dentifying children with emotional and behavioral disorders has long ...

C hildhood Bipolar D isorder

C h ild h o o d

B ip o la r D is o r d e r : A

D if f ic u lt D ia g n o s is

Kimberly K ode Sutton , Y ork C ollege of P ennsylvania

dentifying children with emotional and behavioral disorders has long been problematic. In a general sense, those children who are most likely to be noticed by teachers and, therefore, referred for possible special education placement are those who exhibit externalizing behaviors, including physical aggression, noncompliance, and rule-breaking. Children who exhibit these kinds of behaviors make up a significant portion of those receiving federal services under the category of emotional disturbance (Hallahan & Kauffman, 2006). It is often the children with internalized disorders who are overlooked. Children who suffer from mental or emotional conflicts may appear to be quiet and compliant in the classroom and, therefore, less likely to stand out to adults as needing supportive services (Flick, 2011). Children with bipolar disorder are among this population. Childhood bipolar disorder affects more than 750,000 children annually (Senokossoff & Stoddard, 2009) and is more common than childhood incidences of juvenile diabetes, cancer, AIDS, and epilepsy combined (Hellander, 2000). Educators, parents, and mental health professionals are just now beginning to recognize the seriousness of bipolar disorder in children. The following discussion describes the difficulties related to both diagnosis of the illness itself and interventions that best improve the outcomes for children and adolescents with bipolar disorder.

I

Diagnosis of Bipolar Disorder Bipolar disorder is "a biological brain disorder that causes severe 30

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and unusual fluctuations in an individual's mood, energy, and ability to function" (Killu & Crundwell, 2008, p. 245). Research suggests that bipolar disorder is caused by a combination of factors including genetic transmission and vulnerability, neurotransmitter abnormalities, and environmental factors, such as stressful life events (Killu & Crundwell, 2008; Geller & Luby, 1997). Bipolar disorder is acknowledged to be the most prevalent psychiatric condition in adults (Senokossoff & Stoddard, 2009); diagnosis is determined through an assessment using those characteristics described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013). The DSM-5 (APA, 2013) differentiates among three different subtypes of bipolar disorder. Those adults diagnosed with the classic form of bipolar disorder, Bipolar I, typically experience a pattern of mood swings ranging from manic or hypomanic episodes (characterized by increased rates of talking and activity, inflated self-esteem, racing thoughts, and less need for sleep) to major depressive episodes (characterized by difficulties with concentration, low energy level, difficulty making decisions, and sleep and appetite disturbances) with potential intervals of wellness between episodes. At least one lifetime episode of mania is required for a diagnosis of Bipolar I disorder. A diagnosis of Bipolar II is given to adults who experience mood swings that alternate from hypomanic episodes, or a predominantly irritable mood, to major depressive episodes. Individuals with Bipolar II disorder do not experience mania. Those individuals

who have alternating moods that are indicative of Bipolar I or Bipolar II but do not meet the full criteria for a diagnosis of either disorder are frequently diagnosed as having Unspecified Bipolar Disorder (APA). Additionally, individuals diagnosed with bipolar disorder can suffer from mood episodes that the DSM-5 (APA, 2013, p. 149-151.) describes as a "mixed state" or "rapid cycling." A mixed state is diagnosed when individuals experience symptoms of both mania and depression simultaneously. Rapid cycling is diagnosed if individuals experience at least four episodes within a 12-month period in which the criteria are met for manic, hypomanic, or major depressive episodes and include either a period of full remission or a switch of mood to that of the opposite polarity (i.e., major depressive episode to either a manic or hypomanic episode; a manic or hypomanic episode to a major depressive episode (APA). Bipolar Disorder in Children Although researchers have documented the origins of bipolar symptoms in childhood (Lish, Dime-Meenan, Whybrow, Price, & Hirschfeld, 1994; Quinn, Lofthouse, Fristad, & Dingus, 2004), the Depression and Bipolar Support Alliance (2002) has concluded that as many as 80% of children with bipolar disorder are undiagnosed for up to 10 years before receiving appropriate treatment. The main issue appears to be that children rarely fit the expected and adult patterns of bipolar disorder, displaying a more complex cycling of moods and a wider range of potential symptoms (Apps, Winkler, & Jandrisevits, 2008). In children the symptoms of depression


