PEDIATRIC BIPOLAR DISORDER:
ASSESSMENT AND INTERVENTION PRACTICES OF
SCHOOL PSYCHOLOGISTS AND THE
IMPLICATIONS FOR TRAINING IN THE UNITED STATES
A DISSERTATION
SUBMITTED TO THE GRADUATE SCHOOL
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE
DOCTOR OF PHILOSOPHY
BY
JEFFREY SCOTT TROTTER
DR. DAVID E. MCINTOSH - ADVISOR
BALL STATE UNIVERSITY
MUNCIE, INDIANA
JULY 2014
i
PEDIATRIC BIPOLAR DISORDER:
ASSESSMENT AND INTERVENTION PRACTICES OF
SCHOOL PSYCHOLOGISTS AND THE
IMPLICATIONS FOR TRAINING IN THE UNITED STATES
A DISSERTATION
SUBMITTED TO THE GRADUATE SCHOOL
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE
DOCTOR OF PHILOSOPHY
BY
JEFFREY SCOTT TROTTER
APPROVED BY:
____________________________________
Committee Chairperson
__________________
Date
____________________________________
Committee Member
__________________
Date
____________________________________
Committee Member
__________________
Date
____________________________________
Committee Member
__________________
Date
____________________________________
Dean of Graduate School
__________________
Date
Ball State University
Muncie, Indiana
July 2014
ii
ACKNOWLEDGEMENTS
This work would not be possible without the attention and commitment of my
dissertation committee, Dr. W. Holmes Finch, Dr. Hernandez Finch, Dr. Scott S. Hall, and
especially my chair Dr. David McIntosh. Thank you so much for persisting with me through the
long process and seeing this work through to completion.
To Tina, my partner of thirty years, I lack the poetry to fully express how much I leaned
on her strength, integrity, and determination. Her tireless ability to be an effective professional
educator, a loving and constantly shuttling mother, and patient spouse, leave me in awe. It is to
her I dedicate this work.
I want to say thank you to my children who lived many years with a father who spent
more time away than at home. Thank you Conner, Morgan, and Bailey, for regularly reminding
me how to live with laughter, courage, and affection.
To my parents who instilled in me the importance of an education and saw the potential
in me to succeed when I could not see it for myself.
iii
TABLE OF CONTENTS
APPROVAL PAGE………………………………………………………………………………ii
ACKNOWLEDGEMENTS.…………………………………………………………….….……iii
LIST OF TABLES…………………………………………………………………………...…..ix
ABSTRACT…………………………………………………………..…………………………xii
CHAPTER I…………………………………………………………………………………….…1
Introduction………………………………………………………………………………..1
Prevalence…………………………………………………...…………………...………..3
Diagnostic Criteria……………………………………………..…..…….……….4
Special Education Identification Criteria …………………………….…………10
Role of the School Psychologist ………………………………………..………..12
Research Questions …………………………………………………………………...…14
Significance of Study …………………………………………………………..………..17
Definitions ……………………………………………………………………..………..19
CHAPTER 2…………………………………………………………………………………..…21
Literature Review.…………………………………………………………….….……...21
Historical Context of PBD.…………………………………………………….….……..21
Prevalence and Onset.……………………………………………………….………..….31
Diagnostic Features……..………………………………………………….…………….37
DSM-IV-TR Criteria ………………………………………………………...…..37
Early Onset Mania ………………………………………………………………43
Child Depressive Features ………………………………………………………46
Phenotyping ……………………………………………………………..………48
iv
Neuropsychological Features……………………………………………………51
Etiological Features……………………………………………………………..59
Comborbidity………………………………………………………………………...…..64
Psychopharmacology ………………………………………………………………..…..68
Psychosocial Treatment …………………………………………………………………73
School-Based Identification ……………………….…………………………………….80
Special Education Identification ……………………………………………….....……..85
Response to Intervention ……………..……………………………………….…85
Assessment Team Issues…………………………………………………...……..86
Assessment Best Practices…………………………………………………...…..88
Comprehensiveness ……………………………………………….…..…89
Functional Behavior Assessment………………………….……..91
Observation…………………………………………………...….92
Context and History…………………………………………..….92
Academic Functioning……………………………………...……94
Multiple Sources of Informatio.…………………………………………94
Multiple Informants……………………………………………...94
Interviewing…………………………………………………..….96
Appropriate Assessment Methods…………………………………….....97
Comprehensive Formulation of Issues………….………………….…….98
School Based Support……………………………………………………………..……..98
Self-Management and –Monitoring Strategies…………………………………102
Classroom Accommodations………………………………………………..…..104
v
Academic Flexibility……………………………………………………...…….104
Sleepiness…………………………………………………………………….....106
Episodes of Intense Emotion……………………………………………………106
Cross-system Communication…………………………………………….…….107
Social Deficits…………………………………………………………………..107
Transition Planning………………………………………………………...…..108
Dealing with Medication Side-effects……………………………………….….108
Training for School Psychologists………………………………………………….…..109
Chapter Summary………………………………………………………………………114
CHAPTER 3……………………………………………………………………………………115
Method………………………………………………………………………………….115
Overview………………………………………………………………………..115
Participants……………………………………………………………………..115
Procedures ……………………………………………………………………..117
Instrumentation…………………………………………………………………119
Statistics………………………………………………………………………...120
CHAPTER 4……………………………………………………………………………………124
Results…………………………………………………………………………………..124
Response Rate…………………………………………………………………..124
Demographics…………………………………………………………………..125
Research Question 1……………………………………………………………127
Perceptions of PBD……………………………………………………..128
Signs and Symptoms……………………………………………………131
vi
Differential Diagnosis…………………………………………………..132
Comorbidity…………………………………………………………….133
Level of Education and NCSP Designation…………………………….135
Research Question 2……………………………………………………………138
General Practice………………………………………………………...138
Role……………………………………………………………………..139
Instruments and Methods……………………………………………….139
Pre-referral Involvement………………………………………………..141
Services Provided……………………………………………………….142
Level of Education and NCSP Designation…………………………….144
Research Question 3……………………………………………………………147
Training…………………………………………………………………147
Research Question 4……………………………………………………………148
Preparation and Confidence……………………………………………148
Chapter Summary………………………………………………………………………151
CHAPTER 5……………………………………………………………………………………156
Discussion………………………………………………………………………………156
Chapter Overview………………………………………………………………156
Knowledge……………………………………………………………………………...157
Perceptions of PBD………………………………….………………………….157
Signs and Symptoms…………………………………………………….………159
Differential Diagnosis and Comorbidity…………………...…………………..162
Effects of Training and NCSP Designation…………………………………….163
vii
General Practice………………………………………………………………….……..164
Time Spent in Special Education Activities…………………………….………164
Role of Practitioner…………………………………………………………….165
Evaluation Methods and Instruments…………………………………………..165
Services Provided……………………………….………………………………167
Types of Training……………………………………………………………………….167
Preparation and Confidence…………………………………………………………….168
Limitations of Study……………………………………………………………………169
Recommendations for Future Research………………………………………………...171
Chapter Summary………………………………………………………………………172
REFERENCES…………………………………………………………………………………177
APPENDIX A
Survey…………………………………………………………………………………..245
APPENDIX B
Initial Contact…………………………………………………………………………...255
APPENDIX C
Participation by State and NASP Region ………………………………………………257
APPENDIX D
First Follow Up Contact………………………………………………………………..258
APPENDIX E
Second Follow Up Contact……………………………………………………………..259
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LIST OF TABLES
Table 1
Approximate Number of Years Considered an NCSP……………………………….…125
Table 2
Approximate Number of Years Serving as a School Psychologist……………………..126
Table 3
Estimated Percentage of Time Spent in Special Education Related Services……….....127
Table 4
Participant Perceptions and Opinions about PBD…………………………………...…129
Table 5
Respondents’ Understanding of PBD Signs and Symptoms……………………...……131
Table 6
Mean Level of Difficulty in Differentiating Disorders from PBD……………………..133
Table 7
Participant Estimates of the Percentage of Individuals with PBD and Comorbid
Conditions …………………………………………………………………..….134
Table 8
Selected Symptoms Most Common to and Indicative of PBD……………………..…..135
Table 9
Results of Levene’s Test Level of Education and NCSP on Knowledge……………....136
Table 10
Tests of Between-Subjects Effects Highest Degree Earned……………………………137
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Table 11
Tests of Between-Subjects Effects NCSP ………………………………………..…….138
Table 12
Participant Estimates of the Percentage of Time in Special Education Activities …….139
Table 13
Frequency of Use of Evaluation Procedures ………………………………………...…140
Table 14
Frequency of Use of Assessment Measures………………………………………...…..141
Table 15
Level of Involvement in Three Pre-Referral Activities……………………………..….142
Table 16
Frequency of Provision of Services for Students with an Emotional Disorder …..……143
Table 17
Results of Levene’s Test Levels of Education, NCSP, Years of Service on Practice….144
Table 18
Tests of Between-Subjects Effects Highest Degree Earned…………………………....145
Table 19
Tests of Between-Subjects Effects NCSP……………………………………………....145
Table 20
Tests of Between-Subjects Effects Years of Service…………………………………...146
Table 21
Types of Training across Areas of Concern Reported by School Psychologists……….148
x
Table 22
School Psychologists’ Reported Preparedness for Providing Services to Students with an
Emotional Disturbance…………………………………………………………149
Table 23
School Psychologists’ Reported Levels of Confidence……………………………...…151
xi
ABSTRACT
DISSERTATION/THESIS/RESEARCH PAPER/CREATIVE PROJECT: Pediatric
Bipolar Disorder: Assessment and Intervention Practices of School Psychologists and the
Implications for Training in the United States
STUDENT: Jeffrey S. Trotter
DEGREE: Doctor of Philosophy
COLLEGE: Teachers College
DATE: July, 2014
PAGES: 273
The United States government and professional psychology have made the research on
and the treatment of pediatric psychopathology a priority. As part of this mandate, school
systems are strongly encouraged to participate in the prevention, identification, and treatment of
childhood mental health disorders. Effective and meaningful accomplishment of these goals
requires the training of school in the skills necessary to identify symptoms, be knowledgeable in
assessment best practices, and to provide the necessary supports on behalf of children
experiencing a mood disorder. Pediatric Bipolar Disorder (PBD) has shifted from relative
obscurity to a meaningful, well-researched diagnosis. Although there remains considerable
debate regarding the disorder’s differential diagnosis, it is recognized as a disorder with
devastating effects. A national survey investigated school psychologists’ level of knowledge and
breadth of experience and training pertaining to PBD. Of added interest were the current
assessment practices and variety of direct services provided to students with PBD and/or
Emotional Disturbances (ED) as defined by current special education federal guidelines. Results
indicated levels of training and NCSP designation made no noticeable difference in what was
xii
known or in what was practiced by school psychologists. Of the 251 participants, the majority
was unable to identify selected diagnostic features of PBD but may be able to differentiate PBD
from Attention Deficit-Hyperactivity Disorder. Nearly all of the respondents regularly served as
participants on the multidisciplinary teams responsible for determining special education
eligibility of students with ED as well as utilized both direct and indirect assessment methods;
however, not quite a third of participants reported always utilizing a Functional Behavior
Assessment as a part of the assessment process. When describing the services provided to
students with ED or PBD, most respondents indicated that monitoring the effects of prescribed
medications, providing individual and/or group counseling, and consulting with the student’s
doctor occurred inconsistently if at all. Concerning their training, most school psychologists
reported having received either formal or informal training addressing ED while almost half of
respondents had no training at all concerning PBD. This lack of training in the area of PBD may
be a reason why most participants reported an overall lack of confidence in identifying or
differentiating PBD. These data and previous research suggest school psychologists need more
xiii
Chapter I
Introduction
Both the US government and professional psychology have made investigating
psychopathology in school-aged children a research priority (Atkins, Hoagwood, Kutash, &
Seidman, 2010; Huang, Macbeth, Dodge, & Jacobstein, 2004; George, Taylor, Schmidt, &
Weist, 2013; Lazarus & Sulkowski, 2011; National Center for Health Statistics, 2010; Short,
Weist, Manion, & Evans, 2012; United States Department of Health and Human Services, 2005;
Weist, Rubin, Moore, Adelsheim, & Wrobel, 2007; Weisz, Sandler, Durlak, & Anton, 2005).
Within the last 11 years, school systems have been strongly encouraged to participate in the
identification and treatment of mental health disorders in children (President’s New Freedom
Commission on Mental Health, 2003). Furthermore, it is believed primary care settings, like
schools, should include child mental health as a major component in the promotion of healthy
student development (Huang et al., 2005). A recent report published by the Surgeon General’s
Conference on Children’s Mental Health shaped national policy (McClure, Kubiszyn, & Kaslow,
2002; U.S. Public Health Service, 2000). The policy called for the integration of “family, child
and youth-centered mental health services into all systems that serve children and youth” and
“engaging families and incorporating the perspectives of children and youth in the development
of all healthcare planning” (U.S. Public Health Service, 2000). Pursuing these mandates requires
not only the expansion of prevention and early intervention but includes the training of school
psychologists, teachers and other school personnel to recognize the signs of emotional problems
in children and to make the necessary referrals (Forness, Kim, & Walkedr, 2012; Repie, 2005).
For this goal to be achieved, school psychologists must resist the temptation to relegate the
mental health needs of children to the “health care sidelines,” and instead work as a profession
1
not only to increase awareness but also to organize services necessary to effectively address the
mental health and psychopathology of students (Tolan & Dodge, 2005).
