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Isc310343.qxdand Developing Academic
and Behavioral Interventions
for Students with Bipolar
KIM KILLU AND R. MARK A. CRUNDWELL Despite significant advances in practices for effectively designing and
delivering instruction for students with disabilities, educators continue
to face challenges addressing the needs of students with emotional
and behavioral disorders. Little information is available for educators
on accommodations and modifications that would serve the needs of
these students and address the unique challenges they present in the
classroom. The educational, social, and behavioral needs of students
with bipolar disorder are discussed along with suggestions for provid-
ing effective accommodations and modifications in the classroom.
intervention; academic; modifications; accommodations;
instruction; learning strategies
2008 Hammill Institute on Disabilities10.1177/1053451207310343http://isc.sagepub.com INTERVENTION IN SCHOOL AND CLINIC VOL. XX, NO. X, MONTH XXXX (PP. xx–xx) 1 ffective instructional practices have long exacerbate its development and course. Overall, bipolar been held as the foundation of providing disorder in children and adolescents can be best concep- students with disabilities with an appropri- tualized as a biopsychosocial disorder.
ate education that meets their academic, According to the Diagnostic and Statistical Manual of E social, and behavioral needs. Yet despite Mental Disorders–Fourth Edition, Text Revision (DSM-IV-
continued research and advancements in such effective TR; American Psychiatric Association, 2000), bipolar dis- practices over the years, educators can still face chal- order is characterized by at least one manic episode, with lenges in providing an education to students with emo- or without a major depressive episode. Children and ado- tional and behavioral disorders (EBD). One such group lescents with bipolar disorder display clinically signifi- is students diagnosed with bipolar disorder. This group cant levels of grandiosity and elation that are different of students often struggles both academically and behav- than the normal levels observed in other children. They iorally in the classroom (Lofthouse & Fristad, 2006).
also display manic symptoms, as well as waxing and wan- Furthermore, there are many other undiagnosed stu- ing mood symptoms that frequently arise unexpectedly dents with a similar profile of bipolar characteristics who and are often unrelated to environmental events. These are struggling and who are not labeled or served under students also display altered mood states such as eupho- federal legislation granting services to students with dis- ria or irritability, and additional manic symptoms such as abilities. As a result, it is imperative for general and spe- grandiosity, racing thoughts, and a decreased need for cial education teachers to recognize the possible signs of sleep. The disorder and resulting symptoms can have a this disorder and to utilize strategies that address the significant impact on social relationships, academic and unique needs of these students.
job performance, and behavior and can lead to substance Despite federal mandates to integrate students with abuse and legal difficulties (Bardick & Bernes, 2005).
disabilities with their nondisabled peers to the maximum Few studies have examined the prevalence of bipolar extent appropriate, the plight of educators has not been disorder in children and adolescents. Whereas bipolar dis- well addressed as the general education environment is order was once thought to be rare in children and adoles- often unequipped to provide the resources and support cents, there is evidence that the prevalence of the disorder necessary for success for students with disabilities. Little is similar to that found in the adult population and that the information is available for either general or special edu- rate of the disorder in this age group may be increasing cators on proactive interventions, such as accommoda- (Geller & Luby, 1997). Numerous authors have suggested tions and modifications that would serve to improve that bipolar disorder in children and adolescents is under- engagement and interactions in the classroom for stu- diagnosed and that there is a high prevalence of cases seen dents with bipolar disorder as well as for the diverse in clinics (Gannon et al., 1983; Isaac, 1995). Current esti- group of students with EBD. The following discussion mates indicate that at least three quarters of a million examines the educational, social, and behavioral needs of American children and teenagers struggle with bipolar dis- students with bipolar disorder and provides suggestions order, many of whom are undiagnosed and untreated for effective accommodations and modifications for use (Child & Adolescent Bipolar Foundation, 2004).
in the school and classroom. These accommodations and Quinn, Lofthouse, Fristas, and Dingus (2004), look- modifications can also be effective for students displaying ing at the age of onset for bipolar disorder in children a similar profile of bipolar characteristics.
between the ages of 8 and 11, found that manic anddepressive symptoms were reported by parents to start at8.8 years and 8.6 years, respectively. Whereas no studieshave charted the early development of bipolar disorder in What Is Bipolar Disorder?
children, a retrospective study by Kljun, Lofthouse, Bipolar disorder is a biological brain disorder that Fristad, and Dingus (2004) with 8- to 11-year-old chil- causes severe and unusual fluctuations in an individual's dren suggested that the majority of these children, based mood, energy, and ability to function. The causes of on parent reports, experienced past behavioral problems bipolar disorder have not yet been precisely determined.
in school (77%) and that many had received previous Current research suggests that bipolar disorder is caused by special education services (88%). The majority of parents a combination of factors that include genetic transmission also indicated that their children continued to have and vulnerability, neurotransmitter abnormalities, and behavior problems at school (55%) and receive special environmental factors such as distressing life events (Geller education services (64%).
