Thomas, a 6-year-old boy from an intact nuclear family, had been
diagnosed with ADHD 6 months prior to his initial appointment with me. The
initial evaluation was at the urging of his kindergarten teachers. Although
they found him very endearing and exceptionally bright, they expressed concern
about his over-activity, impulsivity, seeming lack of attention
for dangerous situations or actions, and his episodic anger outbursts. His
classmates found him overwhelming and avoided him. Thomas was referred for
a second diagnostic opinion regarding his behavioral and uncontrolled moods.
His parents, both of whom looked tense and tired, accompanied Thomas, a smiling
little boy who appeared to be all knees and elbows, to the interview. Since
his initial diagnosis of ADHD Thomas had been tried on two stimulant medications.
were ambivalent about the medication's effectiveness and occasionally skipped
doses saying, "He can be hyper with or without it and he can be mellow
with or without it." They had been in weekly play therapy with Thomas
for the past four months. Instead of improving with intervention, Thomas's
behaviors and moods worsened.
Over the past few months Thomas's tantrums had become severe and prolonged,
lasting up to 3 hours. His parents said that during the tantrums, "He
doesn't even hear you." Thomas would smash his toys, kick holes in doors
or walls, rip his clothing, scratch his face or punch himself in the head.
When the tantrum was over, he would be remorseful, seek multiple hugs and reassurances,
and rapidly return to his usual sweet and sunny self. Thomas's moods were increasingly
random and unpredictable. Though usually a sweet child, "with a fantastic
sense of humor," he could, "turn on a dime." During a recent
and particularly severe tantrum, he screamed, "I wish I were dead! Why
don't you just kill me! Get a big knife, cut out my heart, and splatter my
blood all over the walls!" Thomas was having increasing difficulty sleeping,
although his sleep had never been what his mother considered to be, "normal." His
bedtime was 9 p.m. He was routinely up and awake in his room until 1:00 a.m.
or 2:00 a.m. He was ready for the day by 7 a.m. Approximately once weekly Thomas
would, "finally collapse from exhaustion," and sleep for 16 uninterrupted
Thomas was being terrorized by the, "shadow monster," and the "spider
king". For the past few weeks they had been appearing to him multiple
times daily and telling him to do "bad things." They were also present
in his amazingly gross and gory nightmares, which he openly described to others.
Thomas had experienced a sudden onset of excessive sexual curiosity and frequent
masturbation, even in public places. The parents reported a "creepy and
constant" attempt by Thomas to see his younger sister naked.
Family psychiatric history
Thomas's mother was adopted as an infant and her biological history was unavailable.
She had been diagnosed with depression and was successfully treated with
an SSRI (selective serotonin reuptake inhibitor). In session, she presented
as an intelligent and concerned parent who was desperately seeking answers
and help for her child, a child she considered to be very good-hearted and
misunderstood. Thomas's dad experimented heavily with alcohol and marijuana
in high school. He had first and second degree relatives with a variety of
affective disorders. His father had alcohol issues as a younger man. Dad's
aunt was treated for bipolar disorder and had killed herself at the age of
30. In session. Dad presented as a quiet man who seemed a bit uncomfortable
and somewhat skeptical. Both parents gave the impression of being worn down,
running out of options, and fearful for their child. Thomas's three-year-old
sister, Kerry, was not present at the interview. She was described as a happy easy
going little girl. Thomas, reportedly, had looked forward to having a new
baby when mom was pregnant and enjoyed the role of big brother. The parents
were concerned that Kerry was getting less than her share of parental attention
because of Thomas's extreme needs. Thomas's maternal grandparents lived nearby
and were finding Thomas increasingly difficult to tolerate. They readily
provided childcare for Kerry, but declined to have Thomas over unless he
was accompanied by a parent, and then only for short visits. The parents
considered the grandparents to be very supportive in the struggle to get
Thomas the assistance he needed. As noted previously, Thomas's schoolmates
found him overwhelming and odd. His behavior with them was erratic and they
avoided him. He was no longer welcome in the homes of neighborhood children.
Though Thomas said he had lots of friends, his mother discretely reported
he actually had none.