and mania may manifest differently, complicating the ability of clinicians to clearly diagnose the disorder. Depression in children may be exhibited as (a) frequent crying, (b) a lack of self-care, (c) changes in sleeping patterns, (d) increased social withdrawal, (e) self-mutilation, (f) physical complaints such as headaches, stomachaches, or feeling tired, (g) poor school performance, (h) extreme sensitivity to rejection or failure, and (i) suicidal ideation (American Academy of Child and Adolescent Psychiatry, 2008, 2010; Minnesota Association for Children's Mental Health, n.d.). Conversely, childhood mania may appear as (a) unpredictability, (b) hyperactivity and attention problems, (c) speaking more rapidly or loudly than usual, (d) pressured speech (speech that is difficult to interrupt), (e) having racing thoughts or many thoughts at the same time, (f) thoughts that jump from one idea to another without any clear connection, (g) silly, goofy, or giddy behavior that cannot be stopped despite negative consequences, (h) angry behaviors that result in physical property destruction, aggression, yelling, or crying, (i) inappropriate sexual behaviors, (j) unrealistic or unshakable beliefs in one's power and abilities, and (k) engaging in "daredevil" acts or risky behavior (American Academy of Child and Adolescent Psychiatry, 2010; Minnesota Association for Children's Mental Health, n.d.; Papolos & Papolos, 1999). Both irritability and explosive behaviors or "rages" are also frequently associated w ith children who have bipolar disorder. Not formally defined within the DSM-5 (APA, 2013), any determination related to these behaviors is left up to the treating clinician. It is interesting that irritability has been identified as characteristic of children experiencing both mania and depression, as well as attention deficit-hyperactivity disorder (ADHD), oppositional defiant

disorder (ODD), autism spectrum disorder, generalized anxiety disorder, and posttraumatic stress disorder (Axelson et al., 2011; Carlson, 2007; Dickstein, 2010; National Institute on Mental Health, 2000; Papolos & Papolos, 1999). Mixed states and rapid cycling have been reported in more than 70% of children with bipolar disorder, a rate that far exceeds that of diagnosed adults (State, Altshuler, & Frye, 2002). Children demonstrating rapid cycling tend to be inflexible, oppositional, and extraordinarily irritable, and most experience periods of explosive rage and tantrums that can last for hours (Papolos & Papolos, 1999). Some researchers in the field of childhood bipolar disorder also use the terms ultrarapid cycling and ultradian cycling to refer to brief and frequent episodes of bipolar disorder, although neither term is noted in the DSM-5 (APA, 2013). Geller et al. (2000) defined ultrarapid cycling as having between 5 and 365 cycles per year and ultradian cycling as having more than 365 cycles per year. This rate far exceeds that of rapid cycling observed in adults with bipolar disorder.

Difficulties Related to Diagnosis Lacking diagnostic criteria for bipolar disorder as it applies specifically to children, mental health experts must rely on the adult psychiatric classification of the disorder as described in the DSM-5 (APA, 2013). With such a wide range of behaviors considered as potential indicators of the disorder, appropriately diagnosing a child with bipolar disorder is both complicated and confusing. The prim ary difficulty is that clinicians m ust determine whether exhibited behaviors are indicative of bipolar disorder, a different mental health disorder, or nothing at all. Num erous additional issues further diminish the odds of an appropriate bipolar disorder diagnosis in a child or adolescent, including (a) the continuum of normal stages of

