What is Bipolar Disorder?

 For those who are not familiar with Bipolar Disorder (formerly known as manic depression), this is a psychiatric disorder where both positives and negatives are experienced too strongly.  Feelings of happiness or sadness can be extreme without the child having any idea of why they are having these disproportionate reactions.  The mood swings themselves can cause excessive irritability or sadness and can interfere with daily life both at home and in school.  For a child with Bipolar Disorder once they are depressed they may find that they can’t get out of bed to go to school; in fact just the idea of doing school work may seem impossible.  On the other hand, another day they may feel wonderful and appear to have boundless energy or seem to be out of control.  This is a lifelong illness that can move from depression (with sadness, loss of appetite, sleep disturbance) to mania with irritability and anger, to hypomania where the child feels good, they feel as if they are getting things done, but, they might be moving into a manic episode, or mixed mood whether they feelings of mania and depression alternate back and forth very rapidly.  These affective/mood problems are the most obvious problems associated with this disorder, but, there are also cognitive deficits that need to be attended to.

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Bipolar Disorder and Cognitive Deficits

 Since most children with Bipolar Disorder have normal Intelligence Quotients and deceptively normal cognition, teachers often lack awareness of the Bipolar child’s needs for accommodations and specific instructional techniques.  In fact, beyond the mood swings and irritability, there are specific cognitive deficits associated with Bipolar Disorder. These include extensive cognitive abnormalities with a pattern of deficits that can be aggravated by pressure and stress and which wax and wane with the affective symptomatology associated with the disease.  These deficits include deficits in verbal memory and frontal executive tasks that is thinking, planning, organizing, evaluating and judging.  Attention and visual information processing are particular impairments in children with bipolar disorder, especially when symptomatic for wither depression or mania.

 

What Can A Teacher Do?

 First, the teacher may wish to speak with the school psychologist about providing cognitive behavioral therapy specifically designed for relapse prevention once the child has been stabilized on medication. To be most effective, this should involve weekly sessions for the child and include parent training regarding this disorder at least monthly.  To help children with Bipolar Disorder avoid relapse, teachers need to provide a structured predictable environment with a consistent routine and schedule.

 Second, the teacher may wish to ask the IEP team to arrange a “safe place” that the Bipolar child can voluntarily relocate to when they are feeling irritable or as if they are going to cry or have a temper outburst.  This could be, but does not necessarily have to be the nurse’s office or a counselor’s office. It may be that a small garden cove or the library would serve the purpose even better because the child would not stand out as being obviously different in these situations. If peers inquire why a child left the room, the child can be taught to simply reply, “I needed to take care of something”.  Before this safe place is utilized, however, it would be important for a school psychologist or school counselor to have five or six meetings with the child to develop and practice a short list of “quick control” techniques the child might employ. This could be as simple as doing jumping jacks to get out excess energy, or writing what upset them in a private journal, or doing some deep breathing.  What works will be unique to the child, but, before a child goes to a “safe place” to “self-calm” they need some specific skills to accomplish this goal.

 

Mathematics

 

Even between depressed and manic episodes cognitive deficits persist.  Adolescents with remitted bipolar disorder evidence a specific profile of mathematic difficulties associated with neuroanatomical abnormalities that result in cognitive deficits such as a slowed response time. Thus, these children require a specialized diagnostic-prescriptive assessment of mathematics as part of their educational plan with math instruction customized based upon test data. 

 

Behavior Intervention

 A critical point is the fact that when exposed to negative feelings, words or feedback, bipolar children show increased activation in the part of the brain that regulates emotion.  In short, their amygdale is over=reactive to negative stimuli.  Thus, even more than with other disabled children, punishment and negative consequences or comments need to be avoided when educating these children. To assist teachers with this, the school psychologist needs to work with the balance of the IEP to develop a Behavioral Intervention Plan with a wealth of positive supports and rewards.    A major consideration when designing a BIP for bipolar children is that facial expression have a greater impact on children with bipolar disorder than they do on typically developing children.  If we frown at them or alter the tone of the voice, they experience it as a much greater chastisement than we intended; therefore, in interacting with these children adults, must intentionally moderate their own facial expressions and tone of voice.  In short, there is a neural basis for mania (with increased irritability or excessively happy moods) in children with Bipolar Disorder.  One important intervention in the academic environment is to maintain a more neutral mood as evidenced in body language, facial expression, and tone of voice, pitch and volume when offering these children constructive criticism. This may require that the staff working with a bipolar child practice these skills and be videotaped so they can better recognize and control those behaviors that are likely to trigger a Bipolar child’s negative reaction.

