Psychological Society of South A frica. All rights reserved.
South African Journal of Psychology, 40(3), 2010, pp. 241-249
Bipolar Mood Disorder in children and adolescents: in search of theoretic, therapeutic and diagnostic clarity Bruce Christopher Bradfield Psychology Department, University of Cape Town, South Africa [email protected]
I address early onset Bipolar Mood Disorder, exploring the ways in which the disorder manifests inthe lives of children. Complications in current and past literature are clarified, and the dearth of sub-stantive research into the area is noted. I clarify associated risk factors specific to paediatric bipolardisorder. A treatment procedure informed by cognitive-behavioural, narrative and family systemstheories is proffered, and is considered in relation to the development of a pharmacological interven-tion. I highlight shortcomings in psychiatric interventions, and provide a framework for treatmentwhich that takes into account the complex variety of needs which bipolar children present.
Keywords: cognitive therapy; family systems therapy; narrative therapy; paediatric bipolar disorder; paediatric psychiatry; pharmacological intervention
Paediatric psychiatry has been plagued by controversy relating to the diagnosis, management,prognosis and prevalence of childhood-onset Bipolar M ood Disorder (Smith, 2007). W hat seemsevident in the literature is a general underestimation of the prevalence of the disorder. This is coupledwith a misdiagnosis of paediatric bipolar disorder as one of a variety of developmental disorders(Biederman, 1997). The literature also suggests that the attention afforded to paediatric Bipolar M oodDisorder has been insubstantial (Cummings & Fristad, 2007; Strober et al., 2006).
In this paper my aim is twofold: I shall first describe the phenomenology, aetiology and neu-
rology of paediatric bipolar disorder, coupled with an outline of the ways in which it may differ fromadult-onset Bipolar M ood Disorder. Next I shall differentiate paediatric bipolar disorder from disor-ders that may be diagnosed more commonly and incorrectly. In conjunction with this, I shall expoundthe associated risk factors. The second aim is to explore methods of intervention. The behaviouralmanifestations of paediatric bipolar disorder are quite specific in comparison with adult bipolarpresentations. The quality of explosiveness, rapid shifting in mood and intermittent aggressivenesscharacteristic of the disorder can be disruptive of development. The literature highlights specific in-terventions for the disorder, which I shall comment on in the final section.
PAEDIATRIC BIPOLAR DISORDER Phenom enology First to address the primary question: Is there a form of bipolar disorder specific to childhood? There is indeed much controversy regarding the phenomenology of paediatric bipolar disorder (Kowatch, 2005). The author states that reports published concerning its diagnosis and treatment contain dif- ferent diagnostic criteria and methods. In this we see a methodological inconsistency in approaches to assessing mania in children. It is acknowledged that the term ‘childhood onset’ is relative, since the index episode could occur anywhere between early infancy and late adolescence. That aside, diverse statistics are noted in the literature, making it difficult to summarise them. The lowest statistic reflects 0.5% of bipolar disorder in childhood (Biederman, 1997), while the highest reflects an esti- mated 59% of childhood onset (Soutullo et al., 2005). Apart from this variety in commentaries on paediatric bipolar disorder, the question remains as to whether the manifestation of bipolar disorder in childhood is phenomenologically different to that in adults.
Bipolar M ood Disorder is characterised by recurrent, discrete episodes of fluctuation in mood,
South African Journal of Psychology, Volume 40(3), September 2010
which can have a significant impact on functioning. Paediatric bipolar disorder is defined by chronic,non-episodic, ultra-rapid cycling (Faedda, Baldessarini, Glovinsky, & Austin, 2004; Vogel, 2000;W osniak & M cCallaghan 1985). This factor in particular renders paediatric bipolar disorder easilymisdiagnosed as one of the disruptive behavioural disorders, including Oppositional Defiant Disorder(ODD), Conduct Disorder or AD/HD (Soutullo et al., 2005). Presentations of bipolar disorder inchildren are defined by mixed dysphoria and lability, without discreet episodes. The frequency ofmood fluctuations implies that children with Bipolar M ood Disorder are disabled by the disorder,should its course be improperly managed. Thus, the diagnostic outline of the disorder in the Diagnos-tic and Statistical M anual of M ental Disorders (DSM IV-TR) (American Psychiatric Association,2000) is an inadequate description of its manifestation in children. W ith the DSM describing bipolardisorder as defined by distinct episodes of mania or depression with inter-episode return to healthyfunctioning, paediatric bipolar disorder, which manifests as a rapid cycle of fluctuating moods, fallsinto a nosological gap.