Extreme irritability in child onset BPD is sometimes expressed as bipolar rages
(Popolos and Popolos). These rages generally last longer than 30 minutes,
involve an energy level that would leave an adult, trying to imitate the
rage, exhausted. They also can include a seeming loss of contact with reality,
destruction of property (including the child's own) self-abuse, and lashing
out at others. Thomas's tantrums were typical of bipolar rages. Grandiosity
and an inflated sense of self-esteem need to be viewed in an age-appropriate
context. Thomas engaged in dangerous impulsive behaviors with
no apparent fear. His peers found his unpredictability and excesses intimidating.
They generally steered clear of him. He seemed not to notice. He relied heavily,
and successfully, on charm and wit to impress adults, whose company he sought
and seemed to prefer. Was this a 6-year-old version of grandiosity? An argument
could easily be made that the former was and that the latter represented the
same thing could also be argued, but perhaps not as persuasively.
During one of Thomas's periods of dysphoria and rage, he expressed
the desire to die and had a spectacular plan. Suicide in childhood often looks
like an accident because of their limited repertoire and access. Suicidal behavior
in pediatric BPD is as high as 25% (Pavuluri, et al.). The incidence of completed
suicide in BPD is estimated to have a 19% lifetime occurrence (Goodwin and
Jamison). This is an unacceptably high rate of fatality for any illness. Thomas's
auditory and visual hallucinations could be explained away as childish imagination
or as lying. However, Thomas did not find them at all fun and he did not seem
to bring them up only when it suited his purposes. Thomas was still young enough
not to realize how bizarre it was to have these apparitions. Older children
do and they often keep hallucinations to themselves to avoid alarming others
or being indelibly stamped with the label of "crazy".
A healthy child is usually a good sleeper. The development of chronic sleep
problems is cause for concern. Thomas demonstrated difficulty sleeping regularly
since infancy. His sleep now had fallen into a common pattern seen in pediatric
BPD. He needed very little sleep to leave him refreshed and bursting with energy.
Episodically he had periods of hypersomnolence. The spider king and the shadow
monster carried over into Thomas's dreams. Not atypically, children with BPD
have gory, gruesome, extreme dreams that leave one wondering to what deviant
experiences these children have been exposed to. Often no history of such exposure
is found or exists. Hypersexuality is a symptom of BPD in all ages. When it
occurs in a child, sexual abuse is often suspected, and rightly so. The possibility
of sexual abuse should be investigated. Regardless of whether the child has
been abused or the hypersexuality is solely a symptom of the illness, the child
needs to be protected from compromising situations and predators who might
seek to capitalize on the child's disinhibition.
BPD is a heritable condition and it is important to get a complete family
psychiatric history. Family pedigrees of patients with BPD generally include
first or second degree members with affective disorders. While bipolarity is
generally over-represented, other affective disorders, including anxiety disorders,
are present as well. Members with uncontrolled anger and issues of alcohol
or substance abuse also seem to be over-represented (Popolos and Popolos).
Thomas's treatment regime included a peer social skills group, an individual
education plan (IEP), and medication. His parents were provided education
and counseling regarding parenting a child with a chronic mental illness
and access to a parent support group through the local chapter of the Oregon
Alliance for the Mentally Ill (OAMI.) In the peer social skills group, Thomas
was helped to learn friendship skills, increased empathy, cooperative problem
solving, feeling identification, and relaxation/calming skills. Thomas's
IEP, developed for his mainstream kindergarten class, focused on emotional
growth and development (academics were not a problem.) He was encouraged
to further develop feeling identification— but not while in the midst
of an emotional outburst. A "safe place" was provided where Thomas
could go to calm down when he felt or demonstrated increased tension or overstimulation.
He was encouraged to use the friendship skills he learned in group and was
given liberal praise for prosocial and cooperative interactions. Thomas's
teachers were helped to learn effective techniques to work with this child's
particular emotional disability. Thomas's parents donated the book, "The
Bipolar Child," by Popolos and Popolos, for the teachers to refer to.
Aside from being an excellent educational tool on bipolar presentations in
childhood, the book has numerous suggestions for the academic setting. Thomas'
therapist was present for the first few IEP development and review meetings.