 

Compensation for Attention Deficits

 To help compensate for their impaired verbal attention, teachers should simplify verbal directions and then ask children to repeat them before actually beginning a task. For tasks to be completed at another point in time (such as homework or reports) teachers need to provide written instruction.  Teacher should also advocate with the IEP team for common compensations such as:

 

·        placement in a classroom that is organized by rows for independent work and in groups of three or four when the child is capable of profiting from small group instruction

 ·        placement near the teacher for prompting and redirection and away from distracting sights or sounds

 ·        a written schedule on the child’s desk for quick and easy reference

 ·        The opportunity to complete independent work on a laptop at an isolated computer with a noise cancelling headset.

 ·        Provision of an Ipod/MP3 player that can be employed to play soft instrumental music to block out auditory distractions when reading.

 ·        Pre-tutoring by a peer or an aid who presents key concepts or vocabulary prior to the lesson which introduces them in class

 ·        Provision on a stress ball or other small item the child can use to self-calm when necessary

 As a related service, parents and teachers may wish to consider attention based training utilizing Eudofeedback.  Information about this intervention can be obtained at http://www.playattention.com/seminars/?refid=drcrum  

 

Compensation for Memory Deficits

 A working memory deficit is a core deficit underlying multiple neuropsychological deficits in children with Bipolar Disorder.  The lower capacity for verbal and spatial “on-line storage” rate appears to limit the performance of other cognitive functions such as executive functions that rely critically on the phonetic loop, complex visual functions such as shape or object memory, and visual orientation. 

 ·        This means that:  teachers need to repeat more for children with Bipolar Disorder than they do for other children. This should be in the form of first telling the child what they are going to learn, then teaching it, then providing guided drill, and then providing guided application.  For example, we are going to learn about the constitution tomorrow, so tonight your peer tutor will introduce these new words to you that will be in tomorrow’s lesson.  Then, prior to beginning the lesson with the whole class, the same words should be introduced to the class and the class as a whole should chant the words and their definition repeatedly. Then, perhaps, the words can be presented and different rows can take turns providing the definitions.  Then, the Bipolar student might be asked to be the echo and repeat what each row says, and finally, the teacher may proceed to teach the balance of the lesson.  While, this procedure may require 20 minutes, not only will the Bipolar Child benefit, but, so will every other student in the class.

 ·        A common problem for children with Bipolar Disorder is forgetting what their homework assignment is and when it is due.  To minimize this problem, teachers can email the assignment directly to the child’s email, and parents can establish as set place and time for emails to be checked daily.  Having the written directions in front of them will also facilitate the child’s homework completion because when they can’t hold the assignment in working memory they can keep re-reading the written instructions.

 ·        As a function of their impaired working memory, Bipolar children often forget what they have just been told; this frustrates both the teacher and the child. To help compensate for this weaknesses, it is suggested that teachers first assure they have the child’s attention by making eye contact, second, give the direction in as few words as possible and give the direction with redundancy, and third, ask the child to tell you what he is going to do.  For instance, Ms.Jones looks at Kimi and smiles. Then, she says:  “Kimi, turn to page 51 in your math book.  Your math book, page 51.  Kimi, what will you do now?”  If Kimi can’t say: “Turn to page 51 in my math book,” the teacher needs to say:  “Okay, math book, page 51. What book Kimi?  What page?”

 ·        A child with memory impairments secondary to Bipolar disorder may also benefit from the use of a palm pilot as memory journal for a child to record important things there learned or were told during the day, or to list tasks they need to complete- such as getting a permission slip signed, or calling their peer tutor.  The classroom teacher can ask the assistive technology team to evaluate the child for his or her capability to learn how to use such as device and then to provide the training needed.

 ·        Memory Journal as part of classroom routine.  Teachers who have children with ADD, Bipolar Disorder, TBI or other students with memory problems, might benefit the children and make teaching easier if they incorporated 5 to 10 minutes each morning to review memory journals. This is a time for children to share important things they wrote in their memory journals:  i.e. “Book report due next Friday”. Does everyone have that written down?  If not, write it now. “Book report due next Friday; that is the 10th.”

 ·        Due to impaired attention, memory and planning and organization, the child with Bipolar Disorder may experience considerable difficulty listening to the teacher, trying to decide what’s important, planning how to write it down, and organizing it visuo-spatially on the page. As a result, their notes are unlikely to be functional study resources. To avoid this problem, a teacher may wish to make an outline of each lesson that clear states the objective, the primary new vocabulary words or key concepts, and one or two examples.   For example,

 

Notes for 10/11/2008

 Language Arts

 Objective:  To learn to spell words that have the vowels I and E together.