Interest in the clinical and public health implications of pediatric bipolar disorder (PBD)
has been steadily increasing (Birmaher et al., 2006). Although once considered a rarity,
identifying children with bipolar disorder (BD) has increased in prevalence over the past 10
years shifting the disorder from relative obscurity toward being a meaningful diagnosis
(Bhangoo et al., 2003; Blader & Carlson, 2007). In addition, a growing body of literature has
emerged which focuses on the identification of the characteristics of PBD to assist clinicians in
making a differential diagnosis (Faraone, Glatt, & Tsuang, 2003; Lofthouse & Fristad, 2006;
Weller, Weller, & Fristad, 1995).
Even though previous research has increased understanding of PBD, there remains
considerable debate regarding the disorder’s diagnostic features and prevalence (Youngstrom,
2007). Historically, the significant symptomatic overlap of PBD with Attention DeficitHyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD) and Conduct Disorder
(CD) has led to concerns that the disorder is underdiagnosed (Papolos & Papolos, 2006; Weller,
Weller, & Fristad, 1995 ). However, the relatively recent clinical, academic, and public increase
in awareness of mania in children coupled with the apparent lack of clinical training for
assessment, diagnosis, and treatment is giving rise to concerns of misdiagnosis and inappropriate
medical and therapeutic interventions (James & Javaloyes, 2001; Lofthouse & Fristad, 2004).
Despite diagnostic uncertainty, the literature describes a disorder with devastating effects
on the pediatric population resulting in impairments across psychosocial domains including high
risk of suicide, psychosis, and significant family aggregation (Birmaher et al., 2006; Lofthouse &
Fristad, 2004). Research on PBD also suggests a significant need for increased
2
psychoeducational training for teachers and parents, and the creation of research based classroom
interventions for students (Biederman, 1998; Klein, Pine, & Klein, 1998: Lofthouse & Fristad,
2006). Consequently, there is a need for research that would enhance school psychologists’
accurate identification of symptoms, effective collaboration with teachers and parents, and
implementation of meaningful interventions and accommodations, pertaining to students with
PBD.
Prevalence
Estimates of the prevalence of PBD are difficult due to the paucity of any national or
international epidemiological studies to determine the disorder’s prevalence in the pediatric
population (Soutullo et al., 2005; Weller, Weller, & Fristad, 1995); however, there is evidence
the prevalence of PBD may be similar to adult BD levels (Geller & Luby, 1997). Multi-national
studies of adults suggest a lifetime prevalence of bipolar disorder across various clinical and
subclinical forms ranges from three to seven percent (Soutullo et al., 2005; Youngstrom, 2007;
Kessler, Rubinow, Holmes, Abelson, & Zhao, 1997; Merikangas et al., 2007; Weissman et al.,
1996). The American Psychiatric Association (2000) suggests similar prevalence rates and
estimates the lifetime prevalence for adults to be 0.4% to 1.6% for Bipolar I Disorder,
approximately 0.5% for Bipolar II Disorder, and from 0.4% to 1% for Cyclothymic Disorder.
Based on their study of older adolescents (14 – 18), Lewinsohn, Klein, and Seeley (1995;
2003) suggested the lifetime prevalence of bipolar disorders was approximately 1% with an
additional 5.7% of the youths exhibiting subsyndromal symptoms of bipolar disorder (i.e., a
distinct period of abnormally and persistently elevated, expansive or irritable mood). Even so,
limitations of the Lewinsohn and colleagues studies include a sole reliance upon adolescent
interviews, absence of parent interviews or other outside sources, and only using research
3
participants with Bipolar II and Cyclothymia. Nevertheless, other research applying the DSMIII-R (American Psychiatric Association, 1987) criteria have come to similar conclusions and
estimate the prevalence of mania within adolescent populations to range from 0.6% to 0.7%
(Carlson & Kashani, 1988; Kashani et al., 1987). Additional studies with pubescent individuals
indicates the first incidence of bipolar disorder and subthreshold bipolar disorders is greatest in
adolescence and declining in young adulthood (Lewinsohn et al., 2003). Unfortunately, these
studies do not adequately capture the prevalence of bipolar disorder in prepubertal children
(DeJong & Frazier, 2003).
Further evidence of comparable prevalence rates of mania between adult and pediatric
populations may be derived from retrospective studies. In the United States, as many as 60% of
adults reported experiencing the onset of their bipolar disorder before twenty years of age, and
10% - 20% reported an onset before 10 years of age (Egeland et al., 2003; Joyce, 1984; Lish,
Dime-Meenan, Whybrow, & Price, 1994; Loranger & Levine, 1978; Pavuluri, Birmaher, &
Naylor, 2005). A European retrospective study, including 12 national patient organizations in 11
countries, resulted in similar figures (Morselli & Elgie, 2003). Both the US and European
findings support the idea most patients with bipolar disorder had a childhood onset in spite of
Europe’s generally lower rates of diagnosing bipolar disorder in the pediatric population
compared to the US (Soutello et al., 2005) and the international skepticism of the apparently high
prevalence of PBD in the US (Gillberg et al., 2004). Despite the presence of retrospective
studies, our knowledge of the prevalence and onset of bipolar disorder in children remains
deficient.
Diagnostic Criteria
Developing the skill necessary to accurately diagnose pediatric mental disorders is a
4
priority and is typically associated with long-term positive treatment outcomes. Over time, if left
unidentified and untreated, PBD may have a prolonged course, be less responsive to treatment,
and lead to legal difficulties, multiple hospitalizations, severely impaired interpersonal
relationships, diminished academic functioning, and increased rates of substance abuse and
suicide (Findling, Gracious, McNamara, Youngstrom, & Demeter, 2001; Geller et al., 2003;
Lewinsohn et al., 2003; Steinhausen, Haslimeier, & Metzke, 2007). In short, the probability of
recovery from PBD diminishes as time increases between initial symptoms and actual treatment
(Goodwin & Jamison, 1990). This is all the more problematic when one realizes children and
youth with emotional disabilities receive special education services more than approximately one
year later than children with other types of disabilities (Wagner, Kutash, Duchnowski, &
Epstein, 2005).
Identifying the presence of one or more episodes of abnormally elevated mood is central
to diagnosing bipolar disorder and its various subtypes. Manifestations of mania and hypomania
during childhood and early adolescence frequently differ from the symptoms exhibited in
adulthood, thereby complicating the practitioner’s ability to make a differential diagnosis. For
instance, younger adolescents may demonstrate BD symptoms which reflect both childhood and
adult expressions of the disorder (Lewinsohn et al., 2003; Lofthouse & Fristad, 2006; Wozniak et
al., 1995). Even older adolescents have been found to clinically present similar to children by
demonstrating a predominantly irritable and mixed mood (Biederman et al., 2005).
To meet diagnostic criteria for mania, a “distinct period” of euphoric and/or irritable
mood with a cluster of co-occurring symptoms that are functionally impairing must endure long
enough to be significantly different from the child’s usual presentation (Lofthouse & Fristad,
2006 ). Obviously, care must be given to differentiate this period from the expected increase in
5
mood deregulation and variability often accompanying normal development (Bowring &
Kovacs, 1992; Geller & Luby, 1997). Mania in children is atypical by adult standards
particularly in regards to mood presentation (Biederman, et al., 2005). In children, a manic
episode may be defined as either a distinct period of excessively elevated (i.e., inappropriately
happy) or irritable (i.e., excessive temper tantrums, rages out of proportion to events) mood, or
both (Craney & Geller, 2003; Lofthouse, Mackinaw-Koons, & Fristad, 2004). The National
Association of School Psychologists (NASP 1993; NASP, 2005; Lofthouse et al., 2004) suggests
criteria for “altered mood” requires identifying three or more symptoms including: (a) inflated
self-esteem (e.g., child thinks s/he is smarter than everyone else despite failing grades); (b)
grandiosity (e.g., a child believes and tells others s/he is able to run faster than a car); (c)
decreased need for sleep (e.g., a child feels rested after a few hours of sleep); (d) rapid, loud, or
uninterruptible speech; (e) racing thoughts, increased distractibility, increased goal-directed
activity/psychomotor agitation (e.g., a child starts to rearrange the school library, cleans
everyone’s desks, and plans to build an elaborate tree house in the backyard, but never finishes
any of these projects); and (f) excessive involvement in pleasurable or dangerous activities (e.g.,
a previously mild-mannered child writes offensive notes to other children in class or attempts to
jump out of a second story window).
Children also may experience depressive episodes as a part of their mood dysregulation.
An episode of depression is defined by NASP (2005) and the American Psychiatric Association
(2000) as a distinct period of sad or irritable mood or markedly diminished interest and/or
pleasure in most activities. This period of depression includes four or more of the following
symptoms: (a) significant appetite change; (b) sleep problems; (c) restlessness or slowed
movement, (d) fatigue; (e) feelings of worthlessness or excessive guilt; (f) problems
6
concentrating; and (g) recurrent thoughts of death and/or recurrent suicidal thoughts, plans or
attempts.
Unlike adults with BD, children with mania typically do not manifest euphoria, but
severe irritability (Carlson, 1983; Davis, 1979; Emslie, Kennard, & Kowatch, 1994). In a study
of 6- to 12- year old prepubertal children diagnosed with mania using DSM-III-R (American
Psychiatric Association, 1987) criteria, Weller et al. (1995) reported 50% described a primarily
irritable mood. Carlson’s (1983) literature review revealed children younger than 9 years old
reported emotional lability, crying and irritability while those 9 years and older more commonly
described grandiose delusions and euphoria. Without the typical manic presentation, clinicians
may erroneously attribute a child’s emotional outbursts and belligerence to psychosocial factors
or conduct disorder. Severe irritability also may be the predominant mood abnormality in
adolescents with BD (Wozniak et al., 1995). The behavior frequently is described by parents and
clinicians as aggressively out-of-control and is the primary reason why adolescents are referred
for treatment or for hospitalization (Biederman et al., 2005). Not only must clinicians
differentiate PBD from more common childhood disorders but they also need to consider
whether behaviors (e.g., playing, activity levels, rate of speech) are consistent with those
displayed by typical children and adolescents (McClellan & Werry, 1997).
The idea that there is a continuum describing PBD is gaining consensus. In 2001, the
National Institute of Mental Health Research Roundtable on prepubertal bipolar disorder
promoted the idea that PBD can present in “narrow” and “broad” phenotypes. The phenotyping
model is viewed as “critical” in helping researchers as well as clinicians determine variables
related to psychopharmacology, neurophysiology, treatment response, and prognosis (Pavuluri et
al., 2005). Shortly following the roundtable report, Liebenluft and colleagues (2003b) proposed
7
a framework for classifying PBD into three subtypes (i.e., narrow, intermediate, broad) and
suggested the disorder existed as a “spectrum.” The narrow type is marked by recurrent periods
of depression and mania or hypomania and fits the definition of adult mania as described in the
Diagnostic and Statistical Manual, Fourth Edition (DSM-IV; American Psychiatric Association,
2000; Craney & Geller, 2003). The broad phenotype, on the other hand, constitutes the majority
of the referrals to clinicians and is the type most likely to be seen by school psychologists
(Pavuluri et al., 2005). Symptoms include severe irritability, “affective storms,” mood lability,
severe temper outburst, symptoms of depression, anxiety, hyperactivity, poor concentration, and
impulsivity with or without clear episodicity (Biederman & Garcia, 1996).
Birmaher and colleagues (2006) were the first to describe the psychopathological course
of each of the major clinical phenotypes of BD among children as well as adolescents. Of
particular import was their acquisition of the largest subject pool of children and adolescents
with BD ever gathered to date to be involved in the study. General findings highlighted the
substantial morbidity of BD in this age group, including early age of first onset of mood
disturbance, long duration, fluctuating course, high familial loading for mood and other
psychiatric disorders, and high rates of comorbid disorders, particularly attention-deficit/
hyperactivity disorder, disruptive behavior, and anxiety disorders. On average, subjects had 1.5
syndromal recurrences per year, particularly depressive episodes. Analyses of weekly mood
symptoms showed subjects were symptomatic approximately 60% of the follow-up time, with
about 22% of the time in full syndromal episodes and 38% of the time with subsyndromal
symptoms. In addition, youth with BD showed high lifetime rates of psychosis. Furthermore,
subjects in whom BD symptoms developed during their early childhood showed lower rates of
8
recovery, more time in mixed/rapid cycling episodes, and more symptom and polarity changes
than those whose illness started later.
Despite the growing research on PBD phenotypes, consensus is not yet universal and
school psychologists should be aware that researchers continue to use different sets of diagnostic
criteria to define PBD. For example, Geller et al. (1998), in a study comparing clinical
characteristics of children with BD to Attention-Deficit/Hyperactivity Disorder (ADHD) and
healthy controls, found grandiosity, elated mood, hypersexuality, flight of ideas, and decreased
need for sleep differentiated children with BD from the other groups. These results, though
beneficial, must be considered in light of the understanding BD children were identified by
demonstrating symptoms of grandiosity and/or elation. On the other hand, in their research,
Biederman and Garcia (1996) emphasized the centrality of irritability in establishing the
diagnosis of BD regardless of the absence of elation or grandiosity. The breadth of variability in
defining core characteristics of PBD is problematic and not limited to these two particular
defining frameworks. For instance, a review of the literature reveals some researchers employ
strict, unmodified DSM-IV symptom criteria to establish a diagnosis of PBD while others do not
(Pavuluri et al., 2005).
Whereas adults are more likely to present with discrete cycles of mania, hypomania, and
depression, and tend to have an episodic and acute course, childhood BD tends to be chronic and
continuous (Carlson, 1983; 2005a, 2005b; Weller et al., 1995). Some researchers suggest
children with BD may exhibit both manic and depressive symptoms at the same time or within
the same day (Geller, Tilman, Craney, & Bolhofner, 2004; Papolos & Papolos 2006). Geller et
al. (1995) coined the term “complex cycling” to describe the presence of short cycles embedded
within a more prolonged cycle or episode. Applying this model, mood shifts in children are
9
characterized by mixed states (i.e., simultaneous manic and depressive symptoms), rapid cycling
(i.e., four or more mood episodes per year), ultra-rapid cycling (i.e., more than four mood
episodes per year), and ultradian cycling (i.e., multiple episodes per day, requiring more than
four hours of mania per day) (Geller et al., 1995; 2000; Lofthouse et al., 2004).