Thomas's parents were referred to bibliographical references and were provided with several on-line sites for education and interaction
(www.bpkids.org; www.aacap.org; www.nimh.nih.gov; and others.) They were encouraged
to bring comments and questions to their parent education/ counseling sessions.
The OAMI parent support group was of particular help to Thomas's parents. As
Thomas's illness spiraled out of control, the parents felt increasingly judged,
and isolated, by family members, friends and neighbors who did not understand
what the parents and Thomas were going through. The support group gave the
parents an understanding forum to express their frustrations. Also invaluable,
was the opportunity to benefit from others suggestions and experiences raising
children with psychiatric disorders.
Thomas's treatment started with prompt discontinuance of the
stimulant medication. As expected, Thomas's symptoms had broadened and worsened
within weeks of its initiation. Depakote sprinkles were started for mood stabilization.
Baseline and monitoring laboratory tests were done. Thomas achieved adequate
mood swing control with a Depakote level maintained at a high therapeutic level.
At the same time, Risperidone was added and slowly titrated to a final dose
of 1.0 mg at bedtime. The Risperidone was briefly increased to 1.5 mg. but
at this dose, Thomas developed some uncomfortable extrapyramidal side effects.
The dose was dropped back to 1.0 mg and 25 mg of Benadryl was added. The side
effects rapidly resolved. Risperidone was effective in helping Thomas settle
and sleep through the night without
nightmares. The daytime visits from the spider king and shadow monster also
Symptoms of bipolar disorder in children can be complex and confounding. They
often overlap with other diagnostic constellations and the diagnosis of BPD
is not infrequently overlooked. The diagnoses of ADHD, depression or anxiety
sometimes seem more palatable, not only to the parents but also to the diagnostician.
Unfortunately, missed diagnosis and
treatment with antidepressant or stimulant medications can worsen the symptom
presentation, and perhaps even the long-term outcome of BPD. Thomas's case
was no exception. Several key symptoms that were helpful in diagnosing Thomas's
problem as BPD as opposed to ADHD were not present, and others were not fully
expressed, when the initial diagnosis was made and the stimulant medication
prescribed. The multi-modal treatment package developed for Thomas addressed
and assisted in his home, school, and personal environments. The treatment
package also served to provide treatment, if you will, for his parents—and
secondarily his sister and grandparents, his teachers, and his peers, all of
whom experienced ill effects and trauma from Thomas's illness. Thomas is currently
doing well. The charming, cheerful, witty side of Thomas is evident and able
to be enjoyed on a more consistent basis. His moodswings have not completely
resolved but he and the adults in his life are much more adept at managing
the comparatively minor ups and downs when they do
occur. Thomas has developed some friendships and he is now welcome in playgroups.
He continues to excel academically.
- Duval, Sarah J; Six-year old Thomas Diagnosed with Pediatric Onset Bipolar
Disorder: A Case Study; Journal of Child & Adolescent Psychiatric
Nursing; Jan-Mar2005; Vol 18 Issue 1; p38
Reflection Exercise Explanation
Goal of this Home Study Course is to create a learning experience that enhances
your clinical skills. We encourage you to discuss the Personal Reflection
Journaling Activities, found at the end of each Section, with your colleagues.
Thus, you are provided with an opportunity for a Group Discussion experience.
Case Study examples might include: family background, socio-economic status, education,
occupation, social/emotional issues, legal/financial issues, death/dying/health,
home management, parenting, etc. as you deem appropriate. A Case Study is to be
approximately 250 words in length. However, since the content of these Personal
Reflection Journaling Exercises is intended for your future reference, they
may contain confidential information and are to be applied as a work in
progress. You will not
be required to provide us with these Journaling Activities.
Reflection Exercise #1
The preceding section contained information
about a case study of the treatment of bipolar disorder in a 6-year-old boy. Write
three case study examples regarding how you might use the content of this section
in your practice.
Online Continuing Education QUESTION
What were five learning objectives for Thomas, diagnosed with bipolar disorder,
in the peer social skills treatment group? Record the letter of the correct answer