 Rule:  “I before E, except after C”

 Example:  lien – the I comes first and the E comes second because there is NO C. IE

 Example:  receipt – the E comes first and the I comes second because there IS a C. CEI

 

Providing these notes, gives every student a good study guide, serves as a clear reference for the child when doing their independent practice for homework, and keeps parents clearly apprised of what their child is learning. It is a win-win-win!  It also models good note taking and organization day in and day out, so that this skill becomes an engrained one for the students.

 

It should be noted that this is preferential to having a note taker assigned to a given child for a number of reasons.  First, the teacher’s provision of daily  notes benefits all of the children rather than just a given child; and is thus more cost and time effective. Second, this avoid the Bipolar child being signaled out as having a special need that they might be embarrassed about or even worst be teased for.

·        People with memory impairments generally recall best whatever is presented first or last, and poorest what is presented in the middle.  Therefore, if teachers wish to assist children with memory problems, they need to present the most critical information in a unit first, and then expand upon it, and then at the end of the instruction again return to a short hand version of the most critical information.  For example,

 “I before E, except after C”

 

This is the spelling rule we will be learning today.  It means that when we are spelling a word that has both an I and an E, most of the time, the I comes first in the word. But, when the I and the E come after a C like they do in “receipt”. The I follows the E.  So usually, when you are writing, you will write the I first and the E second. But, if you have just written a c, then you will write the E first and the I second.  “I before E, except after C”

 Let’s do a worksheet to learn this together:  “I before E, except after C”.  Bob, can you tell us how you would answer number 1 on page 25? “ F-R-I-E-N-D. That’s correct Bob, you put the I before the E because there was no C”.  Again, the rule is I before E, except after C”  Joe, can you tell us the correct answer for number 2?”  Notice the constant repetition and example and praise sets up an errorless learning situation which is positive for any student and avoid the Bipolar children receiving negative feedback that they might overreact to.

 Tomorrow, this rule would be reviewed and then perhaps expanded upon by adding:  “I before E, except after C or when sounding like “A” as in neighbor or weigh”.

 ·        Daily and Weekly Schedules – It is very helpful if teachers provide children with a weekly schedule each Friday for the following week. This schedule should be reviewed in class on Friday afternoon so that the children’s questions can be answered. Then, the children can take this home so their children can review it with them again, and post it someplace accessible at home for easy reference and reminders.  In addition, each teacher should provide each child with a daily schedule for their particular subject

 

 For Language Arts it might be as simple as: 

 10-10:15      Review important concepts from yesterday

 10:15-10:30            Introduce new vocabulary, drill by row

 10:30-10:40            Guided worksheet on “I before e except after c” done by class

 10:40-10:50            Individual worksheet on “I before e except after c”

 10:50-11:00            Exchange papers and correct worksheet

 Homework   “I before e except after c” practice on page 122

 

If the teacher follows essentially the same schedule each day, it will become routine for all the children. Thus, while the material covered will change, the manner and sequence  in which it is presented will not.  Therefore, it will become an automatic routine for the student, thereby decreasing the demands on the child’s working memory and permitting them to concentrate more completely on the content of the material being presented.

 

Helping the Child Avoid Mood Swings

 As if teachers don’t already have enough to deal with, if they have students with Bipolar Disorder, they also need to help these children avoid triggers that are likely to precipitate an extreme mood swing.  This may include watching their diet at lunch.  Caffeine in Mountain Dew, energy drinks, chocolate, can disrupt the sleep cycle and trigger a significant mood swing. So too can staying up too late to complete homework. With this in mind, try to work out an arrangement with the Bipolar child and their parent that provides an opportunity for the child to skip assignments when in the midst of a mood swing, and catch them up within the next two weeks when their mood has stabilized without other students being alerted to this fact.

 ·        Some common triggers of bipolar mood swings include: inadequate sleep, use of alcohol or drugs, starting medicines for depression, using herbal products, having thyroid or other medical conditions.  With this in mind, there needs to be a very good communication system between the parents and the teachers. If a Bipolar Child couldn’t sleep the night before, rather than push them to come to school and trigger a significant mood swing, it may be better to permit them to sleep late, and make up the lesson over the weekend.  Or, if there is a medical reason that medication needs to be stopped or changed, the team may want to consider permitting the child to receive homebound instruction during the two to three week transition period to avoid exacerbating the child’s problems.