Special Education Identification Criteria
School psychologists attempting to provide mental health services in schools are faced
with the challenge of navigating between two very different approaches to identifying an
emotional disorder. The Individuals with Disabilities Education Improvement Act (IDEIA) of
2004 was developed for educational administrative purposes and establishes the boundaries of
special education services. Whereas IDEIA has limited heuristic application when it comes to
identifying mood disorders, the DSM and ICD are committed to a medical nosological schema
with little concern for school issues (Wodrich et al., 2008). The IDEIA classification system is
significant for doctoral-level, licensed psychologists who work with students outside of school as
well as certified school psychologists – nearly three quarters of whom do not hold a doctoral
degree and are not licensed to practice outside of the school setting (Carlson, Demaray, &
Hunter-Oehmke, 2006). Although licensed psychologists typically serve school children from
private offices, hospital settings, and mental health clinics, and are more likely to use the
standard psychiatric taxonomy, some of these psychologists also work in schools which require
the IDEIA’s administrative classification system (Wodrich et al., 2008).
The number of students receiving services under the IDEIA has grown steadily since its
introduction (Erford, Balcom, & Moore-Thomas, 2007), yet confusion remains among school
professionals at the local and state levels regarding the eligibility guidelines for the category of
emotional disturbance (Cullinan & Sabomie, 2004). The criteria is described by many as vague,
10
poorly defined, and professionally indefensible (Olympia et al., 2004; Skiba, Grizzle, & Minke,
1994). The IDEIA (2004) describes an “emotional disturbance” as:
A condition exhibiting one or more of the following characteristics over a long period of
time and to a marked degree that adversely affects a child’s educational performance:

An inability to learn that cannot be explained by intellectual, sensory, or health
factors;

An inability to build or maintain satisfactory interpersonal relationships with
peers and teachers;

Inappropriate types of behavior or feelings under normal circumstances;

A general pervasive mood of unhappiness or depression; and/or

A tendency to develop physical symptoms related to fears associated with
personal or school problems.
The functional characteristics of children and youth classified with ED results in a wide
range of disabilities including anxiety, Tourette’s, depression, obsessive-compulsive disorder,
psychosis and bipolar disorder (Wagner et al., 2005a,b). Because the decision-making criteria
are so general, the emotional disability category includes students with decidedly heterogeneous
problems and diverse educational needs (Wodrich et al., 2008). Even though students with
emotional disturbances are similar in that their problems are longstanding, significant, and
markedly detrimental to educational success, students with ED are so diverse it often is very
difficult to generalize the type, intensity, and duration of necessary interventions and
accommodations. Consequently, an ED designation provides professionals with extremely
limited planning information, little knowledge of the unique factors affecting a student with BD,
and a tendency to label overt behaviors as a behavioral problem rather than symptomatic of a
11
medical issue (Senokossoff & Stoddard, 2008).
Contrary to intuition, the lack of category specificity has not lead to the overidentification of students but perhaps the opposite. IDEIA identification rates of students with
emotional disturbance remain far below the estimates of the prevalence of severe childhood
mental disorders (Forness, Kavale, & Lopez, 1993; Olympia et al., 2004; Repie, 2005). A report
by the Judge David Baselon Center for Mental Health Law (2003) indicated as many as 80% of
children and adolescents with mental and emotional disorders are not currently being identified
and served under IDEIA. While the U.S. Surgeon General estimates 5% of all school-age
children have mental disorders with “extreme functional impairment” and 11% have mental
disorders with “significant functional impairment” (U.S. Department of Health and Human
Services, 1999), current IDEA data indicate the number of students identified nationally with
Serious Emotional Disturbance is 0.94% (U.S. Department of Education, 1999). This
discrepancy strongly suggests many impaired children are not receiving needed services. Lack
of adequate supports places students with PBD at increased risk of exclusion from general
education settings (Helfin & Bullock, 1999), marginal to unsatisfactory educational performance
(Benner, Nelson, & Epstein, 2002; Cullinan, Epstein, & Subornie, 1992; Greenbaum et al., 1996;
Trout, Nordness, Pierce, & Epstein, 2003; U.S. Department of Education, 2002), and suspension
and withdrawal (Morgan-D’Atrio, Northrup, LaFleur, & Spera, 1996; Wagner et al., 2005a, b).
Role of the School Psychologist
School psychologists possess a unique blend of skills that make them ideal for serving the
mental health needs of children. Their training allows them to conceptualize problems
holistically, to support their ideas about pediatric problems with empirically valid and reliable
data, to collaborate with others to implement solutions to problems, and to evaluate outcomes
12
(Fagan & Wise, 2000). NASP-affiliated practitioners spend the majority (60% to 80%) of their
time performing assessment activities related to special education classification (Curtis, Hunley,
Walker, & Baker, 1999; Hosp & Reschly, 2002) and are in a position to serve as a “bridge”
bringing together the school, family and community services to collaborate on behalf of the wellbeing of the child diagnosed with psychopathology (Cohen, Linker, & Stutts, 2006). Tashman
and colleagues (2000) suggest school-based mental health may even be more beneficial to
children than more traditional forms of mental health service delivery systems. The role of the
school psychologist is critical if schools take seriously the role of complementing services of
outside agencies, serving as a catalyst to coordinate services, and developing programs to
improve and expand mental health programs in schools (Gutkin, 1995).
School psychologists also have at least two advantages many other health care
professionals do not. First, they are able to regularly observe the behavioral manifestations of a
child’s psychopathology in one of their primary ecological systems, and second, they are able to
directly intervene with the student in that system (Davis, Kruczek, & McIntosh, 2006). School
psychologists’ commitment to collaboration with school personnel provides ample opportunity to
integrate and monitor treatments across home, school and community settings (Fagan & Wise,
2000; Pluymert, 2005). In addition, school psychologists may have the education and experience
necessary to observe and report on the effects of medication (Gureasko-Moore, DuPaul, &
Power, 2005; Kowatch et al., 2005), help school personnel identify correlations between
behaviors and mood (Senokossoff & Stoddard, 2008), educate school personnel on the
characteristics of PBD (CABF, 2007), and track the student’s progress resulting from academic
modifications (Pluymert, 2005), all of which have been shown to increase positive outcomes.
13
Of some concern is that the few practices and intervention programs existing for
childhood pathologies remain unknown to many school psychologists (Tolan & Dodge, 2005)
despite an expressed desire to spend more time involved in intervention-related tasks and
consultation (Hanson, Austin, & Lee-Bayha, 2004). For example, researchers have established
the prevalence rates and needs of children with a variety of special education diagnoses, but little
has been written to help school psychologists effectively respond to children with
psychopathology (Davis et al., 2006). It also is expected school psychologists, like other mental
health professionals, experience difficulty in accurately differentiating PBD from other pediatric
pathology (Cassano, McElry, Brady, Nolen, & Placidi, 2000; Wozniak et al., 2003).
Additionally, a review of the literature reveals very few studies have been conducted examining
school psychologists’ preparation, methods for assessment, intervention practices, and
competency for working with children with PBD in the school setting.
Research Questions
Despite the ongoing controversies regarding the core features of PBD, there is overall
consensus on the disorder’s existence. There also is increased agreement between clinicians and
researchers on the presence of narrow and broad phenotypes of PBD. Academic difficulties due
to cognitive and behavioral interference, high comorbidity with ADHD, disruptive and anxiety
disorders, chronicity, recurrence, rapid cycling, and mixed episodes also are believed to
characterize the disorder. However, there is little research to show how closely American
schools in general and school psychologists in particular align their practices with known
parameters. In addition, evidence demonstrating school psychologists’ preparation to adequately
serve children with PBD is lacking. It is suspected, due to the rapidly changing landscape of
PBD research, the complicated aspect of diagnosing the disorder, and the low prevalence of PBD
14
compared to higher prevalence concerns like ADHD, school psychologists vary greatly in their
approaches to PBD. The purpose of this study, therefore, is to investigate school psychologists’
identification and intervention practices as they relate to PBD. Specifically, a survey will be
created and administered to licensed school psychologists in the United States to ascertain an
accurate picture of their knowledge and their specific practices pertaining to PBD. The survey
will focus on four central questions:
1. What is the general level of knowledge of school psychologists in the area of
PBD? Current research emphasizes the importance of training and experience in
order to make an accurate assessment of children with psychopathology (Huang et
al., 2005; Tolan & Dodge, 2005). However, review of the literature reveals very
little research has been carried out that examines the current level of knowledge
and experience of school psychologists currently practicing in the schools in the
United States. Related questions include:
a. What is the general understanding and perceptions of school psychologists
in regard to the diagnostic category of PBD?
b. What is the general understanding and perceptions of school psychologists
concerning the differential diagnosis, comorbidity, and signs and
symptoms of PBD?
c. Is there a difference in the levels of knowledge in the area of PBD when
considering a practitioner’s level of education (e.g., Masters, Specialist,
PhD), as well as whether or not nationally certified (i.e., NCSP)?
2. What are the general practices of school psychologists with regard to the
identification of children suspected to have PBD? State and federal law mandate
15
certain methods for evaluation and intervention (IDEIA, 2004) and best practice
research also describes an optimal approach (McConaughy & Ritter, 2005;
Pluymert, 2005); however, how closely do school psychologists adhere to and
follow these guidelines when addressing PBD?
a. How much time in general do school psychologists spend providing the
following special education services: assessment for special education
services, counseling students, providing academic and/or behavioral
interventions, providing functional behavioral analyses, consulting with
teachers, and doing research.
b. What is the primary role of school psychologists in the determination and
classification of an emotional disorder?
c. What instruments and methods do school psychologists use when
evaluating children suspected of an emotional disorder?
d. What is the level of involvement of school psychologists in pre-referral
activities of children suspected having an emotional disorder?
e. What services are typically provided for students identified with an
emotional disorder?
f. When considering the types of interventions and special education
services provided for students identified with an emotional disorder, is
there a difference in the above-mentioned practices between doctoral and
non-doctoral school psychologists, those school psychologists who are
nationally certified, or between school psychologists with greater and
lesser amounts of experience?
16
3. What types of training have school psychologists received in the area of PBD
identification and intervention, and do those with more formal training understand
the symptomology of PBD better than those with informal training?
4. How prepared do current school psychologists feel to consult, assess, and
intervene in cases suspected of PBD and what is the level of personal confidence
related to their involvement in these activities?
Significance of Study
Dunner and Clayton (1987) concluded the biggest deterrent to treating PBD is
recognizing it in the first place. Although more recent research has enhanced the ability of
clinicians to make better diagnostic decisions, the perspective of Dunner and Clayton continues
to be accurate. Are school psychologists doing a good job of recognizing PBD and perhaps more
importantly are they contributing to the meaningful implementation of interventions for students
with bipolar disorder? Unfortunately, the answer to these questions are unknown. If school
psychologists are not receiving adequate training or staying current with recent research
concerning PBD, then it is very likely many children with BD are at best being misidentified or
worse, ignored. Not only is this a disservice to children, families, and school personnel, but it is
a failure to fulfill the professional mandate to identify and treat childhood mental illness. This
study intends on gathering the information necessary to assess the current practices and
perceptions of school psychologists in America pertaining to PBD. However, the more
important result of this study will be providing the data necessary for training institutions and
academic systems to address shortcomings in school psychologists’ understanding and practice.
Surveys are “…one of the most important tools in the institutional research toolbox
(Porter, 2004a),” and understandably, institutional research using surveys is one of the most
17
common approaches (Schlitz, 1988). Acquiring meaningful information about the current
practices of school psychologists through the use of surveys is frequently employed (Chafouleas,
Clonan & Vanauken, 2002; Fairchild & Zins, 1992; Hosp & Reschly, 2002; Reschly, 2000).
Response rates for paper surveys sampling school psychologists across a variety of academic
related issues have ranged between 37% and 74% (e.g., Carlson et al., 2006; Chafouleas, RileyTillman, & Eckert, 2003; Curtis, Grier, & Hunley (2004); Curtis, Hunley, & Chesno-Grier, 2002;
Gureasko-Moore et al., 2005; Hosp & Reschly, 2002; Koonce, 2007; Shannon & Bradshaw,
2002; Wilczynski, Mandal, & Fusilier, 2000). However, a meta-analysis of web-based survey
response rates, by Fricerk and Schonlau (2002) reported rates as high as 78%. In addition,
multiple follow-up contacts may significantly improve response rates (Fowler & Harrison, 2001;
Pelco et al., 2000).
Web surveys appear to have the greatest benefits and lowest costs compared to other
available alternatives (Porter, 2004). Web surveys not only avoid the costs of printing and
postage but also reduce administration time and data entry errors, increase access to more people
and turn-around time, and allow for design flexibility (Schmidt, 1997; Umbach, 2004; Zhang,
1999). In addition, the probability of increasing survey response rates is expected when the cost
to the respondent decreases (e.g., Web surveys may be quicker to fill out than paper and pen
surveys).
Although prepayments and postpayments may operate as an incentive in longitudinal
studies (Collins, Ellickson, Hays, and McCaffrey, 2000), a meta-analysis of sixty-eight electronic
surveys reported incentives actually depressed response rates slightly (Cook, Heath, &
Thompson, 2000). This conclusion is further supported by numerous studies examining the
effect of lottery postpayments showing there was little to no effect on response rates from lottery
18
incentives (Hubbard & Little, 1988; Porter & Whitcomb, 2004; Warriner et al., 1996). However,
numerous studies of various populations indicate the use of prepaid incentives may increase
response rates (Singer, van Howeyk, & Maher, 1998; Willimack, Schuman, Pennell, and
Lepkowski, 1995).