In children living with bipolar disorder, impairment is seen in school functioning, and in peer
and family relationships. M ood oscillates rapidly from a depressive state to manic excitation. Amongthe potential symptoms of a depressive episode, the following may be observed: Persistent sad orirritable mood, loss of interest in previously pleasurable activities, fluctuations in appetite, psycho-motor agitation or retardation, feelings of worthlessness and guilt, and suicidal ideation (Papolos &Papolos, 2002). On the manic spectrum, the following symptoms are likely: fluctuations in moodranging from extreme irritability, elation and fatuousness; inflated self-esteem or grandiosity; in-creased energy with a decreased need for sleep; increased rate, volume and quantity of speech;distractibility; hyper sexuality; an elevation in the amount of goal-directed behaviour, and disregardfor the dangers involved in high-risk activities (Kowatch, Youngstrom, Danielyan, & Findling, 2005).
The clinical description of paediatric bipolar disorder is discernibly different from adult-onset
bipolar disorder. The presentation falls into nine symptom classes (Pavuluri & Bishop, 2005). Firstlythere is elated mood, defined by silliness, giddiness and feeling invincible. Children in this state areeasily overwhelmed, and their affect may oscillate quickly from excitation to a state of anxious dis-tress. Secondly, irritable mood (one of the cardinal features of paediatric bipolar disorder) manifestsin aggressive, hostile behaviours with intense, inconsolable responses to stressors. Inflated self-esteemor grandiosity is the next category of reported symptoms. The child may make unsupportable state-ments such as “I am the cleverest boy in the whole world”, or “The teachers could learn a few lessonsfrom me”.
A decreased need for sleep is evident in children with bipolar mood disorder. They awaken from
little sleep, feeling refreshed and energised. Pressure of speech is noted, with children constantlytalking, dominating the interpersonal space, and seeking attention by being excessively entertaining. Constant goal-directed activity is observed by Pavuluri & Bishop (2004) as a central feature. Children may be overwhelmed by a frenzy of activity, with aims to achieve unrealistic goals. Theconstant search for pleasurable activities is also observed, a feature that often manifests in childrenshowing little awareness of the social surroundings.
The emergence of depression in children living with bipolar disorder is age-specific in its mani-
festation. Depressed children may report feeling “crabby”; their parents may describe “excessivewhining” in the child; they may cry for no apparent reason, withdraw and isolate themselves, exhibitfluctuations in mood from irritability to tearfulness, and may engage in minor self-injuriousbehaviours such as skin-pinching. These children may develop a painful sensitivity to rejection, dueto the incongruity of their behaviours compared with their peers.
The final category of symptoms in bipolar children relates to the psychotic spectrum. Children
presenting what could be called an atypical mania (Ballenger, Reus, & Post, 1982) could exhibitauditory and visual hallucinations, usually in relation to mood-congruent delusions of grandiosity. In terms of thought form, the significance of flight of ideas, tangentiality and excessive speed andproduction of thoughts has been noted.
South African Journal of Psychology, Volume 40(3), September 2010 Aetiology I shall now discuss issues relating to the aetiology of the illness. First to mention the findings from neurology: Evidence exists confirming the presence of right ventricular enlargement, structural abnormalities in the orbito-frontal cortex, medial temporal lobe structures, striatum and cerebellum; structures that contribute to mood regulation and the modulation of behaviour (M onkul, M alhi, & Soares, 2005). W ith reference to abnormalities in the orbito-frontal cortex, Schore (1994; 2000) comments on the function of this structure in the auto-regulation of positive and negative emotional states. The orbito-frontal structure is elsewhere described as the senior executive of the emotional brain (Joseph, 1996), emphasising its role in the regulation of mood. The potential role of structural abnormality in this area has been clearly shown.
