle for parents: promotes social skills and self-care for parents, (6) Oh how do we solve this problem, (7) Ways to get support: for the family, in school, and the community.19 )
  • Family-focused Therapy for Adolescents (FFT-A): designed for youth ages 12-17 with BD that involves 21 sessions of varying frequency. Involves psychoeducation, self-management, medication adherence, understanding symptoms, relapse prevention, communication enhancement raining, and problem-skills training.20  Has also been adapted for children and adolescents at high risk for developing BD, FFT-HR. FFT-HR is 12 sessions over 4 months for youths ages 9-17 and their families. The goal is to help families identify and intervene on early BD symptoms and to improve family communicaiton and problem solving.21 
  • Dialectical Behavioral Therapy (DBT) for Adolescents
    • An evidence-based intervention that has demonstrated efficacy for adulst with borderline personality and adapted for adolescents with BD.22 
    • Focus is on emotional dysregulation to improve symptoms.23 
    • Involves family skills trianing for the entire family on psychoeducation and the skills of mindfulness, distress tolerance, emotioanl regulation, interpersonal effectiveness, and therapy for the youth on applications of skills to manage problem behaviors and mood states in daily life.
  • Interpersonal and Social Rhythm Therapy for Adolescents (IPSRT-A)
    • Based on biopsychosocial therapy that is supported for adults with BD.24 25 
    • Specifically targets biology of BD and the instability of circadian rhythms, neurotransmitter systems dysregulation, and social routines that affect circadian systems.24 
    • IPSRT-A is a 16-18 session individual-based treatment with brief family psychotherapy.
      • Stabilizing social and sleep routines
      • Addressing psychosocial stressors
      • Interpersonal conflict
      • Role transitions
      • Interpersonal functioning deficits26 
  • Medications – mood stabilizers (lithium), antipsychotics, antidepressants (less common)
    • Examples: Abilify, Wellbutrin, Prozac, Haldol, Lamictal, Zyprexa, Seroquel, Risperdal, Geodon27 
  • Self-management strategies – education and recognition of an episode’s early symptoms
  • Complementary health approaches: aerobic exercise, meditation, religious support (not effective in isolation) 2 

Occupational Therapy Considerations

  • The child should be involved in making treatment decisions.
  • Early detection and intervention can help to stabilize children who are experiencing mood changes.28 
  • Effective interventions mentioned share common elements of using an adjunctive approach, incorporating psychoeducational about the nature and symptoms of BD in pediatrics, involvement of the family, focus on developing skills for coping with mood dysregulation, and interpersonal functioning.29 
  • Provide interventions that maintain general health and wellness [health management].30 
  • Provide interventions to support performance with IADL tasks.31 32 33 34 
  • Provide interventions for educators to support school participation associated with mania and depression.
    • Be flexible in education, planning, and interventions based on client’s fluctuations in mood and energy.
    • Provide flexible scheduling and additional time for assignments.
    • Minimize distractions and surprises.
    • Be mindful of fatigue, agitation, and frustration.
    • Provide feedback.
    • Picture schedules may be helpful.
    • Teach students to develop short-term goals and long-term goals.
    • use daily planners and visual organizers.
    • Work with parents to develop consistent and structured routines in the home and school environment.
    • Break down assignments into smaller more manageable segments.
    • Provide short breaks as needed between assignments.
    • Set realistic timelines based on student’s progress.
    • Provide a smaller, secluded, comfortable, and more secluded testing environment.
    • Use scribes and technology to enhance performance.35 
    • Provide social skills groups or interventions.
    • Call 911 if the client is suicidal, homicidal, or delusional.
    • Place the client in the least restrictive environment and safe place.
    • Use positive reinforcement.
    • Use organizational strategies (notebooks, planners, color coding) 36 
    • Collaborate on a behavior modification plan and sign a behavior contract37 
  • Help clients manage sleep and stress.
  • Support clients to make healthy lifestyle changes.
  • Provide clients with access to support networks.38 
  • Address social skills performance and participation in school, family, and community as adolescents with BD lag behind their peers in social skills performance.39 40 
  • Promote programs that assess bullying.41 
  • Prevent relapse and provide strategies for maintenance.42 
  • Address parent’s feelings of guilt and self-blame from the misperception that BD is caused by ‘bad parenting’.
  • Until a child’s mood is stable, behavior-management skills typically are not effective.
  • Minimize communication breakdown with parents and be a good listener.
  • Do not assume sexual abuse when symptoms of hypersexuality arise.43 
  • Help clients develop a self-care plan and identify barriers to goal attainment.
  • Provide homework such as thought diaries for situations such as stressful interactions.44 
  • Address functional motor ability, e.g., handwriting.
  • Identify problem behaviors and performance skills that pose safety risks and provide alternatives or compensatory techniques to maintain participation.45 

Don’ts

  1. Don’t talk about the child in front of the child.
  2. Don’t ignore mood.
  3. Don’t blame parents for lack of treatment success.43 