development as interpreted by clinicians (Papolos & Papolos, 1999), (b) the exhibition of behaviors that are setting-specific, with the child behaving one way at home and another at school (Bardick & Bernes, 2005), (c) the view that educators may have of disruptive behavior as a behavioral issue rather than a medical one (Pavuluri, Naylor, & Janicak, 2002), and (d) the overlapping or mimicking of symptoms with medical conditions such as diabetes, thyroid disorders, and iron-deficient anemia and other psychiatric disorders such as ADHD, depression, ODD, or anxiety disorders (Bardick & Bernes, 2005; Papolos & Papolos, 1999). The relationship of bipolar disorder to other mental health issues seems to be particularly problematic, because coexisting disorders complicate both correct diagnosis and treatment. In one study researchers found that as m any as two thirds of children diagnosed with bipolar disorder have at least one additional mental health or learning disorder (Kessler, Chiu, Dernier, Merikangas, & Walters, 2005). Other researchers determined a diagnosis of ADHD to be of significant concern, because more than half of all children with bipolar disorder m ay also have ADHD (Geller, Sun, Zimerman, Luby, & Frazier, 1995). It is further suspected that a considerable num ber of children who are currently diagnosed with ADHD and are nonresponsive to treatm ent may instead have bipolar disorder (The Balanced Mind Foundation, 2010; Faraone & Kunwar, 2007). Despite the challenges of making an appropriate diagnosis, the incidence of childhood bipolar disorder in the United States has grown significantly over the last decade. Dobbs (2012) documented a 4,000% increase in the diagnosis of bipolar disorder in U.S. children since 2001. This spike in numbers has led some to conclude that clinicians may have adopted a more expanded view

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C hildhood B ipolar D isorder

of the disorder, interpreting the criteria of bipolar disorder in a broader sense, thus sparking a new diagnostic trend (Mikita & Stringaris, 2012) .

B

associated with academic demands can both trigger bipolar episodes and increase episodic behaviors (Hellander, 2000).

Associated Issues

Hoping to reduce any overdiagnosis that may be attributed to a less literal interpretation of the behaviors associated with the disorder, the APA has developed the criteria for an entirely new disorder included in the most recent revision of the DSM-5 (APA, 2013). Disruptive mood dysregulation disorder (DMDD) is categorized as a depressive disorder and applies to children who are at least 6 years old and have "severe recurrent temper outbursts manifested verbally and/ or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation" (APA, 2013, p. 156). Additionally, under the DSM-5 criteria (APA, 2013), the mood between temper outbursts is required to be "persistently irritable or angry" (p. 156). Considering that diagnosis requires a mood that is severe and recurrent as well as irritable, clinicians may be better able to differentiate between DMDD and childhood bipolar disorder. Criticism of DMDD arose prior to the APA's May 2013 release of the DSM-5. In his 2011 journal article "DSM-5 Approves New Fad Diagnosis for Child Psychiatry," Dr. Frances Allen, chair of the DSM-IV Task Force, stated that "DMDD is a made up and unstudied diagnosis with no real scientific support." Authors of another research study concluded that although the concept of DMDD is "reasonable," it is "not clear whether DMDD is a distinct condition," wondering instead whether DMDD is not really "a more severe comorbid form of ADHD and ODD" (Margulies, Weintraub, Basile, Grover, & Carlson, 2012, p. 494). Additional questions have been raised about whether DMDD will turn childhood temper tantrums into a mental disorder or become overdiagnosed 32

the same way some perceive bipolar disorder to be (Dobbs, 2012; Margulies et al.).

eyond

B ehavior

In addition to the difficulties surrounding diagnostic accuracy, children diagnosed with bipolar disorder often experience a variety of related concerns, including struggles with relationships, academic issues, substance abuse, and suicide attempts. These issues touch all aspects of childhood. Relationships Relationships with peers and siblings can be particularly problematic. Children with bipolar disorder may be unable to respond appropriately to social cues and boundaries. Their "frenzied and erratic behavior" may result in children with bipolar disorder being socially rejected by their peers (Senokossoff & Stoddard, 2009, p. 91). Reports indicate that 50% of children with bipolar disorder have no friends, are made fun of, and have poor sibling relationships (Pavuluri et al., 2002). Even parents may describe their child with bipolar disorder as bossy and intrusive or too overwhelming and aggressive (Papolos & Papolos, 1999). Academics Children with bipolar disorder may also face academic concerns. Researchers have indicated these children experience an increased risk for learning disabilities and a higher likelihood of deficits in cognitive functioning, math, and verbal memory (Kowatch, Youngstrom, Danielyan, & Findling, 2005). In one study of children with bipolar disorder, 79% of parents and 72% of teachers reported difficulties with academics (Griffith, Lofthouse, Fristad, & Dingus, 2004). Further complicating matters for children with bipolar disorder, the stress

