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Pediatric Bipolar Disorder and Executive Functioning Deficits

To begin to understand the challenges faced by children with early-onset bipolar disorder, it is helpful to look at how many of these children experience the following symptoms of ADHD:

• Easily distracted - 96%
• Difficulty paying attention - 96%
• Restlessness, as if driven by a motor - 71%
• Often talk excessively - 80%
• Has difficulty waiting for his/her turn - 96%
• Blurts out thoughts - 96%
• Often has difficulty organizing tasks - 91%

With this list from Demitri Papolos, MD, we see that at least seven of the DSM-IV criteria used to diagnose ADHD are shared with bipolar disorder.

These challenges help define what are recognized as "executive functioning deficits" or problems with thinking, planning, acting, assessing, and monitoring a process in time and space. The cerebral cortex is the part of their brains where these difficulties reside. These children face difficulties with cognitive activities in all aspects of their daily lives but especially at school.

As Demitri Papolos stated in his workshop at NAMI-NC's Spring Conference, if there were an astrological sign for children with bipolar disorder, it would be "Yield Right of Way." They often operate in what he calls "Mission Mode." These children are impulsive, very intense, and are driven by whatever they feel they need at the moment. They have extreme difficulty in shifting direction and focus.

All of this creates endless challenges for these children in school. They have learning disabilities as well. Written expression is especially difficult and can be unforgiving. They also cannot estimate time, have no idea how the day will go for them, or what the next hour will bring. These challenges are the result of problems in the prefrontal cortex in their brains. There are glitches in sequencing, in how to go about a task. They need everything "broken down" into manageable steps. An example of this would be preparing for class. First, they need to put their coats in their lockers and second, take out their homework folders. Next, they should close their locker door and go their seats.

And then there is the challenge with working memory. When asked a question, they often feel trapped, lost, and cannot remember what they need to know. Because of these difficulties, they then feel disappointed in themselves and often give up. Their self-esteem plummets.

Often the result is that with young children the mother becomes the child's frontal lobe. If a child has difficulty organizing and planning, his mother will step in and help. This is not necessarily a good thing. The child could come to rely too heavily on his/her mother. It does not help the child learn to cope. Later when the adolescent years approach, the teen may pull away from his mother and problems often increase.

Children with early-onset bipolar disorder also experience executive functioning deficits outside the classroom. They have problems with anticipating cause and effect, making complex decisions, and with being flexible. They cannot shift their focus easily and often experience intense irritability and poor self-control. This pattern can lead to a sense of shame. This is something parents witness often. It makes it difficult for these children to make friends and to be invited to birthday parties and other social functions.

Too often, the bipolar child will "lose it" when he gets home from school. Dr Papolos said that one thing parents can do at home is to provide a lot of structure. All clothes, toys, sporting equipment, and other items needs to be "simply organized." Each routine must be broken down into simple steps. Too many choices may not be helpful so reducing the number of distractions is recommended. "Keep it simple" sums it up. Use prompts as needed and practice, practice, practice.

How can educators and parents help children with bipolar disorder become more accountable? One idea is to give clear specifics about acceptable behavior. An example would be to demonstrate or explain the sound of an "inside voice." Teachers could also use a colored card system which not only rewards appropriate behavior but gives a warning when the child's behavior is becoming less acceptable.

Movement is always a good thing when a child is beginning to experience difficulty. Sheryl Pruitt ("Teaching the Tiger") calls it a "graceful exit plan" because it gives the child a way to leave the room while not embarrassing him in any way.

Checklists are helpful for all children but especially for those with executive functioning issues. This helps with memory problems and sequencing. Also, preparation is key. These children do not handle changes well and need help in knowing what is coming next. They can feel threatened if something unexpected occurs. A visual sign for when an activity is about to change would be helpful.

All of this requires a lot of practice, an abundance of patience, and hope.

While children with bipolar disorder do face a lot of challenges, they are our future scientists, teachers, writers, and artists. They have many strengths and often see things in a different light.We need that!

Sources:

Demitri Papolos, M.D., "Neuroanatomy of Juvenile-onset Bipolar Disorder: Impact of Executive Functioning Deficit," April 1, 2005, NAMI North Carolina Spring Conference;

Janice Papolos, "Educating and Nurturing the Bipolar Child," Juvenile Bipolar Research Foundation, September 2004.

 

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BethAnn Russell, Recipient of the Consumer Voice Awards
For the State of North Carolina

The Consumer Voice Award is sponsored by the US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services, as part of the Elimination of Barriers Initiative. The award serves to recognize those who have helped give a voice to people with mental illness by raising awareness in a positive, dignified manner.