& Luby, 1997). Current research indicates that the initial Bipolar disorder in adults typically shows a classic manifestation of bipolar disorder in children and adoles- pattern of mood swings, from high-energy manic periods cents can be activated by environmental factors such as to extremely low-energy periods and depression (Bardick (a) family, teacher, or peer conflict; (b) academic stress; and & Bernes, 2005). The few studies that have examined (c) disruption of the sleep-wake cycle (Lofthouse & Fristad, how bipolar disorder manifests differently with age have 2004). Furthermore, these environmental variables may reported that, in comparison to adults, children with 2 INTERVENTION IN SCHOOL AND CLINIC Characteristics of bipolar disorder in the classroom across the dimensions of social/behavioral,cognitive/academic, and affect/mood Easily frustrated Overwhelmed/short fuse Oppositional, defiant Withdrawal from peers Combative, explosive rages Nonresponsive to praise and encouragement Difficult to engage Exhaustion due to poor sleep Hyperverbal/pressured speechExtroversionHigh activity levelsExhaustion due to increased nighttime physical activityRisk-taking behavior Cognitive dulling Delusions of grandeur Off-task behavior Flight of ideas, racing thoughts Difficulty recalling information Unwilling to transition to different topics Difficulty problem solving Extremely high levels of work production Difficulty starting tasks Impaired judgment Psychomotor retardation Easily distracted Excessive involvement in activities ConfidenceDifficulty evaluating and thinking criticallyAgitation early-onset bipolar disorder often exhibit both manic and extraordinarily irritable and that most experience periods depressive symptoms at the same time or within the same of explosive rage and tantrums that can last for hours.
day (Kowatch et al., 2005). In children with bipolar disor-der, mood shifts are characterized by more incidents ofmixed states (i.e., simultaneous manic and depressive symp- What Does Bipolar Disorder Look
toms) and by more rapid cycling and short durations (e.g., Like in the Classroom?
several hours, several times daily for several days in a row).
Manic and depressive moods in children often manifest as Children and adolescents with bipolar disorder are at intense irritability (Wosniak, Biederman, Mundy, Douglas, increased risk for school failure as the symptoms of the & Faraone, 1995). In a meta-analysis study of clinical char- disorder represent a significant change from typical stu- acteristics of mania in children and adolescents with bipolar dent functioning (see Table 1). Within the classroom, the disorder, Kowatch, Youngstrom, Danielyan, and Findling manic and depressive symptoms may express themselves (2005) found that the most common symptoms of mania in a variety of ways and may escalate and become poten- were increased energy, distractibility, and pressured speech.
tially harmful to the child or other students (Lofthouse & On average, 80% of bipolar cases had significant irritability Fristad, 2006). These may include engaging in danger- and grandiosity, and more then 70% of all cases showed ous activities and behaviors that put themselves at risk, elated/euphoric mood, decreased need for sleep, or racing hitting other students and teachers, destroying property, thoughts. Most cases of bipolar disorder also showed poor or making inappropriate sexual comments or advances judgment (69%), whereas only half of bipolar cases were toward other students. In some cases, severe levels of mania noted to display flight of ideas. Only one third of the bipolar or depression may lead to psychotic symptoms such as cases showed hypersexuality. Papolos and Papolos (2002) paranoia, delusions, and auditory and visual hallucinations reported that children with bipolar disorder have a more (Papolos & Papolos, 2002). Compounding the recognition chronic course of the illness and cycle much more rapidly.