Substance Abuse Many children and adolescents with bipolar disorder struggle to appropriately manage these relationships and school stressors. Drug and alcohol abuse is estimated to be between 40-50% (Kowatch & DelBello, 2006). Other researchers have reported the rate of substance abuse among adolescents with bipolar disorder to be six times higher than among adolescents without mood disorders (Science Daily, 2008). Geller et al. (1998) suggested that the use of drugs and alcohol also makes controlling the symptoms of bipolar disorder more difficult and increases the risk of suicide (Isometsa, Aro, Henriksson, Heikkinen, & Lonnqvist, 1994). Suicide Attempts Researchers have found that during a 1-year period, 44% of adolescents with untreated bipolar disorder were suicidal at some point (Goldstein et al., 2005). Additional research suggests suicide to be the sixth leading cause of death for 5- to 14-year-olds (Birmaher, 2004), with suicidal ideation observed in children as young as 4 years old (Papolos & Papolos, 1999). Alarmingly, suicidal ideation combined with the rapid cycling observed in many children and adolescents creates a serious risk for suicide that may seem to occur without warning (Geller et al., 1998). Improving Outcomes

The seriousness of these concerns highlights the important role parents and teachers play in the life of a child or adolescent with bipolar disorder. Considered a lifelong illness, effective treatment requires a combination of medication, psychotherapy, and educational support.

BeyondBehavior


Medication Although bipolar disorder is a recurrent illness, long-term preventive treatment is effective. Mood stabilizing, antiseizure, and antipsychotic medications are often prescribed to help control the severe mood symptoms and mood swings experienced by individuals with bipolar disorder. Lithium, Risperdal, Ability, Zyprexa, Seroquel, Symbyax, Depakote, Depakene, Tegretol, Trileptal, and Lamictal are all examples of medications taken by children and adolescents with the disorder (American Academy of Child and Adolescent Psychiatry, 2012). Prescribing medication is not without risk. Such medications have side effects that complicate both treatment and recovery, including (a) weight gain, (b) excessive thirst, (c) nausea, (d) frequent urination, (e) diarrhea or constipation, (f) cognitive dulling, (g) muscle tremors, and (h) drowsiness (American Academy of Child and Adolescent Psychiatry, 2010; The Balanced Mind Foundation, 2010). Parents must be informed about all known risks and any related Food and Drug Administration warnings before starting a child on any medication and then should continue to work closely with the prescribing physician to monitor medication effects. As the child matures, self management of medication may become a consideration. Under those circumstances, it is important that he or she understands the purpose of the medication and how it works to control mood symptoms. Positive reinforcement may also be needed to ensure consistent use, because lack of adherence to a medication treatment plan can result in a relapse of bipolar symptoms (American Academy of Child and Adolescent Psychiatry, 2012). Psychotherapy Some research has suggested that medication combined with psychotherapy provides improved

outcomes for children with bipolar disorder (Kowatch & Delbello, 2006). Therapy options vary and may include (a) cognitive behavioral therapy, which focuses on "improving mood, anxiety, and behavior by examining distorted thinking," (b) group therapy, which "uses peer interactions to increase understanding" of the illness, (c) psychodynamic therapy, which helps "identify typical behavior patterns, defenses, and responses to conflict," and (d) interpersonal therapy, which focuses on minimizing the disruptions in routine and interpersonal problems that may trigger episodes of bipolar disorder (American Academy of Child and Adolescent Psychiatry, 2011, p. 1-2). Additionally, given that a diagnosis of bipolar disorder in a child will impact everyone in the home, family-focused therapy can provide the support necessary to help the family function in more positive, constructive ways (American Academy of Child and Adolescent Psychiatry, 2010, 2011). With research concluding that 89% of individuals with bipolar disorder have a relative with either depression or bipolar disorder (APA, 2005), family-focused therapy may prove particularly important. Educational Support Teachers are often among the first people to recognize patterns of behavior in children that differ from the expected norm. Therefore, teachers at all grade levels need extensive information on how to recognize the symptoms of possible bipolar disorder in children. Communication and coordination with appropriate specialists within the school building may be the first step in securing needed intervention and supportive services for the child. Symptoms of bipolar disorder and medication side effects can impact a child's ability to function well in school. Depending on the child's level of stability, the areas of