Definitions
Pediatric Bipolar Disorder (PBD). PBD will be considered a distinct period of euphoric
and/or irritable mood which is significantly different from a child’s typical presentation and
results in functional impairment. The entire continuum of the disorder will be considered as
represented by narrow and broad phenotypes which are informed by the DSM-IV.
Attention Deficit/Hyperactivity Disorder (ADHD). ADHD is a neurodevelopmental
disorder typically diagnosed in childhood and often lasting into adulthood. Symptoms include
difficulty paying attention, controlling impulsive behaviors, and/or being overly active. The
DSM-IV will inform understanding of the diagnostic features, prevalence, and course of the
disorder.
Full-time practicing school psychologist. An individual who maintains a current
psychology license or school psychology certificate and who spends at least 25 to 40 hours per
week working in a school system providing school psychology services including, but not
limited to, assessment, consultation, psychoeducation, and intervention.
School Psychologist. “A professional psychological practitioner whose general purpose
is to bring a psychological perspective to bear on the problems of educators and the clients
educators serve” (Fagan & Wise, 2000, p. 4).
Emotional Disturbance (ED). ED is a special education classification defined by the
Individuals with Disabilities Education Improvement Act of 2004 and is typically associated
19
with mental health issues resulting in an “inability to learn that cannot be explained by
intellectual, sensory, or health factors (IDEIA, 2004).”
Nationally Certified School Psychologist. A school psychologist who has met the
standards of the National Association of School Psychologist (NASP) Standards for the
Credentialing of School Psychologists, Standards for the Provision of School Psychological
Services, Standards for Training and Field Placement Programs in School Psychology, and
Principles for Professional Ethics.
20
Chapter 2
Literature Review
Chapter Overview
Diagnosing a child with Pediatric Bipolar Disorder (PBD) remains highly controversial
(Harrington & Myatt, 2003; Healy, 2006; Klein et al., 1998) and is an area of ongoing research
which crosses several disciplines. Research concerning the identification and treatment issues
associated with PBD provides critical information foundational to the study at hand. First, the
history and current context of recognizing bipolar disorder (BD) in children will be examined.
After surveying the historical controversies associated with PBD, the research associated with
the disorder’s prevalence, differential diagnosis, neuropsychological and bioecoological features,
and comorbidity will be reviewed. Next, treatment options for children diagnosed with BD,
including pharmacology and psychosocial therapy, will be reviewed. Following this the issues
related to the role of public schools in helping students with PBD is examined. This will include
educational law, special education eligibility, best practices in school identification, and
classroom accommodations and modifications. Finally, an overview of how school
psychologists are trained and prepared to work with special populations such as PBD and ED
will be outlined.
Historical Context of PBD
Historically, the concept of pediatric manic-depressive or bipolar disorder has undergone
multiple changes and continues to be a subject of ongoing controversy, debate, and refinement
(Drabkin, 1955; Klein et al., 1998; Lofthouse & Fristad, 2004; McClellan, 2005; Youngstrom,
2007). A summary account of the historical development of PBD will be provided; however, a
search of the literature will allow the reader to access several more detailed accounts (e.g.,
21
Baethge, Glovinsky, & Baldessarini, 2004; Faedda et al., 1995; Glovinsky, 2002; Pavuluri et al.,
2005).
Over the last 40 years, there has been an explosion of knowledge about the identification
and treatment of mental health disorders in children starting first with adolescents and then
eventually school-age children (Angold & Costello, 2009). However, recognizing mental health
suffering in infancy and early childhood has been difficult for society to accept (Egger & Emde,
2011). As recent as the mid 1930’s, Spitz (1949) urged practitioners to recognize the critical
importance of psychosocial factors during infancy which he thought contributed to and created
various forms of infantile suffering (e.g., anaclitic depression resulting from maternal emotional
deprivation). Spitz’s views created controversy and were strongly criticized up through the
1950’s (Emde, 1983). Further illustrating an apparent resistance to admitting the existence of
early childhood suffering may be the medical community, which failed to recognize child
maltreatment until the 1960s (Helfer & Kempe, 1974). Resistance to children’s emotional and
physical suffering has not been confined to early childhood. For example, not until the 1970s
was childhood depression recognized as a valid psychiatric disorder and only at the end of the
decade was the disorder included in psychiatry textbooks (Cytryn, 2003.)
The concept of bipolar psychopathology has been traced to ancient Greece. Mania and
melancholia (depression) were two of the three forms of madness described by Alcmaeon of
Crotona and other Greek physicians (Glovinsky, 2002). At that time, the disorder was believed
to be the product of an interaction between bile and the brain resulting in a chronic disease
without fever (Jackson, 1986). Ancient descriptions of both mania and melancholia typically
encompassed a broader range of disorders than current definitions. For instance, delusions and
delusional states were considered to be part of the definition of depression as well as mania. The
22
term “melancholicus mania” was first used by Bonet in 1679, and it appeared again in 1700 in an
edition of Bonet’s work revised by Johannes and Jacob Mangetus (Altschule, 1976). The
connection between melancholia and mania also was discussed throughout the seventeenth and
eighteenth centuries. During this period it was typical to conceptualize melancholia as “partial
insanity”, that is, the individual’s “derangement” was limited to a single idea or small number of
related ideas while mania was viewed as “universal insanity” because the derangement pervaded
through all of the individual’s thinking (Jackson, 1986). Thus, a continuum of increasingly
disordered intellectual functioning became a representation of the ideas of melancholia
degenerating into mania or worsening to become mania.
“Mania” in the 19th century, often referred to nearly every sort of socially inappropriate
excitation or exaltation. As early as 1816, Jean-Etieene-Dominique Esquirol described three
cases of prepubertal mania and melancholia, including an 8-year-old girl who displayed manic
symptoms that are clearly recognizable as such today (Baethge et al., 2004). Jean Pierre Falret
(1854) described a form of insanity which ran in a repetitive circle of pathological states he
named la folie circulaire – the circular madness. The concept was quickly accepted throughout
Europe, particularly in Germany, and cyclic recurrences of mania and depression in children
were noted in many later nineteenth-century case vignettes, including separate reports by
Emminghaus (1887) and Ritti (1883).
Throughout the twentieth century, mania was considered the most frequent type of
psychosis and at other times as virtually non-existent in children. Between 1900 and 1910,
Soukhanoff and Gannouchkine (1903) identified an onset of mania before age 15 years in 18%
of 84 adult BPD patients. During the same decade, Friedman (1909) distinguished three types of
PBD; periodic psychosis with brief alternating episodes of depression and manic excitement and
23
short euthymic intervals, isolated episodes of depression or excitement, sometimes related to
stress, and brief episodes of mild depression or excitement progressing to more typical cyclic
BD. In his seminal early textbooks, Ziehen (1926) classified BPD in children as involving single
or recurring episodes of mania, or circular (bipolar) insanity. Amidst significant opposition,
Ziehen established it was possible for the illness to start before adulthood, and he often is
credited with setting the “standard” view of mania (Baethge et al., 2004). In Ziehen’s opinion,
the psychopathology of children does not differ in principle from adult psychopathology.
Although his view that children were simply not-fully-developed adults was prevalent in his
time, it differed from the views espoused by other experts in child psychiatry who stressed the
way children think and feel differs qualitatively from adults. Ziehen explicitly reported his
views of acute mania and melancholy, as well as recurring mania and depression, were based
significantly on Kraepelin’s concept of manic-depressive insanity. The often-cited Kraepelin
(1921) study documented the onset of mania before age 10 in 4 of 903 manic-depressive patients
and noted an increasing likelihood of mania after puberty. Furthermore, during this decade,
mania was described as the most frequent psychosis in children (Rumke, 1928), commonly
involving brief episodes and catatonic features (Lange, 1928), and frequently comorbid with
anxiety (Homburger, 1926). However, despite growing practitioner and research awareness, a
shift would soon occur over the coming decades, which would keep the idea of pediatric mania
and depression from taking hold.
From the 1930s through the 1960s, mania and depression in children and adolescents
typically were not considered by clinical theorists when making a diagnosis; instead, these
symptoms frequently were associated with psychotic disorders of children with schizophrenia or
identified as a dysfunction of the post pubertal or late adolescent superego (Klein, 1934; Rie,
24
1966; Rochlin, 1959). Bradley (1937), who inaugurated the modern era of pediatric
psychoparmacology, stated BPD was very rare before puberty, and Lurie and Lurie concluded in
1950 that it simply did not occur in childhood. Kanner (1957) wrote in his seminal, midtwentieth century American textbook of child psychiatry that mania in the pediatric population
was “. . . so rare as not to be worthy of consideration.” This interesting omission may be
reflective of the then-dominant psycholoanalytic assumption that manic-depressive disorder was
only possible in those who demonstrated higher-level cognitive structures which emerge with
further psychosexual development after puberty (Glovinsky, 2002). At the start of the 60s,
Anthony and Scott (1960) proposed operational diagnostic criteria for PBD based primarily on
contemporary conceptualizations of the adult syndrome. Based on the literature, they concluded
“occurrence of manic-depression in early childhood as a clinical phenomenon has yet to be
demonstrated.” Unfortunately, Anthony and Scott did not assess BD in adolescence, and it is
likely their review reflected the diagnostic expectations of that era without necessarily
authenticating them (Faedda et al., 1995).
A host of others (e.g., Anthony, 1975; Lefkowitz & Burton, 1978; Lester & LaRoche,
1978; Rutter, 1972) sustained the hypothesis that a postpubertal level of maturity was necessary
to exhibit and sustain mania and major depression well into the 1970s. Disbelief in a common
occurrence of adult like bipolar disorder in pediatric populations broadly restricted interest in
PBD despite the clinical observations of mania and melancholia in the young since antiquity
(Mora 1980). It appears the interest in bipolar disorders at all ages was greatly stimulated by the
discovery of the anti-manic effects of neuroleptic drugs, and the anti-manic and mood-stabilizing
effects of lithium salts and certain anticonvulsants (Annell, 1969; Brumback & Weinberg, 1977;
DeLong, 1978; DeLong & Aldershof, 1987; Weller, Weller, & Fristad, 1986; Youngerman &
25
Canino, 1978). Lithium became widely accepted as an innovative treatment for mania
(Baldessarini, 1970), and toward the end of the 70s, several notable researchers suggested the
implementation of new diagnostic criteria based on those proposed for adults (Davis, 1979;
DeLong, 1978; Weinberg & Brumback, 1976). This renewed interest in bipolar disorder resulted
in a significant increase of published research focused on better understanding the diagnostic
features of mania with children and adolescents (McClellan & Werry, 1997) and effectively
challenged the preconception mania did not occur in children and adolescents (Joyce, 1984;
Loranger & Levine, 1978).
The rapid expansion of literature during the 1970’s and 80’s supporting a diagnosis of
PBD was not without strong opponents and even today, PBD remains a debated diagnosis in
pediatric mental health (Klein et al., 1998; McClellan, 2005; Youngstrom, 2007). Yet the
number of scholarly publications has risen geometrically since 1995 (Lofthouse & Fristad,
2004), and there has been increasing recognition in the psychiatric literature as well as a growing
public awareness and acceptance of pediatric bipolar disorder over the past two decades
(Pavuluri et al., 2005).
In 1996, as part of a National Institute of Mental Health (NIMH) funded study, Geller et
al. framed the first set of criteria for possible bipolar disorder in children. Applying these
criteria, initial studies reported essentially little was known about the condition (Geller et al.,
2002; Healy & Le Noury, 2007). Although there were children who met the criteria, those
children had a very severe condition, which in other circumstances likely would have been
diagnosed as childhood schizophrenia or patterns of hyperactivity against a background of
mental retardation (Geller et al., 2003). However, also in 1996, an influential group based at
Massachusetts’ General Hospital (MGH) nearly derailed the debate by suggesting there were
26
pediatric patients who may appear to have ADHD who in fact had mania or bipolar disorder
(Biederman et al., 1996; Faraone et al., 1997b). It may be worth noting the MGH study used lay
raters, did not interview the children about themselves, failed to use prepubertal age specific
mania items, and used an instrument designed for studying the epidemiology of ADHD (Healy &
LeNoury, 2007). Despite these significant limitations, the message stuck – cases of bipolar
disorder were being misdiagnosed as ADHD. During a time when clinicians were searching for
alternative options to treat children diagnosed with ADHD who did not respond to stimulants,
this was a potent message (Healy & LeNoury, 2007). Further fueling the debate was a study
(Lewinsohn et al., 2000) involving adolescents which pointed toward ill-defined over-activity
rather than bipolar disorder. However, the resultant message may have reinforced the idea BD in
minors was occurring at a greater frequency than previously suspected (Healy & LeNoury,
2007).
Perhaps responding to these developments, an NIMH roundtable meeting on prepubertal
bipolar disorder met in 2001 to discuss the issues further and concluded PBD can present as
“narrow” or “broad” phenotypes. Children with the narrow type have recurrent periods of major
depression and mania or hypomania fitting the classic definition of BD type I or II described in
DSM-IV (American Psychiatric Association, 1994). The majority of these children experience
multiple episodes with rapid cycling (Findling et al., 2001; Geller et al., 2002), and their
symptomatology is colored by their developmental stage. Despite having classic symptoms of
mania or hypomania, a great proportion of children fail to meet the duration criteria of 4-7 days
required to meet DSM-IV criteria for either and are usually diagnosed as BD not otherwise
specified (NOS). During this same period, the Juvenile Bipolar Research Foundation website
noted bipolar disorder in children did not present like bipolar disorder in adults due to rapid
27
cycling and called for the DSM to be updated to “. . . reflect what the illness looks like in
childhood” (Pavuluri et al., 2005). In contrast to the narrow type, children with the “broad”
phenotype constitute the majority of the referrals to clinicians and present with severe irritability,
“affective storms,” mood lability, severe temper outburst, symptoms of depression, anxiety,
hyperactivity, poor concentration, and impulsivity with or without clear episodicity (Biederman
et al., 1996).