W hat is interesting to bear in mind in considering the aetiology of bipolar disorder and the docu-
mented diagnostic blurring of the borderline/bipolar classification is the notion that those right brainstructures that function in the regulation of emotion develop in the first 18 months of life. T heirnormative development is promoted by the presence of a growth-facilitating emotional environmentthat is provided by a secure attachment relationship with a primary caregiver (Schore, 2000). Thisinsight is interesting, considering the observation that borderline personality disorder is connectedaetiologically with trauma in the context of early attachment relationships (Fonagy, Target, Gergely,Allen, & Bateman, 2003; Herman, Perry, & Van der Kolk, 1989; Holmes, 2004). Both bipolar andborderline presentations are characterised by instability of affect regulation; a feature which makesthem appear quite similar. W hat is being suggested here is a structural neurological similarity in theaetiology of borderline personality disorder and bipolar mood disorder, mitigated by a secureattachment relationship in early infancy. It is suggested that further research is required to establishthe neurological basis of this connection.
M onkul et al. (2005) investigated neuroanatomic and neurochemical abnormalities in people
with bipolar mood disorder, attending to the possibility that such abnormalities may be progressive. W hat emerged from their study is the notion that there is a lack of evidence supporting the possibilityof progressive neurological processes, but that there exist a variety of processes, including environ-mental, educational and nutritional processes, which could effect such progression of the pathology. T he impact of medication on the correction or reversal of such neurological processes as seen inbipolar disorder is proposed as an untapped area of research.
An important consideration in relation to the neurochemistry of bipolar mood disorder is the
extreme heritability of the illness, an element of the assessment process that features centrally ingiving the diagnosis. The literature suggests that paediatric bipolar disorder is associated with asignificantly greater genetic load with one or both parents being diagnosed with the illness (Stroberet al., 2006). Papolos and Papolos (2002) indicate that over 80% of bipolar children have parents onboth sides with histories of mood disorder and/or alcoholism. Faedda et al. (2004) found a 90%chance of bipolar children having a family history of the illness.
Further on in this paper, when discussing recommended treatments for paediatric bipolar dis-
order, I shall comment on the importance of accurately diagnosing and promptly treating thisdisorder. I shall also highlight the possible dangers of misdiagnosis and delayed treatment.
THE PROBLEM OF COM ORBIDITY Confusion exists in the identification of paediatric bipolar disorder, given the variety of pathologies that may mimic the disorder or manifest comorbidly. Frequently, the histories of children with bipolar disorder will reflect a range of diagnoses including (in order of frequency) Attention Deficit/ Hyperactivity Disorder (60%), Anxiety Disorders including Obsessive Compulsive Disorder (39%), M ajor Depressive Disorder (37%) and Oppositional Defiant and/or Conduct Disorder (21%) (Faedda et al., 2004).
Four spectrums of pathology exist in relation to paediatric bipolar disorder. Firstly, the anxiety
disorders: Biederman, Harpold, and W ozniak (2005) observed that paediatric bipolar disorder is
South African Journal of Psychology, Volume 40(3), September 2010
associated with an increased risk for developing anxiety disorders, with Obsessive CompulsiveDisorder and Social Phobia being the most frequently observed. An important consequence of thebipolar/anxiety disorder comorbidity is the challenge that this poses to pharmacological interventions. Anxiety disorders in children occur far more frequently with bipolar disorder than they do in relationto AD /H D and other disruptive behavioural disorders such as Oppositional Defiant and ConductDisorders (Biederman, 2005). The reason for the co-occurrence of anxiety disorders with bipolardisorders could be connected with the pervasive impairment in functioning seen in paediatric bipolarpresentations. In children with the disorder, there is often a delay in time between the index episodeand diagnosis of the illness. Faedda et al. (2004) have noted an average delay of seven years betweenonset and diagnosis. The consequences of this could be highly disruptive of the child’s developingsense of self. Underperformance at school, tumultuous peer and family relationships, and feelingeasily overwhelmed could cause the child to develop a sense of insecurity and isolation.