executive functioning, attention, memory, and information processing may be affected. These, in concert with more physical impacts of the medication, may impede school success. The classroom teacher, therefore, will continue to play an important role long after a child's diagnosis: addressing academic concerns, monitoring medication effects, and helping the child better manage behaviors in the classroom. Communication with parents will prove essential as all care providers coordinate to manage manic and depressive symptoms and medication side effects. Anglada (2002) developed a list of essential questions that teachers should discuss with parents about the specific needs of their child: 1. Does the child have a co-occuring condition? If so, you may ask the parent to provide additional information regarding this condition. 2. Is the child experiencing any specific medication side effects? (e.g., dry mouth, frequent urination, dizziness, upset stomach, cognitive dulling, etc.) 3. What are his or her specific stressors or triggers? (e.g., crowds, excess noise level, etc.) 4. What helps him or her stay calm or focus better? (e.g., breathing exercises, quiet plan, seating position, etc.) 5. Does the child have a special gift or area of interest? (e.g., music, art, hobbies, etc.) 6. How does this illness specifically affect him or her academically? (e.g., difficulty concentrating, specific impairment, etc.) Some children who struggle with the manic and depressive episodes of bipolar disorder may benefit from special education services provided in an environment separate from the general classroom. In fact, children with childhood bipolar disorder are more likely to have an educational placement in a special education F

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Table 1 A ccommodations to Address the N eeds of S tudents W ith B ipolar D isorder Instructional Needs: 1. Assist the student in prioritizing work (Massachusetts General Hospital, 2010) 2. Teach students to develop short- and long-term goals (Levendoski & Cartledge, 2000) 3. Provide alternative modes of expression (Massachusetts General Hospital, 2010) 4. Adjust timelines for work completion (Massachusetts General Hospital, 2010) 5. Allow flexibility in both the length and difficulty level of assignments (Senokossoff & Stoddard, 2009) 6. Provide students with additional time to acquire and practice academic skills (Killu & Crundwell, 2008) 7. Minimize work distractions (McIntosh & Trotter, 2006) 8. Allow the child to wear headphones to reduce noise levels (Anglada, 2002) 9. Provide notice of any schedule changes beforehand (Senokossoff & Stoddard, 2009) 10. Provide a picture schedule of the activity sequence to decrease anxiety (Killu & Crundwell, 2008) 11. Provide students with a break between assignments (Killu & Crundwell, 2008) 12. Develop a plan for down time during naturally unstructured periods of the day (Killu & Crundwell, 2008) 13. Use assignment completion checklists (McIntosh & Trotter, 2006) 14. Provide increased levels of feedback (Killu & Crundwell, 2008) 15. Check frequently on student progress (Killu & Crundwell, 2008) Medication Effects: 1. Allow the child to have unlimited access to bathroom facilities (The Balanced Mind Foundation, 2010) 2. Work with parents to promote stable sleep habits (American Academy of Child and Adolescent Psychiatry, 2007) 3. Allow naps as needed for primary students (The Balanced Mind Foundation, 2010) 4. Allow the student to move around the classroom environment as needed (The Balanced Mind Foundation, 2010) 5. Allow a water bottle in the classroom (Anglada, 2002) Social, Emotional, and Behavioral Needs: 1. Ignore minor behavior infractions (Anglada, 2002) 2. Work with parents to develop consistent routines across home and school environments (Killu & Crundwell, 2008) 3. Identify possible triggers that may precede loss of control (Killu & Crundwell, 2008) 4. Identify a contact individual that the student can go to in times of stress (Anglada, 2002) 5. Develop a simple explanation regarding the disorder that the student can use with peers or other teachers (Massachusetts General Hospital, 2010) 6. Identify a place where the student can go for privacy until he or she regains control (Minnesota Association for Children's Mental Health, n.d.) 7. Provide training in self-esteem development, social skills, conflict resolution, anger management, and problem-solving as needed (The Balanced Mind Foundation, 2010) 8. Reinforce appropriate behaviors (Massachusetts General Hospital, 2010) 9. Develop a Positive Behavioral Intervention Plan (The Balanced Mind Foundation, 2010) 10. Develop a Crisis Management Plan (Killu & Crundwell, 2008)

