Treating the Ups & Downs of Bipolar Children

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,
psychological, interactive, and family patterns.

Bipolar patterns
The disorder is pervasive in that it affects all area of the child’s functioning, and it bears little resemblance to adult bipolar disorder (Faedda & Carlson). We feel that these patterns are best understood within a developmental bio-psychosocial model that relates biological factors, including patterns of sensory processing and sensory modulation, to psychological factors in a context of relationships with significant figures in the child’s life. The research on bipolar disorder has focused on the phenomenology and the pathophysiology of the disorder. The major missing piece in our understanding of these bipolar patterns, however, has been the early developmental pathways that underlie their emergence. Akiskal approached the developmental question from an "adult" perspective, suggesting that affective temperamental dysregulation may represent putative developmental pathways to bipolarity. An understanding of bipolar patterns in children requires a more complete developmental perspective. Through clinical work and observational studies of typically developing infants, toddlers and young children, as well as children who present clinical challenges, we have had the opportunity to develop a developmental bio-psychosocial model that we have applied to bipolarity in children The developmental bio-psychosocial model developed by Dr. Greenspan and described more recently in his new book, considers how genetic and biological factors interacting with developmental experiences express themselves in a hierarchy of intervening developmental organizations. These organizations mediate between genetic-biological etiological and experiential factors and presenting symptoms and behaviors. Genetic-biological differences are expressed through differences in sensory reactivity, sensory processing, sensory affective processing and motor functioning. These differences should be viewed in the context of parent-child interactions, and through a sequence of functional emotional developmental levels.

A developmental signature
In our clinical work with children who present with bipolar patterns, we have observed that children at risk for this severe emotional dysregulation pattern may have a "developmental signature" that is marked by certain behavior patterns.

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
in a dialogue.

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 developmental profile we have been describing leads to a comprehensive treatment program that has a number of components. The most important component is the home program where parents and child work on learning affective signaling, including more effective and sensitive patterns of up- and down-regulating cues. They do this as part of spontaneous play or conversations (a special type of Floor Time or "hang out time"). Parents also engage in daily problem-solving discussions where they help the child think about tomorrow and visualize and describe feelings associated with anticipated positive and negative expectations. The goal in their discussions is to help the child use more differentiated and subtle rather than polarized descriptions of feelings. The home program also focuses on providing stable, nurturing caregiver relationships and firm, persistent, but not punitive limits and guidance. The close relationship with the same sexed parent is also important. In addition, the specific processing weaknesses need to be identified — e.g., motor planning or sequencing, or executive functioning ability — and a program to strengthen these capacities must considered. Many children will also require psychotherapy, which has the same goals as the home program, and enables the therapist to support the family in the implementation of the home program. For some children, medication will need to be considered to help the child stabilize his or her mood and participate in the home or psychotherapeutic program. Many children will not require medication. However it is best to begin with a home and psychotherapeutic program before deciding whether medication should be considered.

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.

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Personal Reflection Exercise #3
The preceding section contained information about patterns in children with bipolar disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 17
According to Greenspan, what are the four patterns in the developmental signature of children with bipolar disorder? Record the letter of the correct answer the CEU Answer Booklet.