Building on this discussion, Leibenluft and colleagues (2003b) introduced a similar
framework for classification of PBD spectrum into subtypes: “narrow,” “intermediate (2 types),”
and “broad” phenotypes. In their model, the narrow phenotype is attributed to those who meet
the full DSM-IV diagnostic criteria for mania or hypomania, including the duration criterion, and
have the hallmark symptoms of elevated mood or grandiosity. The intermediate phenotypes
include two sub-categories: those with the hallmark symptoms of short duration, i.e., 1-3 days,
and those with episodic irritable mania or hypomania meeting the duration criteria without
elation. The broad phenotype consists of non-episodic symptoms of severe irritability and
hyperarousal, without symptoms of elated mood or grandiosity. The BD-NOS category in DSMIV corresponds to the intermediate and broad phenotypes (National Institute of Mental Health
Research Roundtable, 2002).
Healy and LeNoury (2007) note there are several significant ambiguities to keep in mind
about this uniquely American position. For instance, there appears to be a willingness to set
aside adult symptomology, which involves mood states persisting for week or months, to argue
children’s moods may oscillate rapidly, up to several times per day, while maintaining the
position the disorder is continuous with the adult illness. An additional caution raised by the
authors is that the DSM-IV criterion for adult bipolar disorder requires fewer manic episodes to
28
make a diagnosis than the International Classification of Disease does. It is likely the
international community views the DSM-IV criteria as making it too easy to diagnose bipolar
disorder in adults. European articles concerning pre-pubertal bipolar disorder express continued
agnosticism as to whether there is such an entity (Kyte, Carlson, & Goodyear, 2006), and PBD is
much more rarely diagnosed in countries other than the United States (Soutullo et al., 2005).
Similar concerns were voiced by Lofthouse and Fristad (2004) in their response to the question
“Why now and why in America?” Another dynamic contributing to the increasing embrace of
pediatric bipolar disorder may be due to the emerging concept of the bipolar spectrum (Akiskal,
1983) in adult psychopathology. This concept has helped establish a broader view of what
constitutes bipolar disorder in adults and youth, including both “hard phenotypes” (psychotic and
nonpsychotic Bipolar One) and “soft phenotypes” (BP-II, Cyclothymia, BP-NOS; Akiskal 2003).
With broader criteria and more comprehensive methods to assess a wider range of symptoms,
more children and adolescents are receiving diagnoses of bipolar disorder in the US (Lofthouse
& Fristad, 2004).
An additional contributing factor to the growing contemporary acceptance of PBD in the
US may be the de-stigmatization and increasing acceptance of the use of pharmacological
solutions to mood disorders combined with what has been pejoratively termed “disease
mongering” (Moynihan & Cassels, 2005). Starting in the 1950s, the depression experienced by
those with manic-depressive illness has been treated with antidepressants and the manias with
antipsychotics or lithium (Healy, 2006). Although lithium was believed to be the only agent
effective as a prophylactic against further episodes of manic depressive illness (Healy, 1997), the
drug was rarely referred to as a “mood stabilizer” before 1995. It was at this time Abbott
Laboratories got a license to use the anticonvulsant sodium valproate (Depakote) for treating
29
acute mania (Department of Health and Human Services, 1995). After 1995, use of the term
“mood stabilizer” increased dramatically and by 2001, more than a hundred article titles a year
featured this term (Healy, 2006). Ironically, the academic psychiatric community has not yet
come to consensus on the meaning of “mood stabilizer” (Bowden, 1998; Ghaemi, 2001; Sachs,
1996). However, lack of consensus has not appeared to hinder the message that patients with
bipolar disorder needed to be identified and treated with mood stabilizers through the use of
psychotropic drugs (Ghaemi, Sachs, Chiou, Pandurangi, & Goodwin, 1999; Ghaemi, Lenox, &
Baldessarini, 2001). In July 2003, the Child and Adolescent Bipolar Foundation (CABF)
convened a meeting concerning the treatment guideline process. This meeting was significantly
supported by unrestricted educational grants from pharmaceutical companies including Abbott
Astra-Zeneca, Eli Lilly, Forrest, Janssen, Novartis and Pfizer (Kowatch et al., 2005). At the very
least, this assumed the widespread existence of pediatric bipolar disorder and reinforced the idea
there was a need to treat it psychopharmacologically.
Finally, increased use of the Internet in the 1990s enabled parents of children with bipolar
disorder to start numerous online support groups (Lofthouse & Fristad, 2004). In 1999, many of
these parents were associated with the Internet-driven national organization, Child and
Adolescent Bipolar Foundation (CABF), which continues to receive over 100,000 unique visits
per month (Hellander, Sisson, & Fristad, 2003). Three years later, the Juvenile Bipolar Research
Foundation (JBRF) became the first charitable foundation dedicated to the support of research in
early onset bipolar disorder. There also has been a surge of attention in the popular media,
ranging from special segments on news shows or Music Television to a cover article in Time
magazine (Kluger et al., 2002), to nearly two dozen trade books aimed at parents and families, as
well as health professionals (Lofthouse & Fristad, 2004).
30
Prevalence & Onset
There are several significant difficulties with obtaining an accurate prevalence figure for
PBD. First there is the complication of understanding and distinguishing developmental norms
from sociocultural expectations. For instance, the characteristics and extent of pediatric
psychiatric disorders are not universally recognized nor is there consensus on the extent to which
they differ on their core definitions and constellation of symptoms (Canino & Alegria, 2008). It
should also be kept in mind that rates of mania and hypomania may be higher during prepubertal
and early adolescence than during adulthood because of the difference in developmental
trajectories (Geller et el., 2004a). In other words, mania or hypomania may predominate during
the prepubertal and early adolescent age range, and depressive states may become more
prevalent with age.
The lack of agreement concerning prevalence is likely due to the absence of a gold
standard for validating most psychiatric conditions in general and PBD in particular (Robins,
1985). Classifications and the operationalization of child emotional disorders vary in different
classificatory systems and within different iterations of the same category (APA, 1987, 1994;
Canino & Alegria, 2008; World Health Organization, 1978, 1992, 2004). To illustrate this type
of discrepancy, one needs look no further than the rates of ADHD between and within countries.
For example, although the International Statistical Classification of Diseases and Related Health
Problems, 10th edition (ICD-10), developed by the World Health Organization (WHO, 1992) and
the Diagnostic Statistical Manual, Fourth Edition (DSM-IV) of the American Psychiatric
Association (APA, 1994) both require that the symptoms present be developmentally
inappropriate, persistent, and frequent, there are higher rates of ADHD when using the DSM-IV
(Bird, 2002; Polanczyk, Silva de Lima, Horta, Biederman, & Rhode, 2007). In population-based
31
studies performed in the United States, rates of ADHD Hyperactive Type have varied from less
than 1% to approximately 20% (Bird, 1996; Roberts, Attkisson, & Rosenblatt, 1998). To further
complicate matters, nearly all children and youth at some time, in some context, could be
described as exhibiting the symptoms of an emotional disorder (Kaufman & Landrum, 2009).
Therefore, it is critically important to answer the question of how frequently a student’s
emotional problems clearly stand out from the isolated, transitory, or minor problems of typical
development thereby limiting their options for social and personal development.
Cultural perspectives also have an impact on acquiring accurate prevalence figures.
There is evidence European countries are skeptical of the seemingly high prevalence of pediatric
BD in the US (Gillberg et al., 2004). There is a lack of evidence as to why epidemiological and
phenomenological differences across cultures exits especially since PBD is considered to
primarily be a biological and genetic psychiatric disorder. Soutello and colleagues (2005)
propose the differences may be due to any number of reasons including: relative lack of
European data, differences in diagnostic criteria, clinician bias against pediatric BPD, over
diagnosis in the US, or true higher prevalence of the disorder in the US due to
environmental/cultural differences.
Social policy and economic realities also complicate the estimation of PBD prevalence.
State and federal practices and economic restrictions often stand in the way of the legislative
mandates that educational systems should provide thorough preventative and responsive mental
health care for school-aged children. For example, the decision about who does or does not fit
the criteria for special education services is often influenced by the State and Local Education
System’s budgetary concerns. Inadequate funding typically results in a lack of identification
processes, treatment resources, professional development, and related curriculum (Kauffman,
32
1999, 2003). Over the past several decades, estimates concerning the percentage of students who
should receive services under the special education classification of ED (a category under which
many with PBD fall) fall in the range of three to six percent of the student population (see
Anderson & Werry, 1994; Brandenburg, Friedman, & Silver, 1990; Costello et al., 1998;
Costello, Egger, & Angold, 2005; Cullinan, Epstein, & Kauffman, 1984; Friedman et al., 1996;
Juul, 1986; Kessler, Berglund, Demler, Jin, & Walters, 2005; Smith, Wood, & Grimes, 1988; U.
S. Department of Health and Human Services, 2001; Wang et al., 2005), yet in practice, schools
rarely identify two percent or more of their population as having an ED. Since the Office of
Special Education Programs (OSEP) began collecting data in 1976 the identification rate for ED
has remained stable at approximately 0.9%, which is significantly less than the predicted
prevalence by the U.S. Department of Education (1980; Oswald & Coutinho, 1995). Mental
health studies suggest even higher rates of diagnosable psychological and psychiatric
impairments in youth (Costello et al., 1988; Friedman et al., 1996; McInerney, Kane, & Pelavin,
1992). There also is tremendous variation in identification rates between States. Data collected
during the 1996-1997 school year revealed a 33-fold difference between the lowest and highest
State identification rates. Unfortunately, it is likely only students with the most offensive and
disruptive behaviors receive appropriate services.
Estimates concerning the lifetime prevalence of BD in adults may provide some
indication of the prevalence of the disorder in children. The lifetime prevalence of BD I in adults
typically ranges between 0.8% (American Psychiatric Association, 1994) to 1% (Soutullo et al.,
2005) across gender and culture in the US. However, if other subclinical or subsyndromal forms
of the spectrum (e.g., bipolar II disorder, cyclothymia) are included, prevalence ranges between
three to seven percent (Kessler et al., 1997; Merikangas et al., 2007; Weissman et al., 1999).
33
Interestingly, the epidemiology and phenomenology of adult BPD internationally is similar to the
US, with some countries reporting higher prevalence.
Research indicates the first incidence of BD and subthreshold BD is greatest in
adolescence and declines in young adulthood. Clinical observers report very few new episodes
occur after the age of 24 years (Lewinsohn et al., 2003b). Retrospective studies in adults with
BD have reported as many as 60% experienced the onset of their BPD before 20 years of age
(Pavuluri et al., 2005a; Soutullo et al., 2005) and 10%-20% reported the onset before 10 years of
age (Egeland et al., 2003; Joyce, 1984; Lish et al., 1994). Loranger and Levine (1978)
interviewed adults classified with BD and reported age of onset was found to be between five
and nine years for 0.5 % of the patients and between the ages of 10 and 14 years for 7.5%.
Similar figures were reported by a European study including 12 national patient organizations,
supporting the hypothesis most patients with BPD had a childhood onset.
Providing trustworthy prevalence estimates for the pediatric population are dependent on
a consistent definition. Therefore, given the ongoing debate in characterizing PBD, it is not
surprising that there is a paucity of data on the prevalence of preadolescent BD. Aside from one
community study evaluating the rates of bipolar spectrum disorders in adolescents in high school
(Lofthouse & Fristad, 2004), there is an absence of any national (or international)
epidemiological study to determine the disorder’s prevalence in the pediatric population
(Pavuluri et al., 2005a; Soutullo et al., 2005; Weller et al., 1995). The Lewinsohn and colleagues
(1995) study surveyed 1700 adolescents (14 – 18 years of age) and reported a lifetime prevalence
of bipolar disorders (primarily BPII and Cyclothymia) of approximately one percent. An
additional 5.7% of the youths were described as having subsyndromal symptoms of BD defined
as a “distinct period of abnormally and persistently elevated, expansive or irritable mood” as
34
well as multiple comorbidities, and associated psychosocial impairment which may have
constituted a group of adolescents with BP-NOS (Lewinsohn, et al., 2003). In addition to being
limited to an older adolescent population, the study solely relied on the Schedule for Affective
Disorders and Schizophrenia for School-Age Children (K-SADS) (Orvaschel and Puig-Antich,
1987) and neglected other sources of information such as caregiver interviews (Dejong &
Frazier, 2003).
A six-month study in a national sample of 13 to 18 year-old Dutch adolescents reported a
prevalence of 1.9% for mania and 3.6% for major depression (Verhulst, vanderEnde, Ferinand,
& Kasius, 1997). Because instrumentation included The Child Behavior Checklist (CBCL;
Achenbach & Edelbrock, 1983) and the parent and child versions of the Diagnostic Interview
Schedule for Children (DISC; National Institute of Mental Health, 1992), these results should be
interpreted with caution (Pavuluri et al., 2005). The reason Pavuluri and colleagues encourage
caution is that the CBCL is not a diagnostic instrument and fails to identify specific manic
symptoms, and the items on the DISC are not robust enough to identify bipolar diathesis.