classroom than children with other internalized disorders (Fristad, Goldberg-Arnold, & Gavazzi, 2002). Children with bipolar disorder will need accommodations to improve academic performance in general and special education environments. These accommodations may include those that ameliorate medication side effects, such as unlimited bathroom use, access to water as needed, and permission to move around the classroom, or those that reduce those stressors known to trigger manic or depressive episodes, such as breaking down assignments into smaller tasks, 34

B EYOND B EHAVI OR

providing breaks between work requirements, and providing a less distracting work environment (see Table 1).

Students diagnosed with bipolar disorder may also benefit from additional services to address relationship concerns associated with the disorder. This specialized instruction may include social skills training and conflict resolution to help with peer relationships, anger management and problem-solving strategies, and self-esteem development (The Balanced Mind Foundation, 2010).

Conclusion

Children with bipolar disorder are often disadvantaged by inappropriate identification and diagnosis. Although long-term treatment of the disorder through medication, psychotherapy, and educational support is available and effective, oftentimes symptoms that could provide caregivers with initial indications of manic and/or depressive episodes are confused with other disorders, considered part of the continuum of normal development, viewed as a behavior


BeyondBehavior

B? Table 2

R esources for P arents and E ducators

American Academy of Child and Adolescent Psychiatry www.aacap.org The Balanced Mind Foundation www.thebalancedmind.org Bipolar Significant Others www.bpso.org Bipolar World www.bipolarworld .net BP Children www .bpchildren. org Bring Change 2 Mind www .bringchange2mind.org Depression and Bipolar Support Alliance www.dbsalliance.org

problem , or ignored altogether. Some of this confusion is understandable, and p erh ap s even desirable in an effort to correctly identify pathology; how ever, the und erly ing issue revolves around a lack of education on w hat bipolar disorder both is and is not. A lthough nu m ero us resources related to identification, treatm ent, an d su p p o rt are w idely available online (see Table 2), the m ost im p o rtan t step in better u n d erstan d in g bipolar disorder in children an d adolescents is an im proved education for the adults w ho care for them . N ot until there is clearer attention p aid to that education w ill it be possible to im prove bo th the short- and long term outcom es for children w ith bipolar disorder.

REFERENCES Allen, F. (2011, July 22). DSM-5 approves new fad diagnosis for child psychiatry: Antipsychotic use likely to rise. Psychiatric Times. American Academy of Child and Adolescent Psychiatry. (2007). Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. Journal of American Academy of Child and Adolescent Psychiatry, 46, 107-125.

International Bipolar Foundation www.internationalbipolarfoundation.org International Mental Health Research Organization www.imhro.org National Alliance on Mental Illness www.nami.org National Federation of Families for Children's Mental Health www.ffcmh.org National Institute on Mental Health www.nimh.nih.gov Substance Abuse and Mental Health Services Administration www.samhsa.gov

