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Bipolar Disorder: Pediatric/Occupational Therapy Perspectives - June 2009

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Bipolar Disorder: Pediatric/Occupational Therapy Perspectives, June 2009

By: Susan N. Schriber Orloff, OTR/L

I have written before on Bipolar Disorder and those articles have appeared in Advance for Occupational Therapists. I continue to receive many requests for additional information. In response to those questions, this article is going address two major aspects: how to communicate this disorder as different from ADD: noting “red flags” for diagnosis and what activities and protocols can most best help these children.

No doubt that this is a difficult disorder to diagnose, but certain specific considerations should be acknowledged. Too often these children are quickly labeled ADHD, ADD, Behavior Disordered, etc., given Ritalin or other similar drugs without much relief of symptoms and the parents sent to “parenting classes”.

The typical profile, if there is such a thing, may look something like this:
  • Bright child
  • Learns easily
  • Advanced vocabulary and verbal expression
  • History of biting—as early as getting his first tooth
  • Hyperactive/fidgets/lying (even when confronted with the truth)
  • Loving and wanting to be cuddled one moment and in a rage the next
  • Not easily calmed
  • Silliness, goofiness, giddiness
  • Racing thoughts
  • May have been dismissed from several preschools due to behavior/social skills are lacking
  • Family history of depression/mood disorders or an adult in the family who was bipolar

The parents get “advice” such as “…he needs a stronger hand”….or “he will outgrow it”…or owing to the latest ‘buzz word’…”it is a sensory problem”. None of these well-meaning words help at all!.

An excellent resource is the book, "The Bipolar Child" by Demitri Papolos, M.D., and Janice Papolos, which has been reviewed as a “shot in the arm” for parents of children with bipolar disorder.

School situations are often the most difficult to navigate. Teachers are “tuned into” ADD and go there first whenever there are any behavioral concerns. It is important to guide these concerns so that the most beneficial academic adaptations can be implemented. The key in IEP meetings and similar teacher/administrator discussions is to ask the key questions. I have found that checklists are extremely helpful in that they are specific and help the respondents to organize thoughtful responses that they then can review and elaborate upon. A diagnosis of bipolar disorder requires the intervention of a developmental pediatrician, as general pediatricians are often not as well trained in the subtleties of this and other discrete disabilities.

A sample checklist is suggested below:
(adapted from the works of Papolos and Papolos)

[Image: bipolar1.jpg]

When answering, simply accept “yes” or ”no”, sometimes is not an acceptable response, if it is true ever, it is “yes”. Too many times families try to dismiss these behaviors as situationally based when in fact they are symptomatic of a very serious condition. (The more “yes” responses the more important it is to refer this child to a developmental pediatrician—I suggest if there are more that 2 yes responses in any one area that further action needs to be taken.

In addition there are similarities and difference that should be noted between ADD/ADHD and Bipolar Disorder. They are charted below for easy reference:*

[Image: bipolar2.jpg]
*From Practical Applications of Recent Research in Pediatrics©2009 Susan N. Schriber Orloff, OTR/L

There are many activities to help children with bipolar disorder that may be helpful to families, therapists (occupational and others) and to teachers. They are provided below with resources for your further investigation.* (*Where there is no resource noted, it is from treatment protocols I have written.)

Home environments* and considerations:
*Bipolar Disorders: A Guide to Helping Children and Adolescents by Mitzi Walsh, copyright 2000 by O'Reilly & Associates, Inc

  1. Lighting is bright where it is needed for reading and studying, soft where the mood should be restful.
  2. Furniture large and comfortable but too heavy to throw
  3. Limited “knick-knacks” (that can be thrown)
  4. Valuables out of reach
  5. Suicide and personal harm items stowed or locked (knives in kitchen for example)
  6. A designated space to go when upset—not a padded room but a place to go to regroup and pull self to center—there should be toys in the room that are age appropriate.
  7. Do not isolate the child, it is essential that they know that they are loved unconditionally and that their behaviors do not change that.
  8. Even when they are teens, unsupervised times can be very counter productive (There have been many studies about children with and without disorders and the negative impact of being a “latch-key” child. However, this is particularly true to children with bipolar disorder.)
  9. Stability and continuity is essential for these children, so childcare arrangements should not be changing even if job hours change, etc. Try to approach family members, church/community resources to help out on a consistent basis.
  10. For older teens investigate “drop-in centers” that are usually run by local mental health agencies.