 ·        Other factors that teachers need to keep in mind include seemingly innocuous events such as seasonal changes, holidays, a cold coming on, being disciplined at home for misbehavior, a typical disagreement with a peer, the loss of a pet; all normal things which most children are able to deal with and bounce back to normal with relative ease, but which may be major stumbling blocks for a child with Bipolar Disorder. This means, they need more lead time, more preparation and post even adjustment time than their nondisabled peers; and they need this to be provided in a fashion that does not signal them out as different.  For example, if you see the Bipolar Child over reacting to a comment a friend made. This might be a teachable moment for the class.  You might be able to say something like:  “I heard one friend tell another she was bossy.  I think that hurt her friend’s feelings.  What else might Alyssa have said if she didn’t want to do what a friend suggests?  If your friend hurts your feelings. what could you do to calm down and feel better in school?”  Or, if you know Christmas Vacation is coming up, you may want to talk take some time to talk with the class about the holiday and what they will do during that time.  For the child with Bipolar Disorder, you might reinforce this by just pulling them aside and asking if they might bring in photos after the holiday to share with the class.  Or, you might just give them a phone call a few days before school is scheduled to resume letting them know you are looking forward to seeing them; and pop the schedule for the first week back to school in the mail so they can look over it during the holiday break.

 

ABC’s of Bipolar Disorder

 The important things for teaches to understand are:

 While Bipolar disorder cannot be cured, there are ways to help control it.  The interventions outlined above will go a long way to supporting the private therapy and medication therapy the child receives outside of school

 Bipolar disorder is not easy to diagnose.  Doctors often mistake it for ADHD in younger children.  But, once a child has received this diagnosis you need to learn more about it so you can give the child the appropriate support to maintain emotional stability.

 Most people with Bipolar Disorder are treated on an outpatient basis and have productive lives.  They can be good students, and eventually good employees. But, they need our help in learning to recognize and avoid their own triggers, and learning to self-calm no matter where they are.

 There are many medications used to help control the symptoms of depression and mania and to reduce the frequency of mood swings. These include mood stabilizers such as Depakote or Tegretol, Antidepressants such as Prosac or Zoloft, Antipsychotics such as Haldodrol.  But, the negative side effects of any of these medications may be greater on children whose nervous systems are still developing than they are on adults. For this reason, many physicians and parents try to avoid using medication any sooner than necessary and to use as minimal amount as possible.  This is also why parents may wish to explore alternative interventions such as feedback based attention training to improve attention, cognitive remediation to improve memory and transcranial electrotherapy to improve mood stability.

 

As a teacher in the classroom, you can help a child with Bipolar maintain wellness by:

 ·        being available after school or at lunch for the child to drop in and speak with you

 ·        encouraging the child to keep all medical and psychotherapy appointments by making it manageable for him or her to make up any missed work

 ·        incorporating exercises into your regular class routine that will give this child and others an opportunity to release tensions and relax

 ·        Complementing lessons with fun hands on learning activities

 ·        Making certain that your class spends some time each day outdoors

 ·        Encouraging all the children in your class to avoid caffeine, sugar and heavily salted foods when they pack or select their lunch, or when they bring items for class celebrations.

 ·        Asking all your students to keep a strengths and accomplishments journal in which they have to write something positive about themselves each day and something they learned or accomplished.

 ·        Balance is the key for children with Bipolar Disorder. They need to go to sleep and wake up about the same time each day. They need physical activity each day; they need to avoid caffeine and non prescription drugs.  Children with Bipolar Disorder need to be taught to take frequent breaks during the school day, and how to use personal planners to help manage their time.  They need to learn how to avoid stress and other triggers of mood swings.  They need to try and avoid illness because illness may trigger their mood swings.  As a teacher, this means you may need to remind this child a little more often to wash their hands, or stand up and stretch, but, because of their tendency to over react this needs to be done gently.

 Important Message to Parents

  If you are a parent of a child with Bipolar Disorder, it is important for you to realize that most teachers have had an Introduction to Psychology Course, a Child Development Course, and perhaps one Abnormal Psychology Course. They have not had extensive training in affective mood disorders and probably know very little about Childhood or Early Onset Bipolar Disorder. So, you may wish to share this newsletter and other useful information that you come across with your child’s teachers and with members of the IEP team.  Remember; don’t attack your child’s teacher for not knowing your child or your child’s illness as well as you do.  Instead, work to educate all the educational staff that works with your child.

 Submitted as a community service,

 By Susan L. Crum, B.S., M.S., Ph.D.

 Special Needs Coach

 Able2Learn

 Website:  wwwspecialeducationsupport.org

 Voice and Fax:  863-471-0281

 Email:  Able2learn@live.com