American Academy of Child and Adolescent Psychiatry. (2008). Facts for families: Bipolar disorder in children and teens (No. 38). Washington, DC: Author. American Academy of Child and Adolescent Psychiatry. (2010). Bipolar disorder: Parents' medication guide for bipolar disorder in children and adolescents. Washington, DC: Author. American Academy of Child and Adolescent Psychiatry. (2011). Facts for families: Psychotherapies for children and adolescents (No. 86). Washington, DC: Author. American Academy of Child and Adolescent Psychiatry. (2012). Facts for families: Psychiatric medication for children and adolescent, part II— types of medications (No. 29). Washington, DC: Author. American Psychiatric Association. (2005). Let's talk facts about bipolar disorder (manic depression). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Anglada, T. (2002). The student with bipolar disorder: An educator's guide. Internet site: www.BPChildren.com Apps, J., Winkler, }., & Jandrisevits, M. D. (2008). Bipolar disorders: Symptoms and treatment in children and

adolescents. Pediatric Nursing, 34, 84-88. Axelson, D. A., Birmaher, B., Findling, R. L., Fristad, M. A., Kowatch, R. A., & Youngstrom, E. A., et al. (2011). Concerns regarding the inclusion of temper dysregulation disorder with dysphoria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Journal of Clinical Psychiatry, 72, 1257-1262. The Balanced Mind Foundation. (2010). An educator's guide to pediatric bipolar disorder. Internet site: h ttp :// www.thebalancedmind.org/learn/ library Bardick, A. D., & Bernes, K. B. (2005). A closer examination of bipolar disorder in school-age children. Professional School Counseling, 9, 72-77. Birmaher, B. (2004). New hope for children and teens with bipolar disorder. New York: Three Rivers Press. Carlson, G. (2007). Who are the children with severe mood dysregulation, a.k.a. "rages"? American Journal of Psychiatry, 164, 1140-1142. doi: 10.1176/appi.ajp.2007.07050830 Depression and Bipolar Support Alliance. (2002). Living with bipolar disorder: How far have we really come? Internet site: http://www.bpkids.org Dickstein, D. (2010). DSM-5 and pediatric irritability: Acknowledging the elephant in the room. Brown F all 2 0 1 3

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University Child and Adolescent Behavior Letter, 26(10), 1-6. Dobbs, D. (2012, December 7). Will doctors start labeling kids who have temper tantrums as dysfunctional? Slate. Internet site: www.slate, com Faraone, S. V., & Kunwar, A. R. (2007). ADHD in children with comorbid conditions: Diagnosis, misdiagnosis, and keeping posted. Medscape Psychiatry and Mental Health: ADHD Expert Column Series. Internet site: http: / / www.medscape.com Flick, G. L. (2011). Understanding and managing emotional and behavioral disorders in the classroom. New York: Pearson. Fristad, M. A., Goldberg-Arnold, J. S., & Gavazzi, S. M. (2002). Multifamily psychoeducation groups (MFPG) for families of children with bipolar disorder. Bipolar Disorders, 4, 254-262. Geller, B., Sun, K., Zimerman, B., Luby, J., & Frazier, J. (1995). Complex and rapid cycling in bipolar children and adolescents: A preliminary study. Journal of Affective Disorders, 34,259-268. Geller, B., Williams, M., Zimerman, B., Frazier, J., Beringer, L., & Warner, K. L. (1998). Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultrarapid, or ultradian cycling. Journal of Affective Disorders, 51, 81-91. Geller, B., Zimerman, B., Williams, M., Bolhofner, K., Craney, J. L., & DelBello, M. P., et al. (2000). Diagnostic characteristics of 93 cases of prepubertal and early adolescent bipolar disorder phenotype by gender, puberty, and comorbid attention deficit hyperactivity disorder. Journal of Child and Adolescent Psychopharmacology, 10, 157-164. Goldstein, T. R., Birmaher, B., Axelson, D., Ryan, N. D., Strober, M. A., & Gill, M. K., et al. (2005). History of suicide attempts in pediatric bipolar disorder: Factors associated with increased risk. Bipolar Disorders, 7, 525-535. Griffith, A., Lofthouse, N., Fristad, M. A., & Dingus, C. (2004). The school