of bipolar disorder in the classroom is that there is no clas- The rapid cycling includes frequent spikes of highs and lows sic pattern for the disorder's manifestation, and research is within a twenty-four-hour period. They also indicated that still needed that will help in better understanding the over- these children tend to be inflexible, oppositional, and lap of the symptoms with other childhood and adolescent VOL. XX, NO. X, MONTH XXXX 3 disorders (Biederman, 1998). The symptoms of bipolar dis- with bipolar disorder had moderate to severe difficulties order, though outlined clearly in the DSM-IV-TR, have with antisocial behavior, interpersonal skills, and self- variable presentation and may be specific to a particular management skills. Finally, children and adolescents with setting. Consequently, early-onset bipolar disorder is fre- bipolar disorder have also been reported to show higher quently misdiagnosed as conduct disorder, attention-deficit/ levels of aggression than their peers (Geller, Warner, hyperactivity disorder (ADHD), or oppositional defiant Williams, & Zimmerman, 1998).
disorder (Bardick & Bernes, 2005). Overall, bipolar disor-der can severely impact a student's ability to acquire aca-demic skills, interact socially with peers and adults, and School-Based Accommodations and
follow rules and routines within the classroom.
Impact on Academics and Cognitive
Whereas school staff must find ways to assist children and adolescents with bipolar disorder in the school andclassroom, there are currently no evidence-based school Children and adolescents with bipolar disorder often interventions for the disorder that school personnel may struggle in the classroom with regards to their academic draw from (Lofthouse & Fristad, 2006; McIntosh & achievement and cognitive functioning. In terms of spe- Trotter, 2006). Although no research-supported interven- cial education placement, students with bipolar disorder tions are available, school personnel can draw from a num- were more likely to have a placement in a special educa- ber of strategies that will benefit these children and tion classroom than children with a major depressive dis- adolescents in the classroom and in the school based on order or dysthymic disorder (Fristad, Goldberg-Arnold, preliminary research demonstrating the utility of psycho- & Gavazzi, 2002). Furthermore, Griffith, Lofthouse, educational therapies (McIntosh & Trotter, 2006). The fol- Fristad, and Dingus (2004) found that both parents and lowing sections provide educators with a discussion of teachers reported difficulties with academics at school possible suggestions and strategies to assist these students (i.e., 79% and 72%, respectively).
based on this preliminary research. As previously noted, Recent studies have also explored neurocognitive these strategies may also be helpful for students with simi- impairments in children and adolescents with bipolar dis- lar characteristics and a clinical profile of difficulties.
order. In terms of measures of cognitive functioning, chil-dren and adolescents with bipolar disorder have been Intervention Strategies and
found to score higher on verbal measures of IQ than on visual-spatial measures, suggesting that their difficulties inmathematics achievement and decoding of nonverbal Students with bipolar disorder benefit from environ- social cues are impacted (Shear, DelBello, Rosenberg, & ments that reduce distractions and assist them in both Strakowski, 2002). Studies have also reported that children organization and attention to tasks. The accommoda- and adolescents with bipolar disorder are more impaired tions listed in Table 2 are often helpful for these students.
in (a) executive functions and verbal memory (Smith,Muir, & Blackwood, 2006); (b) systematic problem solving Examination and Assignment
and self-monitoring (Shear et al., 2002); and (c) set shifting/ inhibition, planning, and visuospatial tasks (Olvera,Semrud-Clikeman, Pliszka, & O'Donnell, 2005).
Examination and assignment completion may be impacted more by the student's mood changes, difficul-ties with sleep, attention span, frustration tolerance, and Impact on Social Functioning
increased level of stress. Table 3 outlines strategies willassist these students in the completion of examinations Few studies have investigated the social problems of and assignments.
children and adolescents with bipolar disorder withinschools. Studies that have investigated the area indicated Behavior Management and Social
that children and adolescents with bipolar disorder tended to have few or no friends (Geller et al., 2000). Children withbipolar disorder also reported difficulties with their peers, Children and adolescents with bipolar disorder have and parental reports confirm these same difficulties (Kljun difficulty behaving appropriately in the classroom and in et al., 2004). In this regard, the majority of parents in the the school. Whereas medication often assists them in Kljun et al. (2004) study reported that their children had controlling their behavior, they are more reactive to fluc- difficulties with peers and more than half reported that their tuations in their moods, impulses, and surrounding envi- children did not have a best friend. Half of the children in ronmental stimuli. Table 4 outlines strategies that can the study also reported having no friends. Griffith et al.
assist these students within the school in terms of man- (2004) found that teachers reported that 8- to 11-year-olds aging their behavior.
