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Section 15
Case Study: Treatment of Bipolar Disorder in a 6-Year-Old Boy

Question 15 found at the bottom of this page
Answer Booklet | Table of Contents
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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. His parents 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 hours.

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.

Discussion
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).

Treatment
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 stopped.

Conclusion
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.

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Personal Reflection Exercise Explanation
The 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.

Personal 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.

QUESTION 15
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 the Answer Booklet.