The second diagnosis in a cluster with paediatric bipolar disorder is Attention Deficit/Hyper-
activity Disorder (Singh, DelBello, Kowatch, & Strakowski, 2006; Scribante, 2009). The magnitudeof the AD/HD-bipolar correlation has led some researchers to postulate AD/HD as a developmentalprecursor of paediatric bipolar disorder. However, little evidence exists to confirm this hypothesis(Leibenluft, Charney, Towbin, Bhangoo, & Pine, 2003). The authors conceptualise the link betweenAD/HD and bipolar disorders as representing one of three possibilities: a) AD/HD as a true comor-bidity, b) a phenotypic variant of bipolar disorder, or c) AD/HD as manifesting symptoms within thebipolar spectrum. Singh et al. (2006) propose AD/HD as a prodromal condition preceding the onsetof paediatric bipolar disorder.
Given the implications of paediatric bipolar disorder for the child’s development, personality
could be significantly influenced by the bipolar process (Goldstein et al., 2005). The authors com-ment on the prevalence of certain behaviours in the bipolar adolescent that may overlap with ClusterB personality pathologies, specifically Borderline and Histrionic Personality Disorders. The manicexuberance of bipolar children may be perceived in adolescence as an indication of histrionic traits. M ore frequently noted is self-injurious behaviour, often observed in adolescents with Bipolar M oodDisorder or borderline traits. Although insufficient research has been done to establish a link betweenthe two, it has been postulated that Bipolar M ood Disorder and Borderline Personality Disorder existon a spectrum of their own, with certain overlapping behavioural manifestations. The severity ofaffect dysregulation in both disorders is a diagnostic overlap that deepens the uncertainty regardingthe diagnosis of paediatric bipolar disorder.
The final diagnostic correlates with paediatric bipolar disorder are M ajor Depressive Disorder
and Dysthymic Disorder. Kovacs (1989) observes that more than half of children diagnosed withbipolar disorder were diagnosed initially with a depressive illness. Furthermore, depression in earlychildhood, coupled with evidence of a multi-generational family history of bipolar disorder, servesas a strong predictor of onset of the illness.
The vicissitudes of manic-depressive cycling in paediatric bipolar disorder are varied and com-
plex. I have described the ultra-rapid cycling (W osniak et al. 1985) that characterises paediatricpresentations. This, coupled with the emphasis on irritability and aggressiveness in children withbipolar disorder, suggests that clinicians could well emphasise depressive features and thus downplaythe manic component of the presentation. T he consequence of this is seen in the pharmacologicalintervention in which depressed children are frequently treated with Serotonin Re-Uptake Inhibitors(SSRIs) (M cShane, M ihalich, W alter, & Rey, 2006). Pavuluri et al. (2005) consider psychopharma-cological treatments for paediatric bipolar disorder and emphasise prescription hygiene in which theyinclude weaning off inappropriate medications. They identify the over-use of SSRIs, even in the faceof compelling evidence revealing the latter’s deleterious impact on the progress of paediatric bipolardisorder.
In relation to this lack of clarity regarding diagnosis, two consequences are of particular sig-
nificance in the literature: The first consequence involves the evidence of a large space in time
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between onset and diagnosis, which can have particularly negative impacts on the disorder. Primarily,delayed recognition of the illness leads to complex difficulties as far as the stabilisation of mood isconcerned (Faedda et al., 2004). Delayed recognition and intervention is also correlated with dis-ruptions in personality development, which may manifest in disordered personality traits. The secondconsequence of the lack of diagnostic clarity for paediatric bipolar disorder relates to the mistreatmentof the illness. The frequency with which AD/HD (instead of paediatric bipolar disorder) may bediagnosed may reflect clinicians’ tendencies to emphasise attentional processes during the assessment. Frequently observed is the mistaken diagnosis of a bipolar child with AD/HD, and his/her consequentpsychopharmacological treatment with a stimulant such as Ritalin (Faedda et al., 1995). Ritalin canhave a destabilising effect on the child’s mood, with consequent debilitation in functioning at schooland home.
