Bipolar Disorder: Educational Implications for Secondary Students

Student Services 

Bipolar Disorder: Educational Implications 

for Secondary Students 

Handling the symptoms of childhood bipolar disorder appropriately is 

vital to students’ ability to learn. 

By J. Elizabeth Chesno Grier, Megan L. Wilkins, and Carolyn Ann Stirling Pender 

Bipolar disorder (BD) is a neurobiological 

disorder with cycling 

periods of mania and depression 

that was historically recognized as occurring 

only in adulthood but can now 

be diagnosed in children. Although 

controversy continues regarding the 

definition and diagnosis of BD in children, 

it is chronic and can cause major 

disruption in schooling for children and 

adolescents. 

Widely accepted estimates of the 

prevalence of BD in adults range from 

1%–2% (American Psychiatric Association 

[APA], 2000), and incidence is 

similar in adolescents (Wolf & Wagner, 

2003). BD is considered one of the most 

heritable mental illnesses: children 

of parents with BD are more likely to 

develop a mood disorder. Other risk 

factors include rapid onset of depressive 

symptoms with psychotic features 

(e.g., delusions), family history of mood 

J. Elizabeth Chesno Grier is an associate professor in Clinical Pediatrics and a school 

psychologist at the University of South Carolina School of Medicine. 

Megan L. Wilkins is a post-doctoral fellow at St. Jude Children’s Research Hospital. 

Carolyn Ann Stirling Pender is a doctoral student in the School Psychology Program at 

the University of South Carolina. 

Student Services is produced in collaboration with the National Association of School 

Psychologists (NASP). Articles and related handouts can be downloaded from www. 

naspcenter.org/principals. 

12 PL April 2007 

disorders, and history of manic or hypomanic 

symptoms following antidepressant 

treatment (Faedda, Baldessarini, 

Glovinsky, & Austin, 2004). In addition, 

research has shown that children treated 

with stimulants may experience early 

onset manic symptoms (Giedd, 2000). 

Manic and depressive episodes of BD 

disturb mood, behavior, energy, and sleep. 

During a manic episode, a student may 

show a period of abnormally elevated, 

expansive, or irritable mood (APA, 2000) 

that is significantly different from his or 

her typical behavior. In class, for example, 

the student might be excessively happy 

and cause disruption by laughing hysterically 

for no reason. When with friends, 

a student with mania may be grossly 

irritable, short-tempered, and frustrated 

when not given his or her way. Minutes 

later, the student may become hyperverbal 

while expressing a flight of ideas or a 

desire to engage in risk-taking behavior. 

A depressive episode consists of loss 

of interest in activities or a low mood. 

A student having a depressive episode 

may no longer be interested in a favorite 

subject and may show a significant loss of 

energy. He or she may be anxious, argumentative, 

or aggressive with teachers or 

friends. Feelings of worthlessness or guilt 

and persistent thoughts of death or suicide 

resulting in an inability to concentrate 

also may be present (APA, 2000). 

Criteria for the length of manic and 

depressive episodes in adults are specific 

(APA, 2000); the duration in children 

and adolescents, however, is not clear. 

Adolescents who have BD may vacillate 

between depressive and manic symptoms 

on a weekly, daily, or hourly basis. 

This rapid cycling is a hallmark symptom 

of BD in children and adolescents 

(Wolf & Wagner, 2003). 

Mixed episodes cause extreme 

dysregulation of mood and energy. The 

student might appear enraged, anxious, 

and upset all at once. Frequent mood 

changes may produce severe irritability, 

serious temper outbursts, rage reactions, 

and behavior that is difficult to 

manage. Because of the cyclical nature 

of the disorder, students have periods 

of calm during which their problems 

seem miniscule and may not be apparent 

in the classroom. It is important to note 

patterns in students’ behavior to better 

predict when erratic behavior may occur.

Coexisting Disorders 

BD commonly overlaps with other 

psychiatric disorders. Biederman, Mick, 

and Faraone (2004) found that 87% of 

children with BD also had attention 

deficit/hyperactivity disorder (ADHD), 

although only 20% of children with 

ADHD met criteria for BD. Symptoms 

of grandiosity, elevated mood, flight 

of ideas, and decreased need for sleep 

distinguish BD from ADHD (Pavuluri, 

Birmaher, & Naylor, 2005). The combination 

of ADHD with BD often results 

in severe impairment with increased 

psychotic symptoms, need for hospitalization, 

and school failure (Wolf & 

Wagner, 2003) in addition to increased 

impulsivity that may lead youth to act in 

lethal ways, such as suicide (Biederman 

et al.). Children and adolescents with 

BD often meet criteria for oppositional 

defiant, conduct, anxiety, and learning 

disorders. Accurate diagnosis of BD is 

complicated by the complexity of symptoms 

and frequent co-occurrence with 

other disorders. 