Data from the Great Smoky Mountains Study (GSMS) reported no BD Type I cases using
the Child and Adolescent Psychiatric Assessment (Costello et al., 1996). Brotman et al. (2006)
pooled items from several diagnostic sections of the Child and Adolescent Psychiatric
Assessment (depression, hypomania/mania, hyperactivity/attention deficit, sleep disorders,
oppositional defiant disorder/conduct disorder) to construct a severe mood and behavioral
dysregulation approximating the proposed broad phenotype of Leibenluft et al. (2003b). Using
the data from the GSMS, they reported a 4% prevalence of severe mood and behavioral
dysregulation. Unfortunately, the Brotman and colleagues analysis lacked validity studies of the
severe mood and behavioral dysregulation construct, and especially its link with bipolar
35
diathesis. Kashani et al. (1987), utilizing the DSM-III-R (American Psychiatric Association,
1987) reported that 0.7% of a community sample of 150 non-referred adolescents met the
diagnostic criteria for mania. Carlson and Kashani’s (1988) survey of 14- to 16-year-olds found
the prevalence of mania was 0.6% when severity and duration criteria were applied to the 13%
displaying manic symptoms.
Obviously, the lack of broad representation and a varied understanding of PBD limits the
usability of the above referenced studies to accurately project rates of PBD. Even though there is
growing evidence the prevalence of BD among children is similar to both adolescent and adult
BD levels (Geller & Luby, 1997), it is apparent more population-based studies using valid
diagnostic instruments, multiple informants, and accepted construct definition are needed. Given
the reluctance of clinicians in the past to diagnose children with BD, it is likely the prevalence
rate has been underestimated historically. In addition, understanding prevalence and age of onset
is made all the more difficult by the disorder’s diagnostic complexity. Developmental
influences, atypical presentation, comorbidity, and symptomatic overlap with other disorders
have resulted in misdiagnosis and under diagnosis of BD in children (Biederman 1998; Carlson,
Bromet & Sievers, 2000; Emslie, Kennard, & Kowatch, 1994). Obviously, further study is
necessary to clarify prevalence rates and age of onset.
Even though the diagnostic characteristics of PBD are continuing to be operationalized
further, it is not likely over-identification is currently problematic. If this is true within the
mental health fields, there is little reason to think those involved in special education services are
not under-identifying as well. Costello et al., (2005) comes to a similar conclusion, stating:
Substantively, we can say with certainty that only a small proportion of children with
clear evidence of functionally impairing psychiatric disorder receive treatment. Once
36
upon a time, when effective treatments for child and adolescent psychiatric disorders
were rare, this was regrettable but not a major public health issue. Now it is. The
tragedy is compounded by powerful evidence that most psychiatric disorders have their
origins early in life: risk even for adult-onset disorders is often increased by childhood
adversities, and disorders manifesting themselves in the early years often recur in
adulthood. So the public health directive to intervene early is clear, but the reality is
different. (p. 973)
Diagnostic Features
DSM-IV-TR criteria
Bipolar disorder manifesting itself in adolescence and young adulthood is widely
accepted and believed to be similar to that of adult BD. Therefore, diagnosis and treatment of an
adolescent or young adult benefits from applying the criteria established in the DSM-IV-TR.
There also is a quickly growing body of research demonstrating the existence of the disorder in
children. Historically, applying the DSM classifications of psychopathology first to adolescents
and then to school-aged children has led to important advances which have allowed researchers
and clinicians to study how childhood disorders are similar to and different from adult disorders
(Angold & Costello, 2009). Similar to the adult expression of the disorder, PBD involves
episodes of mania and depression; however, whereas mood changes in adults with BD often are
manifested as a euphoric or sad mood, manic and depressive moods in children typically are
expressed differently. Although the criterion for PBD in all of its expressions is yet to be
universally agreed upon, over the past 10 – 15 years, a growing body of published research has
focused on identifying the characteristics of PBD to assist clinicians in making a more consistent
differential diagnosis.
37
Diagnosing a mood disorder requires clinicians to assess not only the presenting signs
and symptoms but also the lifetime history of mood states, family history and response to
previous treatments. Four different diagnoses clearly on the bipolar spectrum are distinguished
in the DSM-IV-TR: Bipolar I and Bipolar II disorder, cyclothymia, and BD not otherwise
specified (NOS) (American Psychiatric Association, 2000). The specific diagnosis requires the
delineation of varying mood episodes, including, major depressive, manic, mixed, and
hypomanic.
Manic episodes vary from individual to individual and occasionally within individuals.
Using factor analysis as well as other approaches, the literature consistently describes the
structure of mania. The most common indicators are motor activation, flight of ideas, pressured
speech, and decreased sleep, while elated mood and increased sexuality are less common
(Carlson & Goodwin, 1973; Carlson & Strober, 1979; Cassidy, Murry, Forest, & Carroll 1998;
Goodwin & Jamison, 2007; Serretti & Olgiati, 2005 ). It has been suggested that the most
objective and reliable single indicator of the diagnosis is decreased need for sleep (Rice,
Rochberg, Endicott, Lavon, & Miller, 1992). The Swann and colleagues study (2003) supports
the idea that impulsivity also is a key phenomenological feature of mania. They used the Barratt
Impulsiveness Scale and reported impulsivity appears to persist even outside of the acute mood
state in bipolar disorder. This suggests impulsivity may represent both a state as well as a trait
feature of the illness. In addition, the literature indicates adults with the disorder tend to exhibit
similar behavior and mood patterns during subsequent episodes (Beigel & Murphy, 1971) and
manic and mixed episodes show diagnostic stability over time (Cassidy et al., 1998).
A diagnosis of bipolar I requires the presence of at least one experience of a manic or
mixed episode. Once either has occurred, DSM-IV-TR and ICD nosologies consider the
38
individual to have a lifetime diagnosis of bipolar I disorder. If the individual is currently
functioning well, then the classification is bipolar I “in remission.” If the person develops classic
major depression, even years after the mania, then the correct diagnosis is “bipolar I, current
episode: depressed.” The mood disturbance must either occur much of the day for most days
over a period of at least one week, or the mood disturbance must be so extreme as to result in
psychiatric hospitalization, in which case the one week duration requirement is waived.
Bipolar II disorder requires both a major depressive episode and a hypomanic episode at
some point in the person’s life. A key difference between the diagnosis of mania and hypomania
is not in the manic symptoms themselves, which are identical. It is the “marked” impact of those
symptoms on social or occupational functioning, the lack of psychotic features, and the nonnecessity of hospitalization, that differentiates the two episodes. If hypomania does not
markedly interfere with daily functioning, then where does the idea of impairment come from?
Vieta and colleagues (1997) suggest almost all the impairment in bipolar-II is a result of the
depressive phase. Furthermore, they suggest even though bipolar II is generally considered less
severe than bipolar I in regard to symptom intensity, it is more severe with respect to episode
frequency. In fact, “. . . bipolar-II disorder is more severe in terms of an increased propensity for
rapid-cycling and a greater number of mood episodes than bipolar-I disorder (Vieta, Gasto,
Otero, Nieto, & Vallejo, 1997).” Bipolar-II also may be associated with higher risk of suicide
(Rihmer & Kiss, 2002) and may be more difficult to diagnose than bipolar I due to hypomania
being more subtle and less impairing than mania (Youngstrom, Youngstrom, & Starr, 2005).
The other distinction between the two disorders lies in the duration of the syndrome. Mania is
defined as lasting one week (less if hospitalization is required), whereas hypomania is for a
minimum of 4 days.
39
Aside from at least one hypomanic episode, the diagnosis of Bipolar-II requires a clinical
course characterized by at least one or more occurrences of a major depressive episode (APA,
2000). There are no evidence-based indications that bipolar depression consistently presents
differently than unipolar disorder at the symptom level. However, the bipolar-unipolar
distinction is important in terms of suicide risk, substance use, choice of pharmacological agent,
and possibly choice of strategies for psychotherapy (Youngstrom, 2007). Data indicates
individuals affected with bipolar II disorder also tend to first present clinically in the depressed
phase of the illness, and therefore early-onset depression may be a marker for BD (Kovacs,
1996). In addition, diagnosis of bipolar II includes the individual’s experience of rapidly
alternating moods. If a patient meets criteria for hypomania but has not experienced a major
depressive episode, then the most appropriate diagnosis may be cyclothymia, which is not easily
distinguishable from bipolar-not otherwise specified (NOS).
During a Mixed Episode, criteria are met for both a Manic Episode and for a Major
Depressive Episode over a one week period where the symptoms are exhibited nearly every day
(APA, 2000). Obviously, the disturbance is severe enough to cause significant impairment in
daily functioning and is not the result of illicit drugs, medications, medical treatments, or a
medical condition. In Kraepelin’s 1899 edition of his text, he placed emphasis on six types of
mixed states that today’s clinicians may label as mania (dysphoric mania) or depression (agitated
depression, depression with racing thoughts) (Marneros, 2001; Salvatore et al., 2002). A
weakness of the DSM-IV criteria for a Mixed Episode may be the lack of empirical studies
supporting the validity of the definition (McElroy et al., 1992). When McElroy and colleagues
(1992) defined the criteria for a mixed episode as mania accompanied by as few as two or more
depressive symptoms (dysphoric mania) there was increased treatment response to the use of
40
valproate over lithium. Perugi and colleagues (1997) investigated the “depressive mixed state,”
and concluded patients (n=32) with depressive mixed states could be distinguished from patients
(n=36) with pure bipolar depression by the presence of increased cyclicity with greater frequency
of episodes in the latter group, compared to longer episodes with less interepisode recovery in
the depressive mixed state group (Perugi, Akiskal, Micheli, Toni, & Madaro, 2001).
Cyclothymia also is part of the Bipolar Spectrum. The diagnosis requires a period of
mood disturbance lasting at least 1 year in children with no more than 2 months free of
symptoms. Mood states include depressive or Dysthymic symptoms along with periods of
Hypomanic symptoms. During the index period, the depressive symptoms cannot become
sufficiently severe to meet criteria for a major depressive episode (in which case the diagnosis
changes to unipolar depression, or perhaps bipolar II disorder), nor can the Hypomanic
symptoms become too impairing (in which case the diagnosis changes to bipolar I disorder).
Cyclothymia is estimated to occur in 0.4 to 6.3 percent of the population (Chiaroni,
Hantouche, Gouyemet, Azorin, & Akiskal, 2005; Depue et al., 1981; Placidi, Maremmani,
Signoretta, Liguori, & Akiskal, 1998). Kochman and colleagues (2005) identified 80 depressed
children and adolescents with Kiddie-SADS semi-structured interview. After the two to four
year follow up period, 43 percent of the sample had been diagnosed as bipolar. Of those
participants who had been categorized as cyclothymic, 64 percent developed bipolar disorder.
Of those children and adolescents who had not been categorized, 15 percent experienced a
hypomanic or manic episode (p<.0001). Akiskal and colleagues (1979) studied the course of
cyclothymia and its relationship to the subsequent development of bipolar affective episodes.
Thirty-six percent of the 50 cyclothymic participants developed full syndromal depression,
hypomania, or mania, in contrast to only four percent of 50 nonaffective controls. Furthermore,
41
of the 25 cyclothymic patients requiring antidepressant medication for depressive illness, 44
percent became hypomanic.
It is especially difficult to assess the Cyclothymia construct. For example, the long
duration required to make a diagnosis makes it hard to distinguish between temperamental traits
and a mood episode (Youngstrom, 2007). In US clinical practice, cyclothymia is rarely
diagnosed in youth (Youngstrom, Youngstrom, et al., 2005b). When pediatric cyclothymia is
identified, it has been shown to be linked to high levels of impairment (Findling, Youngstrom, et
al., 2002).
The DSM-IV-TR gives several examples of possible presentations for BD NOS,
including repeated episodes of hypomania without lifetime history of manic, mixed, or
depressive episodes. Other presentations include manifesting an inadequate number of “B
criteria” symptoms in the context of episodic mood disturbance, or showing sufficient symptoms,
but for an insufficient duration to meet established criteria for a diagnosis. BD NOS, like
cyclothymia, tends to be diagnosed only rarely in clinical practice (Youngstrom, Youngstrom, et
al., 2005b). However, BD NOS is linked to substantial clinical impairment, including poor
functioning academically and interpersonally, high rates of service utilization and suicide risk,
and substantial mood disturbance – whether NOS is defined as insufficient number of symptoms
(Lewinsohn, Seeley, & Klein, 2003), insufficient duration (Findling, Youngstrom, et al., 2002),
or a combination of the two. BD NOS appears to show patterns of familial risk and symptom
severity (Axelson et al., 2006) that are consistent with it being on the bipolar spectrum; and more
than one-fourth of youth with BD NOS progress to more fully syndromal bipolar presentations
within a few years of initially being diagnosed with BD NOS (Birmaher et al., 2006).
42
Early onset mania
PBD is associated with severe impairment and a negative prognosis. It wreaks havoc on
family life, school functioning, and peer relationships (Lewinsohn, Seeley, & Klein et al.,
2003a). Over time, if left untreated, PBD may have a prolonged course, be less responsive to
treatment, and lead to legal difficulties, multiple hospitalizations, and increased rates of
substance abuse and suicide (Findling et al., 2001; Geller et al., 2003; Lewinsohn et al., 2003a).
Similar to the adult expression of the disorder, PBD involves episodes of
mania/hypomania; however manifestations of mania during childhood and pre-adolescent phases
of development often differ from those in adulthood. Mania in children is frequently atypical by
adult standards particularly in regards to mood presentation (Biederman, et al., 2005). For
instance, mania in children is not always characterized by a euphoric mood, and its course tends
to be chronic and continuous rather than episodic and acute (Carlson, 1983, 2005; Lewinsohn et
al., 2003a). In addition, symptoms of grandiosity and excessive involvement in pleasurable
activities typically vary as a function of age and developmental level (Bowring & Kovacs, 1992;
Geller & Luby, 1997). Obviously, care must be given to differentiate from the expected increase
in mood deregulation and variability often accompanying normal development. Clinicians also
need to consider whether behaviors (e.g., playing, activity levels, rate of speech) are consistent
with those displayed by normal children and adolescents (McClellan & Werry, 1997). Further
complicating the diagnostic process is the tendency for preadolescents to experience high rates of
rapid cycling along with very high comorbidity rates with attention-deficit/hyperactivity disorder
and conduct disorder (Carlson, 2005; Geller, Tilman, Craney, & Bolhofner, 2004).