PAEDIATRIC BIPOLAR DISORDER: ASSOCIATED RISK FACTORS Children living with Bipolar M ood Disorder present with significant associated risk factors including suicide, self-harm, substance use, risk of sexual exploitation and functional impairment. The lack of systematic research into the course of paediatric bipolar disorder makes it difficult for clinicians to conduct satisfactory risk assessments (Strober, 2006). The risk of completed suicide in people with Bipolar M ood Disorder is among the highest of all psychiatric disorders (Goldstein et al., 2005). The author provides statistics derived from a North American psychiatric population. Reportedly between 25 and 50% of adults with bipolar mood disorder will make at least one attempt, with 8 to 19% of bipolar patients dying from suicide. Such statistics may be poorly reflective of the associated risks of the disorder in developing countries. In this context, the prevalence of cumulative strain trauma, inadequate access to primary health facilities, and an often-reported difficulty with people in rural areas adhering to their medication may aggravate the course of the disorder and increase the risk of completed suicide.
Having said this, the literature makes three claims unequivocally: Firstly, the risk for completed
suicide in adolescents with Bipolar M ood Disorder is high (Brent, Perper, & M oritz, 1993; Goldsteinet al., 2005). Secondly, the risk of suicide in adults presenting with childhood onset bipolar disorderis higher than in adults presenting with a later onset. Thirdly, suicidal behaviour in early-onset bipolardisorder occurs at a younger age than most psychiatric presentations, and is defined by more lethaland frequent attempts (Goldstein et al., 2005). In general, there is a strong association between earlyonset illnesses and eventual suicidality.
Considering the significantly elevated risk of suicide, it is important to systematise an assessment
procedure that could enable clinicians to assess risk. The following can be considered as red flagspointing to heightened risk: Firstly, people with Bipolar M ood Disorder who have a family historyof suicidal behaviour are more likely to attempt suicide than those who do not. Secondly, a historyof physical or sexual abuse is positively correlated with suicide attempts (Goldstein et al., 2005). These two factors must be seen in combination with the specific clinical presentation of the bipolarchild. The majority of people with Bipolar M ood Disorder who attempt suicide frequently presentwith mixed manic states, multiple depressive episodes, comorbid anxiety or panic disorders and/orsubstance abuse or dependence (Cox, Direnfeld, Swinson, & Norton., 1994; Rudd, Dahm, & Rajab,1993). Furthermore, children presenting with a history of mixed episodes as well as concurrentpsychotic symptoms are more likely to evince suicidal ideation. An important observation in termsof the bipolar-AD/HD diagnostic blur is that no studies have managed to find a correlation that con-nects suicidal behaviour with AD/HD.
The correlation between bipolar and borderline personality is an important consideration when
assessing suicidality. Specific traits are seen in adolescents with a suspected borderline/bipolar symp-tom structure. Among these are aggression, impulsivity, and fluctuations of idealisation and devalu-ation in relationships with primary attachment figures (Oquendo & M ann, 2001). Such interpersonal
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fluctuations can have an impact on the individual’s sense of safety, and could be continuous relational traumata precipitating suicidality. In addition to these features, the presence of non-suicidal self-harm is another possible indicator of risk (Faedda et al., 2004). W ith this in mind, adolescents presenting bipolar mood symptoms in conjunction with the specific personality traits of the borderline spectrum are a particular risk. One final factor is the severity of the symptoms. W ith this in mind, a diagnosis of Bipolar Type 1, in which more extreme episodes of mania and depression may manifest, increases the risk of suicidal behaviour. THE TREATM ENT OF CHILDHOOD-ONSET BIPOLAR M OOD DISORDER Pharmacotherapy and the child The treatment of children with psychiatric medication is a sensitive process that requires nuanced judgements and considers each child in relation to his/her development. The use of psychotropic medication is an important consideration that has received insufficient scientific attention, with the bulk of research addressing adult responses to medication (M cClellan, 2005). M cShane et al. (2006) observed that the use of SSRIs is widespread, irrespective of diagnosis. Such medication is prescribed with insufficient proof of its effectiveness. In developing prescription hygiene, a history should be obtained to establish which medications have been helpful or unhelpful in the past. Patients should then be weaned off ineffective medications. In working towards effective medication strategies for bipolar children, Pavuluri and Bishop (2005) developed a M edication Algorithm in which they promote prescription hygiene, mood stabilisation and addressing breakthrough symptoms. SSRIs, unless they have been shown to be effective, should be discontinued as a matter of course. This is based on compelling evidence suggesting that SSRI administration in children with bipolar disorder either worsens existing mania or could switch the child from a depressive or neutral state to a manic state (Pavuluri & Bishop, 2005).