Treatment and Intervention 

Because of the novel recognition of pediatric 

BD, treatment in children has been 

an extension of adult treatment. Only recently 

has intervention literature focused 

on treatment options that are specifically 

for children and adolescents with BD. To 

stabilize the severe behaviors often seen 

in pediatric BD, psychotropic medications 

are commonly used as first-line 

treatment. Without mood stabilization 

through medication, students may not 

adequately benefit from other interventions 

(McIntosh & Trotter, 2006). 

Current psychosocial treatment 

guidelines for childhood BD are largely 

based on clinical experience, with scant 

empirical research establishing their 

effectiveness. Cognitive-behavioral 

therapy strategies and family psychoeducation 

approaches are highlighted as 

the most effective treatments (Kowatch 

et al., 2005; McIntosh & Trotter, 2006). 

Interventions are delivered at the 

individual or family level and include 

cognitive restructuring for depressive 

symptoms, problem-solving strategies to 

intervene with emotional dysregulation, 

and behavior management techniques 

to establish routine and consistency 

(e.g., Pavuluri et al., 2004). Family psychoeducation—providing 

information 

and guidance to families in a teaching 

format—has also proven to decrease 

symptom expression and increase 

parental knowledge and positive family 

interactions (Fristad, Goldberg-Arnold 

& Gavazzi, 2003; Pavuluri et al., 2004). 

Schools’ Response 

Each student with BD has a unique 

symptom pattern, which makes the 

development and use of intervention 

plans in the school setting challenging. 

A collaborative approach that uses 

Case Study 

problem-solving strategies and includes 

families, school staff members, and 

medical and mental health providers is 

necessary to provide appropriate school 

intervention for students with BD. 

School-based interventions for these 

students can include different levels 

of special education services, specific 

classroom modifications, and direct 

services provided by school counselors 

and psychologists. Students diagnosed 

with BD can be served in general education 

or special education classrooms or 

a combination of both. 

Students who have less-severe symptoms 

but who show limited academic 

progress because of BD may benefit 

from a Section 504 plan, which might 

include specific classroom accommodations 

and school-based counseling. 

An IEP is often created under the 

“Emotional Disability” or “Other Health 

Impaired” (OHI) category of disability, 

but for students to qualify for these 

services, their symptoms must adversely 

affect learning. 

Rylan is an eighth-grade student with early onset bipolar disorder (BD), attention deficit/hyperac- 

tivity disorder (ADHD), oppositional tendencies, social problems, and writing difficulties. Rylan’s 

behavior results in classroom disruptions, peer conflicts, teacher frustration, and poor academic 

performance. Rylan’s educators are struggling with how to best support his needs. 

The assistant principal who deals with Rylan’s misbehavior has noticed escalating concerns 

since earlier this school year. Rylan has only recently been sent to the office because of his short 

temper, refusal to write in most classes, argumentative interactions with teachers, and fights 

with peers. Upon reviewing Rylan’s record and discovering his diagnoses, the assistant principal 

immediately puts a plan together to support Rylan. 

The assistant principal created a plan of action for Rylan when problems first began. A 

proactive meeting was held with his parents and teachers. Medical providers were contacted 

immediately for consultation. School counseling efforts began while medication changes were 

being completed. Learning issues were assessed and teachers were given support to deal with 

Rylan in the classroom via the development and implementation of a 504 plan. These collabora- 

tive prevention measures allowed the assistant principal to manage the situation and support 

Rylan and his teachers. 

PL April 2007 13

Student Services 

Symptoms and Expression of Depressive and Manic Episodes in Children and Adolescents 

Depressive Episode 

1. Depressed Mood and/or 

2. Loss of Interest and 

Four Other Symptoms Possible Expression in Children and Adolescents 

3. Weight loss/gain Uninterested in eating and/or overeats. 

4. Insomnia or hypersomnia Difficulty falling and staying asleep. Sleeps more than usual. 

5. Psychomotor agitation or retardation Hyperactive, difficulty sitting still, and/or impulsive. Less active and interactive. 