In children, a manic episode may be defined as either a distinct period of excessively
elevated (i.e., inappropriately happy) or irritable (i.e., excessive temper tantrums, rages out of
43
proportion to events) mood, or both (Craney & Geller, 2003; Lofthouse, Mackinaw-Koons, &
Fristad, 2004). The National Association of School Psychologists (NASP; 2000; Lofthouse et
al., 2004) criteria for “altered mood” requires identifying three or more symptoms including: (a)
inflated self-esteem (e.g., a child thinks she is smarter than everyone else despite failing grades);
(b) grandiosity (e.g., a child believes and tells others he is able to run faster than a car); (c)
decreased need for sleep (e.g., a child feels rested after a few hours of sleep); (d) rapid, loud, or
uninterruptible speech; (e) racing thoughts, increased distractibility, increased goal-directed
activity/psychomotor agitation (e.g., a child starts to rearrange the school library, cleans
everyone’s desks, and plans to build an elaborate tree house in the backyard, but never finishes
any of these projects); and (f) excessive involvement in pleasurable or dangerous activities (e.g.,
a previously mild-mannered child writes offensive notes to other children in class or attempts to
jump out of a second story window).
Unlike adults with BD, children may manifest severe irritability instead of euphoria
(Carlson, 1983; Davis, 1979; Emslie et al., 1994). In a study of 6- to 12- year old prepubertal
children diagnosed with mania using DSM-III-R (American Psychiatric Association, 1987)
criteria, Weller et al. (1995) reported that 50% described a primarily irritable mood. Carlson’s
(1983) literature review revealed children younger than nine years old reported emotional
lability, crying and irritability while those nine years and older more commonly described
grandiose delusions and euphoria. Without the typical manic presentation, clinicians may
erroneously attribute a child’s emotional outbursts and belligerence to psychosocial factors or
conduct disorder (Wozniak et al., 1995).
This is not to say children even as young as preschool ages do not also present relatively
classic DSM-IV defined manic or hypomanic symptoms. There is evidence symptoms of elated
44
mood, pressured speech, heightened interest in sex, and perhaps grandiosity may be more
specific to mania than other associated symptoms such as aggression, irritability, distractibility,
or increased motor activity (Geller et al., 2000; Geller et al., 2002c). In Geller and Colleagues
(2002c) study of 93 children with prepubertal and early adolescent onset of bipolar disorder
(mean age at onset 7.3 years), Geller and colleagues (1998b, 2002c) found five mania-specific
symptoms were especially likely to discriminate bipolar children from children with ADHD or
normal comparison groups: elation, grandiosity, flight of ideas/racing thoughts, decreased need
for sleep, and hyper-sexuality. They also reported symptoms of psychosis were found in 60
percent of the sample, including half who had delusions of grandiosity. On follow-up, it was
discovered psychosis predicted more weeks ill with mania or hypomania (Geller et al., 2004).
Supporting the prevalence of psychotic features, Pavuluri and colleagues (2004b) reported the
prevalence ranged from 18 to 88 percent with the most common subtype to be the grandiose
type. A history of psychosis also was reported by research groups lead by Biederman et al.
(2004) and Birmaher (2006) with rates of 25 (n=298) and 33 (n=283) percent respectively.
The above-mentioned studies by Geller and colleagues required elation and/or
grandiosity for the diagnosis of mania; however, uncertainty remains about what actually
constitutes these two symptoms (Carlson, 2005). Methods of assessment vary widely, as do
cultural expectations and developmental factors, and all are likely to influence the diagnosis of
both euphoria and grandiosity (Breslau, 1987; Goodwin & Jamison, 2007; Harrington and Myatt,
2003). Some studies have defined mania by the presence of highly labile moods with intense
irritability, rage, explosiveness, and destructiveness; extreme agitation; and behavioral
dysregulation (Biederman, Faraone, Wozniak, & Monuteaux, 2000). Both irritability and rage
are noted as prominent features in many bipolar children (e.g., Faraone et al., 1997a, b; Carlson
45
& Kelly, 1998; Geller et al., 2002c) including those in preschool. Among adolescents and
children diagnosed with BD, retrospective parent reports at the time of diagnosis suggest
irritability, distractibility, increased activity, and other affective and behavioral symptoms may
be present before age 5 (Egeland, Hostetter, Pauls, & Sussex, 2000; Wozniak et al., 1995). In a
community sample of preschoolers selected for high or nonclinical scores on the CBCL, Lavigne
and colleagues (1999) found externalizing disorders to be the most prevalent; 16% met criteria
for oppositional defiant disorder, and 2% met criteria for ADHD. Even though a small proportion
of preschoolers with disruptive behaviors may be experiencing mania, the lack of data clearly
delineating distinct manic states is still lacking (Youngstrom, 2007). Therefore, it remains
unclear whether and when preschoolers’ symptoms reflect mania rather than nonspecific
hyperactivity and irritability.
Child depressive features
Considering PBD, NASP (2005) defines an episode of depression as a distinct period of
sad or irritable mood or markedly diminished interest and/or pleasure in most activities. This
period of depression includes four or more of the following symptoms: (a) significant appetite
change, (b) sleep problems, (c) restlessness or slowed movement, (d) fatigue, (e) feelings of
worthlessness or excessive guilt, (f) problems concentrating, and (g) recurrent thoughts of death
and/or recurrent suicidal thoughts, plans or attempts. For some children, BD first emerges as
symptoms of a depressive episode (Geller, Fox, & Clark, 1994; Lish et al.,1994). Similar to the
study of mania, the study of depression in the pediatric population was overlooked in early
epidemiological research. In particular, depression was viewed as a distinct disorder of adulthood
and adolescent emotional disturbances were thought to be linked to puberty, which were viewed
as transient and universal (Patton, 2007). Unfortunately, studies of bipolar disorder in the
46
pediatric population often combine childhood- and adolescent- onset groups. Even though
unipolar depression in children is more prevalent than mania and described by marked clinical
and etiological heterogeneity, longitudinal studies exploring the outcomes of childhood
depressive episodes are uncommon (Goodwin & Jamison, 2007). Therefore, the ability to
identify depressive episode predictors of eventual bipolar disorder is limited.
Controlling for ADHD across groups, Wozniak and colleagues (2004) compared 43
children with bipolar depression and 109 children with unipolar depression. The results
indicated the children identified with bipolar depression were more severely depressed and
anhedonic. Not only were the children in this group more likely to be suicidal, feel hopeless, and
require medication and hospitalization, but they also demonstrated higher rates of comorbidity
with oppositional defiant disorder, conduct disorder, obsessive compulsive disorder, and alcohol
abuse. In addition, it was reported the likelihood of a family history of bipolar disorder was
double in the bipolar sample (20%) compared to the unipolar sample (8%).
Research on children who have “switched” from an initial diagnosis of depression to
bipolar disorder suffers from small samples sizes and has yielded little information on predictors
of bipolarity. Luby and Mrakotsky (2003) compared preschoolers with and without a family
history of bipolarity with hopes of identifying differences in symptoms. Only one tenuous
difference emerged distinguishing the groups: restlessness (“moves around a lot”). A different
study (Geller et al., 1994) compared 79 severely depressed children 6- to 12-years-old. At the
two and five year follow-up 32 percent switched either to bipolar-I or bipolar-II. The same
individuals were re-contacted as young adults (mean age = 12). Of that group, 49 percent were
found to have switched to bipolar disorder including 33 percent with bipolar-I (Geller et al.,
2001b). According to Geller and associates, family history of mania was a significant predictor
47
of bipolar switching. However, it is worth noting the Geller and colleagues sample likely was
atypical and may be biased due to high rates of referral for suspected bipolar disorder.
Focusing on an outpatient population, Weissman and colleagues (1999) followed up
(M=11 years) on children with prepubertal depression. Although they only found six percent
had developed bipolar disorder, the rate was much higher than the comparison group.
Lewinsohn and colleagues (1995) found an even lower percentage (1%) of adolescents
diagnosed with prepubertal depression had developed BD. As has been the case for most topics
related to pediatric bipolar disorder, these studies differed in diagnostic and exclusionary criteria,
thereby making it difficult to draw confident conclusions.
Currently the onset of clinical depression during adolescence is an accepted clinical
diagnosis and is known to correlate with a poorer long-term prognosis (Walker, 2002).
Adolescents with depression are more likely to experience a chronic course with repeated
episodes than individuals who first experience depression in adulthood. It is expected
adolescents with BD who experience cycles of depression will experience similar psychosocial
correlates as adolescents who are solely diagnosed with depression. Depressed adolescents have
significantly more negative life events, deficient coping capacity, increased negative self-related
cognitions and attribution styles (Steinhausen, Haslimeier, & Metzke, 2007). Adolescents
experiencing depression are more prone to experiencing themselves and their psychosocial
relationships in a negative way. A large longitudinal representative community study of
preadolescence, late adolescence, and early adults, reported low self-esteem, maternal rejection,
and internalization problems showed come causal effects (Steinhausen et al., 2007).
Phenotyping
The phenotyping model is viewed as “critical” in helping researchers as well as
48
clinicians determine variables related to psychopharmacology, neurophysiology, treatment
response, and prognosis. In 2001, the National Institute of Mental Health Research Roundtable
on Prepubertal Bipolar Disorder promoted the idea that pediatric BD can present in “narrow” and
“broad” phenotypes (Pavuluri, Birmaher, & Naylor, 2005). The narrow type is marked by
recurrent periods of depression and mania or hypomania and fits the classic definition of BD as
described in the DSM-IV-TR (American Psychiatric Association, 2000; Craney & Geller, 2003).
Children also experience multiple episodes with rapid cycling (Geller et al., 1995) and have
symptomology that is influenced by the child’s developmental stage (Pavuluri et al., 2005).
Pavuluri and colleagues (2006) also reported that despite having classic symptoms of hypomania
or mania, most children fail to fulfill the criteria for duration of four to seven days, respectively.
In this case, the NIMH Roundtable suggested a diagnosis of BD-NOS is to be applied and serves
to accommodate children with severe affective instability. The broad phenotype constitutes the
majority of the referrals to clinicians (Pavuluri et al., 2005) and is the type most likely to be seen
by school psychologists. Symptoms include severe irritability (“affective storms”), mood
lability, severe temper outburst, symptoms of depression, anxiety, hyperactivity, poor
concentration, and impulsivity with or without clear episodicity (Biederman & Garcia, 1996b).
Perhaps building upon the NIMH Roundtable suggestions, Leibenluft and colleagues
(2003b) also proposed a framework for classifying pediatric BD into subtypes. Their spectrum
also had a “narrow” category, which accounted for children meeting the full DSM-IV diagnostic
criteria for mania or hypomania (including duration criteria) as well as the core symptoms of
elevated mood or grandiosity. An “intermediate” substage included two categories, one with the
hallmark symptoms of short duration (i.e., one to three days) and the other with the
characteristics of irritable mania or hypomania meeting the duration criteria but without elation.
49
Finally, the “broad” type consisted of nonepisodic symptoms of severe irritability and
hyperarousal without the symptoms of elated mood or grandiosity. Leibenluft et al. (2003a)
suggested the BD-NOS category corresponded to the intermediate and broad phenotypes. In
some data, these presentations appear to be on a continuum with bipolar illnesses, albeit
involving more rapid rates and briefer episodes of mood disturbance. Some have noted this
clinical presentation seems highly similar to borderline personality disorder in adults and may in
fact be a juvenile precursor to BD (MacKinnon & Pies, 2006).
It appears the idea there is a spectrum describing pediatric BD, including at least broad
and narrow types, is gaining consensus. However, consensus is not yet universal and school
psychologists should be aware researchers often use different sets of diagnostic criteria to define
PBD. For example, Geller et al. (1998b), in a study comparing clinical characteristics of a
sample of children with BD and Attention-deficit/hyperactivity disorder (ADHD) along with
healthy controls, found grandiosity, elated mood, hypersexuality, flight of ideas, and decreased
need for sleep differentiated children with BD from the other groups. They also reported
“irritability” was highly common in both the ADHD and BD participants. However, the results
must be considered in light of the understanding that the PBD children were identified for the
study by demonstrating symptoms of grandiosity and/or elation. On the other hand, Biederman
and Garcia (1996) in their study of BD children emphasized the centrality of irritability in
establishing the diagnosis of BD regardless of the absence of elation or grandiosity. The breadth
of variability in defining core characteristics of PBD, however, is not limited to these two views.
A review of the literature also will reveal that some researchers use unmodified DSM-IV
symptom criteria to establish a diagnosis (Pavuluri et al., 2005).
In addition to the debate on core symptoms and the presence or absence of episodes, there
50
also is the definition and role of “cycling” to be considered. In contrast to adults, who are more
likely to present with discrete cycles of depression and mania, it is believed children with BD
may exhibit both manic and depressive symptoms at the same time or within the same day.
Instead of being episodic or acute in course, as is the case with most adults, pediatric BD tends to
be chronic and continuous, which makes identifying discrete episodes very difficult (Weller,
Weller, & Fristad, 1995); however, this does not mean that on occasion children will not
demonstrate similar syndromal characteristics observed in adults with BD (Cassano et al., 2000).
Geller et al. (1995) coined the term “complex cycling” to describe the presence of short cycles
embedded within a more prolonged cycle or episode. Mood shifts in children are currently
characterized by mixed states (i.e., simultaneous manic and depressive symptoms), rapid cycling
(i.e., four or more mood episodes per year), ultra-rapid cycling (i.e., more than four mood
episodes per year), and ultradian cycling (i.e., multiple episodes per day, requiring more than
four hours of mania per day; Geller et al., 1995; Lofthouse et al, 2004b).