Another important aspect of prescription hygiene involves working with either the misdiagnosis
of paediatric bipolar disorder as AD/HD, or a Bipolar-AD/HD comorbidity. It is well known that thestimulant Ritalin has a potentially aggravating effect on the mood presentation of bipolar children. It is therefore necessary to undo diagnostic errors and reshape the treatment regime by addressing theprimary concern, mood stabilisation. T he authors suggest that if AD/HD presents as an authenticcomorbidity, the urgency of mood stabilisation should nonetheless be attended to prior to addressingattentional symptoms. The prescription of mood stabilisers such as Lithium and Sodium Valproateis widely recognised as effective. Should this prove ineffective, practitioners are recognising theeffects of second generation anti-psychotic medications such as Clozapine, Risperidone, Quetiapineand Olanzapine (Kafantaris, Dicker, & Coletti. 2001; Ziervogel & M cCallaghan, 2001). Followingmood stabilisation, Pavuluri and Bishop’s algorithm addresses breakthrough symptoms that falloutside of the bipolar diagnostic boundary. Among these are depressive features, psychosis, ag-gressiveness and sleeplessness. The presence of comorbid illnesses such as anxiety disorders anddisruptive behavioural disorders should be addressed separately, and only after mood has beensufficiently stabilised.
W orking therapeutically w ith bipolar children and their fam ilies In this final section I shall discuss an integrative approach to psychotherapeutic interventions. This approach involves elements drawn from systems theory, interpersonal psychotherapy and cognitive behavioural therapy. Each of these elements has individually been seen to be highly effective in the symptom relief and management of childhood mood disorders as well as the impact of such disorders on the child’s experience of self. I consider this approach as of potential value due to its emphasis on the system within which the child’s psychic experience plays out. The system is engaged with thera- peutically, as well as the child. Therapeutic responses to childhood mental illness that are framed in this manner are proposed as more completely addressing and working with the range of precipitating South African Journal of Psychology, Volume 40(3), September 2010
and predisposing factors that are associated with paediatric bipolar disorder. W est, Henry, andPavuluri (2007) have conducted trials of this approach based on their observation that such anapproach facilitates the containment of symptoms by working with the child and the system in whichhe/she exists. This is the primary justification for interest in and further exploration of this method.
The approach, called RAINBOW therapy, is intended for children living with bipolar disorder,
their parents and siblings (Pavuluri et al., 2004; Pavuluri & Bishop, 2005). Importantly, this tech-nique can be moulded into a school-based intervention, addressing the child’s difficulties in thatenvironment. The RAINBOW therapy system is a step-by-step process, with each step carried out inorder. A minimum of 12 sessions is required — one third of the sessions with the child alone, onethird with the parents, and one third with siblings and school, if necessary. Although the process isdesigned to be flexible, certain aspects must be adhered to rigidly. These include the adoption of themedication algorithm, the involvement of parent(s) and child, and the successful completion of theprocess. The RAINBOW therapy process takes place as follows:
Routine: A strict routine needs to be established, included eating habits, sleeping patterns, and
balance between work and play. This creates a containing and predictable environment. The benefitof routine in the child’s development is indisputable and is promoted as a psychological necessityenabling a sense of safety. Routine in the sleep-wake cycle is an important aspect of this step.