4 INTERVENTION IN SCHOOL AND CLINIC Intervention strategies and classroom accommodations Frequent fluctuations in mood and energy Design and deliver instruction to allow for flexibility (including materials used, style of presentation, length of activity, difficulty level, etc.) Provide for flexible schedulingSchedule challenging activities for periods during the day when the student is best able to perform as mood and energy levels improve Minimizing distractions and surprises, and maintaining a stable environment with consistent expectations, provides students with structure andpredictability, and reduces the level of undesirable reactivity to instructionaldemands (McIntosh & Trotter, 2006) Low tolerance and decreased stamina Be mindful of individual characteristics of fatigue, agitation, frustration levels, tolerance and interest that can magnify bipolar symptoms Modify the pace of instruction, opportunities to practice (Greenwood, Delquadri, & Hall, 1984; Heward, 1994), work demands, activity level, anddegree of interactions with peers A picture schedule of the day's sequence of activities helps to preplan and decrease anxiety, irritability, or noncompliance Irritability and noncompliance due Provide students with additional time to acquire and practice academic skills to rapid mood cycling Use strategies such as categorization and "big ideas" (e.g., Ellis, Farmer, & Newman, 2005), concept mapping, graphic organizers and guided notes(Lazarus, 1996) Deliver feedback (Dye, 2000; Konold, Miller, & Konold, 2004) to provide ongoing support to acquire skills due to lack of engagement during class time Schedule homework in a manner that accommodates the emotional needs of the student and avoids frustration and angry outbursts(McIntosh & Trotter, 2006) Anxiety and irritability A picture schedule of the day's sequence of activities helps to preplanIndividualized schedulesAdvanced notice of changes in classroom or daily activitiesDevelopment of a plan for "down time" during naturally unstructured periods of the day Regulating performance and emotion Teach students to develop short- and long-term goals (Levendoski & Cartledge, 2000) due to difficulties in regulating performance and emotionand impact on work production and task completion Use daily planners, visual organizers (Baxendall, 2003), to-do lists, and assignment completion checklists (McIntosh & Trotter, 2006) Provide increased levels of feedbackDuring manic episodes, assist students in taking on more realistic projects and extracurricular activities Work with parents to develop consistent and structured routines across the home and school environments Examination and assignment accommodations Stress and anxiety Break down classroom assignments into smaller segmentsProvide students with a short break in between assignmentsCheck frequently on the student's progress with an assignmentSet realistic timelines with the student (includes extended time if required) (Child and Adolescent Bipolar Foundation, 2004) Cognitive deficits Modify time constraints to ease feelings of pressure/anxiety and decrease difficulties with performance expectations Structure of physical environment Provide smaller, secluded, comfortable and less distracting testing environmentsProvide additional instructions, act as a scribe, monitor progress and frustration levels and use technology that provides outputmodifications (Child and Adolescent Bipolar Foundation, 2004) Dealing With Medication Side Effects
address the symptoms of the disorder and to improvetheir functioning. Most require multiple medications to Many children and adolescents who are diagnosed alleviate symptoms of mania, depression, and comorbid with bipolar disorder are prescribed medication to conditions (Lofthouse & Fristad, 2006). Mood stabilizers VOL. XX, NO. X, MONTH XXXX 5 Behavior management and social accommodations Staff knowledge and response Professional development Maintain positive, calm, firm, patient, consistent, and encouraging interactions with students (Child and Adolescent Bipolar Foundation, 2004) Provide ongoing education to school personnel regarding the disorderBuild teams to work with students with bipolar disorder to provide more consistency, effectiveness and flexibility Positive behavior support Use Functional Behavior Assessment methodologies (O'Neill, Horner, Albin, Storey, & Sprague, 1997) to better understand the student's behavior andallow for the development of more proactive and preventive strategies Facilitate long-term lifestyle changes through proactive, positive, and functional strategies and interventions Develop positive behavioral supports that address affective supports, schedule and activity supports, and peer supports to support long-term changes(Jackson & Panyan, 2001) Promote positive support and positive discipline, and avoid negative consequences as these may in fact escalate undesirable behaviors associatedwith mood swings Establish a "safe" adult and place that the student may seek out when feeling overwhelmed (Child and Adolescent Bipolar Foundation, 2004) Social/behavioral, academic and Design interventions that address skill deficits resulting from the disorder vocational deficits (e.g., problem solving approaches, behavioral and social deficits) Foster an environment of inclusiveness in the classroom through open discussion, providing appropriate peer mediation and support (Bowers, McGinnis, Ervin, & Friman, 1999; Fowler, Dougherty, Kirby, & Kohler, 1986) protect students fromridicule or rejection, and setting the occasion for positive, collaborativeworking relationships Include the student in social skills groups and increase playground and lunch time supervision to avert problems during those times Crisis management planning Due to unexpected and severe shifts in mood and emotion, identify possible triggers that precede a loss of control Develop a crisis management plan for the following areas: explicit instructions to manage the unsafe behavior (i.e., who does what, when and where),identification of a safe place for the student to go and who will provideappropriate supervision, alternative backup plans if the safe place does notwork, recovery procedures for all involved following the crisis (e.g., distressand debrief the class with the student involved) Employ preventative measures (McIntosh & Trotter, 2006), such as shadowing by an adult throughout the day Allow the student to take a break or walk when she becomes frustrated by social or academic demands are often the first line of intervention (e.g., Depakote, rebound effects when the medication is wearing off. When Lithium, Tegretol, etc.), and many are also prescribed students first start taking medication, they often experience antipsychotic medications (e.g., Rispersal, Zyprexa, a greater number of these side effects until medication Clozaril, etc.) that help reduce aggressive or psychotic adjustments or changes are made. Table 5 addresses accom- symptoms. Antihypertensive medications (e.g., Clonidine, modations should be considered for students who are pre- Tenex) are prescribed to improve the sleep-wake cycle scribed medication for bipolar disorder (Packer, 2002).
for those having sleeping difficulties. Once mood is sta-bilized, low doses of antidepressant medications are alsoadded to reduce depressive and anxiety symptoms (e.g.,Celexa, Prozac, Wellbutrin).
ABOUT THE AUTHORS
These medications may undoubtedly result in a num- Kim Killu, PhD, is an associate professor of special education
ber of possible side effects. For both mood stabilizers and at the University of Michigan–Dearborn. Her current interests antidepressants, side effects can impact focus and attention, include functional behavior assessment and behavior interven- alertness, cognitive functioning, learning, memory, and tion planning. R. Marc A. Crundwell, PhD, is a school psy-
stamina. In addition, such medications affect physical issues chologist at the Greater Essex County District School Board.
including increased thirst, more frequent urination, and His current interests include learning disabilities, behavior 6 INTERVENTION IN SCHOOL AND CLINIC Accommodations for medication side effects Medication side effect
Cognitive: cognitive dulling Provide more time to complete assignmentsProvide more feedback regarding performanceAllow the student more frequent breaks if she cannot sustain her effort on intellectually Consider decreasing workload/homeworkAvoid calling on the student to answer questions in class unless he raises his hand or volunteers Physical/visual: impact on Provide alternative tasks visual or motor skills; Unlimited access to water/juice increased thirst; visual Reduce the amount to be read, provide a reader for the student, or use books on tape blurring; increased urinary Provide the student with a permanent hallway/restroom pass, provide preferential seating frequency, nausea, diarrhea, or flatulence Rebound: irritability, Provide less demanding activities during such time Allow the student to move around or engage in more gentle/calming activities Work with medical professionals and parents to determine if in-school medication schedules should be adjusted disorders, and interventions for learning disabilities and behav- Geller, B., & Luby, J. (1997). Child and adolescent bipolar disorder: A ior disorders. Address: Kim Killu, University of Michigan– review of the past 10 years. Journal of the American Academy of Child Dearborn, School of Education, 19000 Hubbard Dr., Dearborn, and Adolescent Psychiatry, 36, 1168–1176.
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8 INTERVENTION IN SCHOOL AND CLINIC
Dental Traumatology 2009; 25: 541–544; doi: 10.1111/j.1600-9657.2009.00811.x Management of a complicated crown-rootfracture using adhesive fragment reattachmentand orthodontic extrusionCASE REPORT Ce´lia Tomiko Matida Hamata Saito, Abstract – Dental trauma is more common in young patients and its sequelae Marcos Heidy Guskuma, Je´ssica may impair the establishment and accomplishment of an adequate treatment