Parent Education

  • Be patient
  • Listen and encourage conversation
  • Pay attention to changes in moods
  • Understand the triggers
  • Encourage leisure activities
  • Knowing that treatments can take time.6 
  1. Mental Health America. (n.d.). Bipolar Disorder In Children. Retrieved from https://www.mhanational.org/bipolar-disorder-children[↩]
  2. NAMI. (2017). Bipolar Disorder. Retrieved from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Bipolar-Disorder[↩][↩][↩]
  3. American Academy of Child & Adolescent Psychiatry. (2015). Bipolar Disorder In Children And Teens. Retrieved from https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Bipolar-Disorder-In-Children-And-Teens-038.aspx[↩][↩]
  4. Epidemiology, diagnosis and management of mixed mania. González-Pinto A, Aldama A, Mosquera F, González Gómez C CNS Drugs. 2007; 21(8):611-26.[↩]
  5. Treatment of rapid-cycling bipolar disorder. Schneck CD. J Clin Psychiatry. 2006; 67 Suppl 11():22-7.[↩]
  6. National Institute of Mental Health. (n.d.). Bipolar Disorder in Children and Teens. Retrieved from https://www.nimh.nih.gov/sites/default/files/documents/health/publications/bipolar-disorder-in-children-and-teens/20-mh-8081-bipolardischildren.pdf[↩][↩]
  7. Psychosocial functioning among bipolar youth.((Goldstein TR, Birmaher B, Axelson D, Goldstein BI, Gill MK, Esposito-Smythers C, Ryan ND, Strober MA, Hunt J, Keller M J Affect Disord. 2009 Apr; 114(1-3):174-83.[↩]
  8. Psychosocial treatments for childhood and adolescent bipolar disorder. West AE, Pavuluri MN Child Adolesc Psychiatr Clin N Am. 2009 Apr; 18(2):471-82, x-xi.[↩]
  9. Social skills knowledge and performance among adolescents with bipolar disorder. Goldstein TR, Miklowitz DJ, Mullen KL Bipolar Disord. 2006 Aug; 8(4):350-61.[↩]
  10. Patterns of comorbidity and dysfunction in clinically referred preschool and school-age children with bipolar disorder. Wilens TE, Biederman J, Forkner P, Ditterline J, Morris M, Moore H, Galdo M, Spencer TJ, Wozniak J J Child Adolesc Psychopharmacol. 2003 Winter; 13(4):495-505.[↩]
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  12. Psychosocial functioning of adolescents with and without pediatric bipolar disorder. Rucklidge JJ J Affect Disord. 2006 Apr; 91(2-3):181-8.[↩]
  13. Kusznir, A., Scott, E., Cooke, R. G., & Young, L. T. (1996). Functional consequences of bipolar affective disorder: An occupational therapy perspective. Canadian Journal of Occupational Therapy, 63(5), 313-322.[↩][↩]
  14. Tsapekos, D., Strawbridge, R., Cella, M., Young, A. H., & Wykes, T. (2021). Does cognitive improvement translate into functional changes? Exploring the transfer mechanisms of cognitive remediation therapy for euthymic people with bipolar disorder. Psychological Medicine, 1-9.[↩]
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  16. Zarate, C. A., Tohen, M., Land, M., & Cavanagh, S. (2000). Functional impairment and cognition in bipolar disorder. Psychiatric Quarterly, 71(4), 309-329.[↩]
  17. Pavuluri MN, Graczyk PA, Henry DB, Carbray JA, Heidenreich J, Miklowitz DJ. Child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: development and preliminary results. Journal of the American Academy of Child and Adolescent Psychiatry. 2004;43(5):528–537.[↩]
  18. West AE, Weinstein SM. A family-based psychosocial treatment model. Isr J Psychiatry Relat Sci. 2012;49(2) [↩]
  19. West AE, Weinstein SM. A family-based psychosocial treatment model. Isr J Psychiatry Relat Sci. 2012;49(2[↩]
  20. Miklowitz DJ, George EL, Axelson DA, et al. Family-focused treatment for adolescents with bipolar disorder. Journal of Affective Disorders. 2004;82(S1):S113–S128.[↩]
  21. Early psychosocial intervention for youth at risk for bipolar I or II disorder: a one-year treatment development trial. Miklowitz DJ, Chang KD, Taylor DO, George EL, Singh MK, Schneck CD, Dickinson LM, Howe ME, Garber J Bipolar Disord. 2011 Feb; 13(1):67-75.[↩]
  22. Goldstein TR, Axelson DA, Birmaher B, Brent DA. Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2007;46(7):820–830.[↩]
  23. Clinical course of children and adolescents with bipolar spectrum disorders. Birmaher B, Axelson D, Strober M, Gill MK, Valeri S, Chiappetta L, Ryan N, Leonard H, Hunt J, Iyengar S, Keller M Arch Gen Psychiatry. 2006 Feb; 63(2):175-83.[↩]
  24. Frank E. Guilford Press; New York, NY, US: 2005. Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal and Social Rhythm Therapy.[↩][↩]
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  27. The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments.
    Ng F, Mammen OK, Wilting I, Sachs GS, Ferrier IN, Cassidy F, Beaulieu S, Yatham LN, Berk M, International Society for Bipolar Disorders. Bipolar Disord. 2009 Sep; 11(6):559-95.[↩]
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  30. The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments. Ng F, Mammen OK, Wilting I, Sachs GS, Ferrier IN, Cassidy F, Beaulieu S, Yatham LN, Berk M, International Society for Bipolar Disorders. Bipolar Disord. 2009 Sep; 11(6):559-95.[↩]
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