Affect regulation/Anger control: This involves cognitive behavioural techniques that can
be creatively moulded. Affect regulation involves psycho-education, in which the nature of the illnessis described in an understandable manner. The child and parents are enlisted in charting the child’saffective states through the day. Techniques from narrative therapy are used in this process, in whichthe child is asked to find a story in the pattern of moods and give each mood an externalisablecharacter which the child can think of as a way of externalising the mood state. In the process ofaffect regulation, both child and parent can work out ways of narrating the unwanted mood state. Suchnarratives enable the child to develop insight into and control over his/her own mood states and thecorresponding behaviours (Pavuluri et al., 2004). “I CAN DO IT!!!”: This process aims to help the child develop positive self-esteem that is not
dominated by the Bipolar M ood Disorder label. This step involves helping the child to construct apositive self-story (Pavuluri et al., 2004) and involves sessions with the child alone. The child couldbe asked to tell the story of who he/she is, with the therapist providing different narratives to replacethose that seem self-destructive and overly self-critical.
No negative thoughts: This aspect of the process derives from cognitive behavioural tech-
niques in which the therapist works with the child towards restructuring those beliefs, thoughts andassumptions that are unhelpful or harmful, and replacing them with more facilitative cognitions. Thetherapist could help the child to articulate what he/she thinks it means to have bipolar disorder; whata person with bipolar disorder is like; what it means to be diagnosed with a mental illness. Theseissues could feature at the foreground of the child’s awareness of the illness and his/her negativeself-statements. Unkind comments from other children based on stigmatising attitudes may fuel suchnegative self-statements and need to be worked with. The child should be encouraged to find morehelpful self-statements, which more adequately reflect his/her character, skills and proficiencies.
Be a good friend: In this component, parents assist their child by organising play dates with
friends and facilitating the development of healthy peer relationships. This element focuses onenabling the parents to develop their own balanced lifestyle. It is suggested that parents will be unableto care for a child with bipolar disorder or meet the variety of fairly intense demands placed on themif they are not leading a balanced life themselves.
“Oh, how can we solve it?”: This element of the process focuses on how family systems
work. Families are worked with in an attempt to provide parents, siblings and the child concernedwith solutions to the relational difficulties that emerge when the child is acting in an aggressive orirritable manner. Families are encouraged to engage in situational problem solving, in which children
South African Journal of Psychology, Volume 40(3), September 2010
and their parents dialogue around why such behaviour is undesirable, what the negative consequencesare, and what positive consequences could arise out of changing the behaviour.
W ays to ask for and get support: Children are taught how to develop what is known as a
support tree. The child is asked to name the people in his/her life who can be trusted. The aim of thisis to sediment in the child’s mind the fact that he/she does have a supportive network of relationshipsto rely on. The sense of safety that this is said to foster is proposed as having important therapeuticvalue for the child.
The RAINBOW therapy process is presented in accessible language and is proposed as being
well suited to the treatment of bipolar children. This is so because the process addresses children intheir lived world, taking into consideration their relational support network. RAINBOW therapyengages with the child’s system of meaning and focuses on enabling this system to become helpfuland facilitative, rather than damaging. The model was developed within the past decade, and soinsufficient evidence exists to support its efficacy. Further research into its effectiveness in thetreatment of paediatric bipolar disorder is greatly needed.
W hat I have attempted to show in this paper is the notion that the management of paediatric
bipolar disorder is a multi-story engagement that should assess the child as an embodied self wholives in a relational world, struggling to come to terms with and to make meaning out of a thing calledbipolar disorder. W e have seen documentation in the literature of the uniqueness of paediatric bipolardisorder. In response to this, our treatment approach needs to be tailored to fit this unique shape. Thispaper has aimed to emphasise the need for further research into paediatric bipolar disorder, itsassociated risk factors in our context, and those interventions that could be most enabling of thechild’s development. Further research into the effectiveness of psychotherapeutic models is alsoneeded. Added to this, the literature consulted reflects a gap in terms of responses to psychotropicmedication, with attention paid more to the responses of adults and less to the responses of children. This article has attempted to highlight the gaps in the current literature, thereby opening up possi-bilities for future research.
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Bemidji High School Industrial Technology Standards – revised 2010 Advanced Construction Technology Grades 9-12 Standards Benchmarks Activities/Examples J The nature and development of technological Students learn how residential buildings are designed to fit within its knowledge and processes are functions of the surroundings and how the design and building materials ar
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