6. Fatigue or loss of energy Needs more rest, complains when pushed to do activities, and/or pretends to 

be sick. 

7. Feelings of worthlessness or inappropriate guilt Makes negative self-comments, such as “I am stupid” and “No one likes me.” 

8. Diminished ability to think or concentrate Has poor concentration, is disorganized, and/or distractible. 

9. Recurrent thoughts of death, suicidal ideation/attempt. Talks about dying or has themes of death in conversation, play, or artwork. 

Manic Episode 

1. Elevated and/or expansive mood and/or 

2. Irritable mood and 

Three (four if mood is only irritable) Other Symptoms: Possible Expression in Children and Adolescents 

3. Inflated self-esteem or grandiosity Demands to be center of attention or overcommits to projects/activities. Has 

hallucinations (e.g., hears/sees things) or tells eccentric stories. 

4. Decreased need for sleep Full of energy and requires little sleep (e.g., wanders around house nightly 

looking for things to do). Gets very little sleep but is full of energy next day 

with no tiredness. 

5. More talkative than usual Talks rapidly, loudly, and incessantly without allowing others to enter conversation. 

6. Flight of ideas/racing thoughts In absence of language problems, does not make sense when they talk. 

Comments they can’t get things done because their thoughts are interrupting 

them. 

7. Distractibility More than typical, has difficulty paying attention and/or is disorganized. 

8. Psychomotor agitation/increase in goal directed activity Overly active, spends more time playing and completing a specific activity 

than usual, and/or displays impulsive behaviors. 

9. Excessive involvement in pleasurable activities that have high potential for 

painful consequences (i.e., poor judgment). 

14 PL April 2007 

Shows hypersexual behaviors (in the absence of sexual abuse) or makes 

inappropriate displays of affection. Engages in risk-taking behaviors and takes 

dares easily from others. 

Sources: 

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders-text revision (4th ed.). Washington, DC: Author. 

Geller, B., Craney, J. L., Bolhofner, K., DelBello, M. P., Axelson, D., Luby, J., et al. (2003). Phenomenology and longitudinal course of children with a prepubertal and early adolescent 

bipolar disorder phenotype. In B. Geller & M.P. DelBello (Eds.), Bipolar Disorder in Childhood and Early Adolescence (pp. 25–50). New York: Guilford. 

Kowatch, R. A., Fristad, M., Birmaher, B., Wagner, K. D., Findling, R. L., & Hellander, M. (2005). Treatment guidelines for children and adolescents with bipolar disorder: Child psychiatric 

workgroup on bipolar disorder. Journal of American Academy of Children and Adolescent Psychiatry, 4(3), 213–235. 

McIntosh, D., & Trotter, J. (2006). Early onset bipolar spectrum disorder: Psychopharmacological, psychological, and educational management. Psychology in the Schools, 43(4), 

451–460.

Certain symptoms of BD lend 

themselves to specific interventions. 

Papolos, Hatton, Norelli, Garcia, and 

Smith (2002) suggest such strategies 

as adjusting the student’s academic 

schedule to accomodate a disturbed 

sleep-wake cycle, allowing a “safe zone” 

for students who experience significant 

irritability or rage episodes, and allowing 

verbal or typed responses on schoolwork 

for students who exhibit perfectionistic 

tendencies. Students who have attention 

problems may benefit from preferential 

seating, frequent breaks, and organizational 

aids. 

School staff members should become 

familiar with the potential side 

effects of the psychotropic medications 

that are used to treat BD. Any change 

in school performance, energy level, 

behavior, social interactions, or mood 

should be shared with parents and 

medical staff members immediately. 

A key role for school administrators 

is consulting with other members of the 

student’s treatment team on an ongoing 

basis. This treatment team typically 

consists of a mental health provider, a 

physician, a school nurse, at least one 

teacher, and at least one parent. Consultation 

may involve discussing situations 

that are difficult for the student and 

problem behaviors, developing intervention 

and crisis plans, and offering 

suggestions as a contributing member in 

a multidisciplinary team meeting. 

Consultation with family members 

of students with BD involves supporting 

the family and providing information 

regarding school services for the 

student. School leaders also can forge 

positive relationships with community 

mental health and medical professionals 

by supporting regular contact with these 

providers or allotting time and resources 

for staff members to do so. 

