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Bipolar disorder in early childhood has been a highly controversial diagnosis.
There is limited prevalence data on Bipolar 1 disorder (classical “manic-depression”)
in children younger than thirteen. The high variability in the presentation
of the disorder, both cross-sectionally and longitudinally, makes it difficult
to identify the disorder at any given moment, and certain developmental components
make it difficult to determine what is age-typical versus pathological in young
children. We do know that there is a “cohort effect,” in that if
we look at the number of diagnosed cases since World War 1 and the age of onset,
we find that the number of cases reported continues to increase and the age
of reported onset is earlier in each generation. In our book, Bipolar Patterns
in Children: New Perspectives on Developmental Pathways and a Comprehensive
Approach to Prevention and Treatment (Greenspan and Glovinsky), we used the
word patterns rather than disorder in discussing bipolarity in children. Because
of the variability in the presentation of the disorder, we now know that we
are not dealing with a single disorder, but rather with patterns of behavior
marked by severe emotional dysregulation and difficulties in executive functioning
that involve interrelated features, including genetic and biological,
A developmental signature
Sensory modulation challenges: A combination of sensory overreactivity and extreme sensory craving. As the child becomes overloaded due to his sensory over-reactivity, instead of becoming cautious as many sensory reactive children do, he switches to a sensory craving mode. He therefore may behave impulsively or aggressively, or become over-agitated and excited. The child often elicits punitive limit-setting because of his impulsivity. However, since he is also over-reactive, he may quickly shift into self-incriminations and depressive states.
Difficulties with co-regulated affective interactions. While most children with bipolar patterns can be highly purposeful and related, many young children, however, tend to have difficulty with long co-regulated affective reciprocity — e.g., reading and responding to emotional cues around themes of aggression as well as sadness and loss. A microscopic study of their affective gesturing shows that they have difficulty responding to their caregivers’ attempts to “up” or “down” regulate them with appropriate caregiving gestures. (For example, the caregiver attempts to be more soothing as they become more agitated). When the child’s caregiver also has difficulty reading or responding to affective gestures, the child’s challenges are compounded. These patterns often begin in infancy and continue throughout childhood
Constricted emotional range and flexibility. Many children
with bipolar patterns tend to be creative and
imaginative but constricted in their emotional range. They
may be strong in verbalizing the theme of nurturance in
pretend play, but then shift to an “action mode” in
their pretend play around aggression, using words that merely
describe an event and accompany the discharge of aggression in
their actions, rather than containing or representing
their intense feelings
Polarized rather than reflective thinking. At higher levels of reflective thinking this earlier pattern continues. Therefore, children with bipolar patterns may remain in polarized “all-or-nothing” patterns and have difficulty with more modulated, gray area and reflective thinking, in thematic or affective areas that are emotionally charged such as aggression, loss, and vulnerability. Without intervention or shifts to more favorable life experiences, these patterns may continue through latency, adolescence, and adulthood.
Treatment: Home, psychosocial, medication, educational
The educational program needs to collaborate closely with parents and the therapeutic program. In the educational setting, the same goal of co-regulated affective interaction, firm but gentle guidance and limit-setting, and subtle differentiated (gray-area) thinking needs to be supported, while pursuing the age-expected academic goals. If there are areas of processing challenges, the school program should work on these and also create opportunities for extra practice interacting with peers, including work with the school mental health counselor and lots of projects solving problems working with other students. In conclusion, we have presented a brief overview of a developmental model to understand, assess and organize a comprehensive intervention program for children with bipolar patterns. For more information go to www.ICLD.com, or www.floortime.org.
- Greenspan, Stanley I and Ira Glovinsky; Bipolar patterns in children: New perspectives on development, prevention, and treatment; Brown University Child & Adolescent Behavior Letter; May2005; Vol 21 Issue 5, p.1The article above contains foundational information. Articles below contain optional updates.
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