36

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behavior and academic peer functioning of children with early onset bipolar spectrum disorders. Poster session presented at the Kansas Conference of Clinical Child and Adolescent Psychology, Lawrence, KS. Hallahan, D. P., & Kauffman, J. M. (2006). Exceptional learners: An introduction to special education (10th ed.). New York: Pearson. Hellander, M. (2000). Easing the burden: Childhood onset bipolar disorder and the Internet. A White Paper commissioned by the National Institute of Mental Health. Isometsa, E. T., Aro, H. M., Henrikkson, M. M., Heikkinen, M. E., & Lonnqvist, J. K. (1994). Suicide in major depression in different treatment settings. Journal of Clinical Psychiatry, 55, 523-527. Kessler, R. C., Chiu, W. T., Dernier, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617-627. Killu, K., & Crundwell, R. M. A. (2008). Understanding and developing academic and behavioral interventions for students with bipolar disorder. Intervention in School and Clinic, 43(4), 244-251. Kowatch, R. A., & Delbello, M. P. (2006). Pediatric bipolar disorder: Emerging diagnostic and treatment approaches. Child and Adolescent Psychiatric Clinics of North America, 15, 73-108. Kowatch, R. A., Youngstrom, E. A., Danielyan, A., & Findling, R. L. (2005). Review and meta-analysis of the phenomenology and clinical characteristics of mania in children and adolescents. Bipolar Disorders, 7, 483-496. Levendoski, L. S., & Cartledge, G. (2000). Self-monitoring for elementary school children with serious emotional disturbances: Classroom applications for increased academic responding. Behavioral Disorders, 25, 211-224. Lish, J. D., Dime-Meenan, S., Whybrow, P. C., Price, R. A., & Hirschfeld, R. M.

(1994). The national depressive and manic-depressive association (DMDA) survey of bipolar members. Journal of Affective Disorders, 31, 281-294. Makita, N., & Stringatis, A. (2012, December 11). Mood dysregulation. European Child and Adolescent Psychiatry, doi: 10.1007/s00787-0120355-9 Margulies, D. M., Weintraub, S., Basile, J., Grover, P. J., & Carlson, G. A. (2012). Will disruptive mood dysregulation disorder reduce false diagnosis of bipolar disorder in children? Bipolar Disorders, 14, 488M96. Massachusetts General Hospital. (2010). School-based interventions: Bipolar disorder (manic depression). School Psychiatry Program and MADI Resource Center. Internet site: www.2massgeneral.org/ schoolpsychiatry McIntosh, D. E., & Trotter, J. S. (2006). Early onset bipolar spectrum disorder: Psychopharmacological, psychological, and educational management. Psychology in the Schools, 43, 451-461. Minnesota Association for Children's Mental Health, (n.d.). Children's mental health disorderfact sheetfor the classroom: Bipolar disorder (manic depressive illness). St. Paul, MN: Author. National Institute of Mental Health. (2000). Child and adolescent bipolar disorder: An update from the National Institute of Mental Health. Internet site: http://w w w .nim h.nih.gov Papolos, D. F., & Papolos, J. (1999). The bipolar child: The definitive and reassuring guide to childhood's most misunderstood disorder. New York: Broadway Books. Pavuluri, M. N., Naylor, M. W., & Janicak, P. G. (2002). Recognition and treatment of pediatric bipolar disorder. Contemporary Psychiatry, 1,

1- 10.

Quinn, C. A., Lofthouse, N., Fristad, M. A., & Dingus, C. (2004). Comorbidity and early onset mood spectrum disorders in childhood: Profiles, gender, associations, developmental onset, and psychological functioning. Poster session presented at the


Association of the Advancement of Behavioral Therapy, New Orleans, LA. Science Daily. (2008, June 4). Increased risk of smoking, substance abuse in bipolar adolescents confirmed. Internet site: www.sciencedaily.

com/ releases/2008/ 06 / 080602105515.htm Senokossoff, G. W., & Stoddard, K. (2009). Swimming in deep water: Childhood bipolar disorder. Preventing School Failure, 53, 89-93.

State, R. C., Altshuler, L. L., & Frye, M. A. (2002). Mania and attention deficit hyperactivity disorder in a prepubertal child: Diagnostic and treatment challenges. American Journal of Psychiatry, 159, 918-925.

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