Resources 

Web sites 

Child and Adolescent Bipolar Foundation: www.bpkids.org 

Depression and Bipolar Support Alliance: www.dbsalliance.org 

Juvenile Bipolar Research Foundation: www.bpchildresearch.org 

Books for Educators 

Understanding and Educating Children and Adolescents With Bipolar Disorder: A Guide for Educators. 2003. 

M. Andersen, J. Boyd-Kubisak, R. Field, & S. Vogelstein. Northfield, IL: The Josselyn Center. 

The Life of a Bipolar Child: What Every Parent and Professional Needs to Know. 2000. T. Carlson. Duluth, MN: 

Benline Press. 

Books for Parents 

Raising a Moody Child: How to Cope With Depression and Bipolar Disorder. 2004. M. A. Fristad & J. S. 

Goldberg-Arnold. New York: Guilford Press. 

The Bipolar Child: The Definitive and Reassuring Guide to Childhood’s Most Misunderstood Disorder (3rd ed.). 

2006. D. Papolos & J. Papolos. New York: Broadway Books. 

Conclusion 

Early-onset BD severely impairs all 

areas of the student’s life. Administrators 

have a unique opportunity to provide 

guidance to various staff members who 

work directly with students with BD to 

support their schooling. To provide this 

support, administrators should continue 

to seek information about BD, help and 

support teachers and other school staff 

members in identifying and devising 

appropriate intervention techniques for 

problem behaviors, consult with parents 

to support their needs in dealing with 

educational issues of students with BD, 

work with school staff members and 

community providers to de-stigmatize 

mental health problems and treatment, 

and forge positive relationships and 

model productive interactions with the 

student’s entire treatment team. PL 

References 

n American Psychiatric Association. 

(2000). Diagnostic and statistical manual 

of mental disorders-text revision (4th ed.). 

Washington, DC: Author. 

n Biederman, J., Mick, E., & Faraone, S. 

V. (2004). A prospective follow-up study 

of pediatric bipolar disorder in boys with 

attention-deficit/hyperactivity disorder. 

Journal of Affective Disorders, 82S, 

S17–S23. 

n Faedda, G. L., Baldessarini, R. J., 

Glovinsky, I., & Austin, N. B. (2004). Pediatric 

bipolar disorder: Phenomenology 

and course of illness. Bipolar Disorders, 6, 

305–313. 

n Fristad, M. A., Goldberg-Arnold, J. S., 

& Gavazzi, S. M. (2003). Multi-family psychoeducation 

groups in the treatment of 

children with mood disorders. Journal of 

Marital and Family Therapy, 29, 491–504. 

n Giedd, J. N. (2000). Bipolar disorder 

and attention-deficit/hyperactivity disorder 

in children and adolescents. Journal of 

Clinical Psychiatry, 61, 31–34. 

n Kowatch, R. A., Fristad, M., Birmaher, 

B., Wagner, K. D., Findling, R. L., & Hellander, 

M. (2005). Treatment guidelines 

for children and adolescents with bipolar 

disorder: Child psychiatric workgroup 

on bipolar disorder. Journal of American 

Academy of Children and Adolescent Psychiatry, 

4(3), 213–235. 

n McIntosh, D., & Trotter, J. (2006). Early 

onset bipolar spectrum disorder: Psychopharmacological, 

psychological, and 

educational management. Psychology in 

the Schools, 43(4), 451–460. 

n Papolos, J., Hatton, M. J., Norelli, S., 

Garcia, C. E., & Smith, A. M. (2002). Challenging 

negative remarks that threaten to 

derail the IEP process. Retrieved February 

19, 2005, from www.bpchildresearch.org/ 

edu_forums/accommodations.html 

n Pavuluri, M. N., Birmaher, B., & Naylor, 

M. W. (2005). Pediatric bipolar disorder: A 

review of the past 10 years. Journal of the 

American Academy of Child and Adolescent 

Psychiatry, 44(9), 846–871. 

n Pavuluri, M. N., Grayczyk, P., Carbray, 

J., Heidenreich, J., Henry, D., & Miklowitz, 

D. (2004). Child and family focused cognitive 

behavior therapy in pediatric bipolar 

disorder. Journal of the American Academy 

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528–537. 

n Wolf, D. V., & Wagner, K. D. (2003). Bipolar 

disorder in children and adolescents. 

CNS Spectrums, 8, 954–959. 

PL April 2007 15

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