Activities to use –home and OT:

  1. Start a journal, this could be pictures drawn, cut from a magazine, or written—topics can be specific like “feelings” or general such as activities participated in that day, etc.
  2. Listening to music—or creating your own such as working from “Garage Band” (MAC computer program) or something similar to make your “music” can be very relaxing
  3. Exercise videos—if possible let him be taped with a trainer so he can see himself as he is working out at home!
  4. Workout routines—done daily not just when feeling anxious
  5. Participating in sports—non-competitive/small group
  6. Puppets, costumes and props for imaginary play
  7. Starting a collection of something of special interest (for example: rocks, toys, stamps, license plates, snow globes, etc.)
  8. Make “down time”—not everything has to be “therapeutic”—A special time for turning off TV, radio, computer, and having “talk time” where anything is “on the table”
  9. Playing cards, board games, memory games
  10. Caring for a pet (if the child is able to do this, be careful about tendencies to be abusive to animals, etc.)
  11. Community “service”: working at a food bank, colleting money for a charity and then going and turning it in.
  12. Learning /acquiring mastery of a new skill: sports, cooking, arts—many community centers have free or low cost lessons.

At school the occupational therapist can:
  1. Evaluate the child’s sensory/perceptual motor abilities
  2. Set goals that teach self-care, hygiene, sensory/motor skills, self-regulation and task management
  3. Help manage classroom, task/homework* and social situations the Homework Box routine as outlined in “Learning Re-enabled” Elsevier Books 2004
  4. Teach handwriting (using the W.I.N.™ Write Incredibly Now™ program which uses a non-repetitive kinesthetic protocol—available at
  5. Educate members of the family and the educational team about the disorder
  6. Assess development since children with bipolar disorder often have erratic development (motor/social)
  7. Application of expressive activities during depressive phase and sensory modulating activities during the manic times
  8. Prevent relapse by helping to establish and maintain healthy routines
  9. Assist the physician with monitoring medication responses

Keep in mind that bipolar disorder does not “go away”, the children do not “outgrow” it, and most important, it is NOT your fault. It is life-long. It is something that will on some level always require medical (medication/psychiatric) and therapeutic management, accommodation and patience, for both the child, and family who loves him/her.


Orloff, Susan N. Schriber “Learning Re-enabled” Elsevier Books 2004
Orloff, Susan N. Schriber “Sensory Implications of Bipolar Disorder” Advance for OT 2008
Orloff, Susan N. Schriber “W.I.N.™ Write Incredibly Now™”
West Virginia University Health Sciences Center: Occupational Therapy and Bipolar Disorder Clinic
Demitri Papolos, M.D., and Janice Papolos, "The Bipolar Child" Juvenile Bipolar Research Foundation 2006
Fink, MD, Candida The Ups and Downs of Raising a Bipolar Child (with Judith Lederman) Simon and Schuster, 2003

This Month's Featured Vendor: Children's Special Services, LLC

Special Thanks to Susan Schriber Orloff for providing an article for this issue's Therapy Corner.

Susan N. Schriber Orloff, OTR/L, is the author of the book Learning RE-Enabled, a guide for parents, teachers, and therapists (and a National Education Association featured book), and the Handwriting on the Wall Program. Children's Special Services, LLC is the exclusive provider of Personal Options and Preferences, tm social skills programs. She was the 2006 Georgia OT of the Year and the CEO/executive director of Children's Special Services, LLC, which provides occupational therapy services for children with developmental and learning delays in Atlanta.

Please support our contributing authors and visit Children's Special Services, LLC on the web at: She can also be reached by email at:

Tags: June 2009 Newsletter OT Article Bipolar Disorder