On July 20, 2005, BethAnn traveled to Los Angeles, CA to receive her award. Actress Mariette Hartley presented the award to BethAnn at the Skirball Cultural Center.

BethAnn is a twenty-five year old student at the University of North Carolina at Greensboro. She was diagnosed as a teenager with schizo-affective disorder. Even while on the most effective treatment, including medication, BethAnn hears voices all the time.

She is also a very creative artist and poet. She is known for her "creative," unpredictable hair color and flair for style.

In spite of the challenges BethAnn faces every day, she remains an active advocate for the mentally ill. She refuses to let her illness get her down or interfere with her advocacy efforts. Several years ago, BethAnn began to share her personal story with others in an effort to erase the stigma of mental illness. She now speaks to hundreds of students and professionals yearly as a co-presenter with NAMI North Carolina's Young Families Education Program.

She especially enjoys presenting to school teachers as this gives her the opportunity to impart what was helpful to her when she was a high school student. She offers advice in a very positive, empathic manner. Workshop evaluations are full of praise for her courage and articulate manner in front of an audience. Her use of humor is often noted. Participants often suggest that she do "stand up comedy." For example, when asked about her personal life, BethAnn replies that "having mental illness is not good for one's social life." To say that the audience pays close attention to what she has to say is almost an understatement. When she speaks, all eyes are focused on her.

She also handles questions from the group well. One educator recently asked how one can tell if children suffer from mental illness and are not just "bad kids." BethAnn calmly said one should not assume these are bad kids, but approach the child in a positive way. "Look for the reason behind the behavior if a child misbehaves," she said. She remembered a friend from high school whom everyone assumed was a trouble-maker when in fact he suffered from bipolar disorder. The stigma was so intense it affected his siblings. No one wanted them in their classes.

Congratulations to BethAnn for this well-deserved recognition!

 

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Book Review
By David Cornwell
NAMI-NC Family Advocate for the Asheville area

Paul Raeburn is doubtless a competent reporter. His success in journalism, in particular as a senior writer and editor at BusinessWeek, attests to that.

And his book, "Acquainted with the Night: A Parent's Quest to Understand Depression and Bipolar Disorder in His Children," is a competent book.

But the same reporter's skills that serve him so well in his career tend to dilute the power of his family's struggle and much of this book reads as if it was written more by the reporter in Raeburn than the father. In that sense it's a good book to introduce the general public to childhood mental illness, but of lesser value to parents of those children.

Raeburn does a solid job providing overviews on a number of critical topics: shortcomings in drug testing, the difficulty in diagnosing mental illness in children, and the failings of the mental health system in general.

But much of the book comes across as a reporter's narrative, and for this reader, failed to capture the sweat, the fear, the exhaustion, the anger, the suffering, and day-after-day chaos of a family coping with mental illness.

The book begins with Raeburn following an ambulance taking his 11-year-old son, Alex, to his first hospitalization after an out-of-control rage at school. Four years later, Alex's younger sister, Alicia, is diagnosed with depression, a situation compounded by rape. And an older son, Matt, while not diagnosed with an illness himself, is caught up in the debilitating havoc of family dynamics.

The book follows the Raeburns' efforts to find a correct diagnosis for their children as they visit psychiatrist after psychiatrist, try medication after medication and hospitalization after hospitalization. It's an all too familiar tale of inconsistencies and inadequacies with psychiatrists, schools and insurance companies.

As they search for answers, Raeburn and his wife, Liz, frequently disagree and a marriage already in trouble ends in divorce. And while the "blame game" is to be expected in such situations, its frequency makes it a distraction.

While Raeburn occasionally accepts the role his own anger and decisions contribute to the situation, more often than not, he blames his wife for the family not growing stronger and the children not getting better.

At times, these grievances verge on the petty, like her wanting a TV in the bedroom."She watched television frequently, I rarely did, and I didn't want the damn thing in my bedroom. I wanted to read and listen to music there."

The blame game is even more evident when it comes to the children's treatment.Time after time, Liz is depicted as thwarting the best treatment options for the children. "As I realized the value of consistency, I tried to work with Liz to establish it at home. My record was far from perfect, but I felt I was learning and I was trying to get better. Liz, on the other hand, found it difficult to acknowledge the value of setting consistent limits."

Despite its flaws, the book is a decent read, if not a compelling one.And there are a number of lessons to be gleaned from its pages, such as the importance of standing up and advocating for your children and that things can indeed get better.

But it's a better read for people unaffected by and wanting to know more about mental illness than those living with it day to day. To the latter, I'd suggest they borrow the book rather than buy.