Neuropsychological features
Children with BD often present with significant cognitive deficits that may adversely
affect school functioning both academically and socially. Compromised academic functioning in
PBD has resulted in the increased use of special education services (Faedda, Baldessarini,
Glovinisky, & Austin, 2004). For instance, a line of research estimated the incidence of math
and reading difficulties in PBD to be approximately 30%-40% (Wozniak et al., 1995). There is
adequate evidence demonstrating the capacity to regulate emotion is hindered by a variety of
neurocognitive activities, including dysfunction of the neurotransmitter systems (notably
dopamine and serotonin) and of the limbic-cortical system, diminished activity of the frontalcortical regions, and/or elevated activity in the amygdala (Miklowitz, 2007). Cognitive
51
neuroscience also has developed neuropsychological test paradigms having the potential to
increase understanding of the neural mechanisms mediating the symptoms of BD in both
children and adults (Dickstein et al., 2004; Leibenluft, Charney, & Pine, 2003).
Neuropsychological research may provide insight into the commonly regarded brain networks
that could be disrupted in PBD and the functional impairments that may underlie the behavioral
and emotional dyscontrol that is characteristic of the disorder (Doyle et al., 2005). It is believed
increasing a school psychologist’s understanding of the biological basis of childhood pathology
should “ . . . facilitate communication with neurologists, neurosurgeons, and other medical
personnel who entrust the care of their patients in the schools to school psychologists (Davis
2006).”
It remains unclear whether neuropsychological deficits are stable and exist independently
of clinical states (Basso, Lowery, Neel, Purdie, & Bornstein, 2002). Some studies have suggested
cognitive dysfunctions may persist in remission states beyond the episodes of the illness; thus,
these deficits may be chronic (Martinez-Aran et al., 2004a; Thompson et al., 2005). On the other
hand, structural and functional neuroimaging techniques have indicated the subcortical white
matter, the basal ganglia, the hippocampus, the amygdala, the frontal lobes, the temporal lobes,
and the cerebellum may be involved in bipolar disorder (Baumann & Bogerts, 2001; Bearden,
Hoffman, & Cannon, 2001). In addition, there are some clinical factors that may influence
cognitive functioning in bipolar patients, episodicity of mania (Ferrier & Thompson, 2002; van
Gorp, Altshuler, Theberge, wilkins, & Dixon, 1998), as well as chronicity (Clark & Goodwin,
2004; Clark, Iversen, & Goodwin, 2002; van Gorp et al., 1998).
It is expected cognitive impairment is related to a worse clinical course and poor
functional outcome. Studies of adults with BD have demonstrated neuropsychological deficits in
52
several cognitive areas including set shifting and sustaining attention (Clark & Goodwin, 2004;
Clark, Iversen, & Goodwin, 2002; Liu et al., 2002), working memory (Ferrier & Thompson,
2002; ; Thompson et al., 2006; Thompson et al., 2007), episodic memory (Krabbendem et al.,
2000), verbal learning and memory (Cavanagh, Van Beck, Muir, & Blackwood, 2002; Clark et
al., 2002; Ferrier & Thompson, 2002; Martinez-Aran et al., 2004b; van Gorp, 1998), declarative
memory (Cavanaugh et al., 2002; Ferrier et al, 1999) and executive function and decisionmaking (Basso et al., 2002; Martinez-Aran et al., 2004b; Murphy & Sahakian, 2001; Rubinsztein
et al., 2001; Thompson et al., 2006; Zimmerman, DelBello, Getz, Shear, & Strakowski, 2006).
Using single photon emission computed tomography with 43 outpatients across a variety of
bipolar states confirmed the presence of functional disturbances in the frontosubcortical
structures, the cerebellum and the limbic system in bipolar patients (Benabarre et al., 2005).
Although it may be expected children and adolescents with BD also will demonstrate
difficulties in these areas, a number of researchers advise caution when inferring neurocognitive
function in pediatric bipolar disorder is similar to that found in adult populations (Pavuluri et al.,
2006). For instance, the psychotropic medications to stabilize mood in children may influence
cognitive function and/or cause sedation, especially if given in high doses (MacQueen & Young,
2003). There also are developmental issues of constant change in a child’s neurocognitive
capacity, so the impact of BD on functional brain differences can be expected to be different in
children than adults (Luna, Garver, Urban, lazar, & Sweeney, 2004). Furthermore, the high rate
of ADHD in youth with BD makes it challenging to identify deficits common to pediatric bipolar
disorder (Geller et al., 2002b). This is especially germane given the cortical-striatal systems
reported to underlie ADHD (Dickstein et al., 2004) are also implicated in bipolar disorder
(Ferrier & Thompson, 2002). Nevertheless, recent studies examining neurocognitive function in
53
children with BD include impairment in attention and set shifting (Dickstein et al., 2004; Meyer
et al., 2004), visuospatial memory (Dickstein et al., 2004; Olvera, Semrud-Clikeman, Pliszka, &
O’Donnell, 2005), processing speed and interference control (Doyle et al., 2005), sensorimotor
tasks and short-term memory for face and names (Castillo et al., 2000), verbal learning and
memory (Glahn et al., 2005; Meyer et al., 2004; McClure et al., 2005; Olvera et al., 2005), and
abstract problem solving or executive function (Doyle et al., 2005; Murphy et al., 1999).
Possessing a significantly higher Weschler Intelligence Scale for Children (WISC)
Verbal IQ (VIQ) than Performance IQ (PIQ) is one of the most commonly reported
neuropsychological findings in children with PBD (Mattis, Papolos, Luck, Cockerham, Thode,
2011). In one study (Pavuluri et al., 2006b), performance IQ from the WISC was reported to be
lower in PBD than in ADHD, conduct disorder, and oppositional defiant disorder and similar to
that seen in schizophrenia. As early as 1983, a greater than 15-point discrepancy between VIQ
and PIQ in children at high risk for PBD was demonstrated by Decina and colleagues (1983).
The discrepancy was most significant with offspring of bipolar I parents versus those of bipolar
II parents. In this high-risk sample, those reported to manifest expansive moods were more
likely to exhibit the aforementioned cognitive discrepancy. Some have suggested this pattern
may be a trait marker of a genetic predisposition to PBD (Mattis et al., 2011). Others have
observed the same VIQ>PIQ pattern (see FlorHenry, 1983; Flor-Henry, Yeudall, Koles, &
Howarth,1979; Sackheim, Decina, Epstein, Bruder, & Malitz,1983) . In contrast, the VIQ > PIQ
finding is not a feature of ADHD (e.g., see Doyle et al., 2005; Jonsdotter, Bouma, Sergeant, &
Scherder, 2006). Kestenbaum (1979) and McDonough-Ryan et al. (2002) also found significant
VIQ> PIQ discrepancies as well as psychomotor deficits in children at risk for PBD.
54
Given the hypothesized correlation between PBD and difficulties with cognition, one
might expect cognitive functioning to improve with symptom remission (Pavuluri et al., 2006b).
However, improvement has not always been found to be uniform across domains and some BD
patients show persistent cognitive impairment during remission (Beardon et al., 2001). McGrath
and colleagues (1997), for example, reported improved executive function when symptoms were
remitted but not in the domains of attention, inhibition, and psychomotor speed.
Interpretation of pediatric neuropsychological data is complicated due to the fact that 6090% of children with BD also meet criteria for comorbid ADHD (Doyle et al., 2005). Because
individuals with ADHD also exhibit neuropsychological deficits, it is necessary for
neuropsychological studies of pediatric BD to address this comorbidity. Several studies have
addressed the role of comorbid ADHD on neurocognitive functioning in youth. Wozniak et al.
(1995) have reported children with BD have lower full scale IQ and lower Wide Range
Achievement Test (WRAT) Arithmetic percentiles and WRAT/Gilmore Reading standard scores
compared with children with ADHD and no disorder. Doyle and colleagues compared 57 youth
with BD and 46 healthy control subjects on a battery of clinical neuropsychological measures
including subtests from the Wechsler Intelligence Scales for Children and Adults -Third Edition
(Wechsler, 1991), the Stroop (Golden, 1978), the Continuous Performance Test (Seidman et al.,
1998) and the Wide Range Achievement Test-Third Edition (Jastak & Jastak, 1993). It was
noted bipolar disorder in children was associated with impairments in sustained attention,
working memory, and processing speed after controlling for ADHD. It also has been
demonstrated subjects with PBD, regardless of medication and illness status, demonstrate
impairments in the domains of attention, executive functioning, working memory, and verbal
learning compared to healthy individuals (Pavuluri, Schenkel, Aryal, et al., 2006). Also, bipolar
55
subjects with comorbid ADHD performed worse on tasks assessing attention and executive
function than patients with bipolar disorder alone. The absence of differences in the deficits of
neurocognitive profiles between acutely ill undedicated patients and euthymic medicated patients
suggests these impairments are trait-like characteristics of pediatric bipolar disorder. The
cognitive deficits found in individuals with PBD suggest significant involvement of frontal lobe
systems supporting working memory and mesial temporal lobe systems supporting verbal
memory, regardless of ADHD comorbidity (Pavuluri, Schenkel, Aryal, et al., 2006). McClure
and colleagues (2005) reported greater impairment of verbal memory in their pediatric bipolar
disorder group that was comorbid with ADHD compared to those with pediatric bipolar disorder
alone. Their report of a lack of impairment in verbal memory in subjects with pediatric bipolar
disorder without ADHD (Clark & Goodwin, 2004; Ferrier & Thompson, 2002; Rubinsztein et
al., 2001) is in sharp contrast to adult studies of bipolar disorder that showed prominent
impairment in memory function. Using the Cambridge Neuropsychological Test Automated
Battery, Dickstein et al. (2004) reported difficulties in attentional set shifting and visuospatial
memory in PBD participants as compared with healthy controls. However, results were limited
due to the various psychotropic medications being taken by participants and the variety of BD
characteristics exhibited amongst the children with BD. In summary, despite methodological
limitations and varied tests, the majority of the available data point to similar neurocognitive
profiles in pediatric bipolar disorder, irrespective of comorbid ADHD (Pavuluri et al., 2006b).
In another study, 35 children and adolescents who met DSM-IV diagnostic criteria for the
narrow phenotype of PBD were compared to 20 psychologically healthy youths using a battery
of verbal (California Verbal Learning Test for Children, Test of Memory and Learning
[TOMAL]) (Delis et al., 1994; Reynolds & Bigler, 1994) and visuospatial (Rey-Osterreith
56
Complex Figure Test, TOMAL Facial Memory) (Rey, 1941) memory tests (McClure et al.,
2005). Results were consistent with findings in adults with BD in that children and adolescents
with PBD performed more poorly than controls on measures of verbal learning/memory and
delayed facial recognition memory. The results of a neuropsychological study by McClure and
colleagues (2003) indicated children with BD misinterpreted sad, happy, and fearful child faces,
but not adult faces, as angry, as compared with anxious and healthy groups. These results
suggest children with BD possibly over perceive anger among peers, which may relate to
increased social difficulties.
Behavioral data in pediatric bipolar disorder suggest deficits in motor inhibition
(Leibenluft et al., 2007; McClure et al., 2005 ), whereas behavioral data in adults with bipolar
disorder show similar deficits and relate them to the impulsivity characteristic of both mania and
depression (Swann, Dougherty, Pazzaglia, Pham, & Moeller, 2004). In addition, functional
magnetic resonance imaging studies in both adolescents and adults with bipolar disorder indicate
differences in striatal activation between patients and comparison subjects while they are
performing motor inhibition tasks (Blumberg et al., 2003b; Strakowski et al., 2005). Deficits in
pediatric motor inhibition have been linked to irritability (Hoeksma, Oosterlaan, & Schipper,
2004) which is a common and disabling symptom of PBD. Other studies have indicated motor
inhibition is mediated by several regions of interest that are also implicated in the
pathophysiology of bipolar disorder (Blumberg et al., 2003; Rubinsztein et al., 2001), including
the ventral prefrontal cortex, striatum, and anterior cingulated. One study found that in relation to
comparison subjects, children with bipolar disorder and a family history of bipolar disorder had
increased ventral prefrontal cortex activation while viewing emotional pictures or performing a
spatial working memory task (Chang et al., 2004). In the same study, the children had greater
57
anterior cingulated activation than the comparison subjects during the spatial working memory
task.
Illnesses such as Huntington’s and Parkinson’s diseases, where the basal ganglia (BG)
are implicated, usually present with mood dysregulation. Previous researchers have reported
adults with unipolar mood disorder have smaller BG than controls; however, available studies
are conflicting with respect to adults with BD. For example, some studies report larger BG in
patients with bipolar disorder, although not all studies have confirmed this finding (Sanches et
al., 2005). Sanches and colleagues (2005) compared the BG of fifteen children and adolescents
who met DSM-IV criteria for bipolar disorder and twenty-one healthy controls.
Among bipolar patients it was found that a statistically significant inverse correlation
between age and the volume of right and left caudate and left putamen among bipolar patients.
There also was an inverse correlation between length of the illness and right putamen volumes
and a significant negative correlation between length of illness and left putamen volumes.
Contrary to studies showing larger striatal volumes in adult bipolar subjects, the researchers
observed that the volumes might eventually become smaller in bipolar patients. Such a
mechanism might underlie, in part, eventual volumetric reductions in striatal volumes and
consequent effects on the processing of emotions. A further implication was that a
neurodegenerative process may be involved with PBD.
Although each of the above-referenced studies possesses limitations, the increasing
support for PBD as a neuropsychological problem has implications on diagnosis and intervention
for school psychologists. Learning disabilities and complications in executive functioning in
children with PBD may not simply be secondary symptoms of the disorder, they may provide
anatomical clues related to the causes of the disorder. Either way, children with PBD are
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expected to have learning difficulties related to cognitive functioning and will need appropriate
educational accommodations.
Etiological factors
Of the many risk factors associated with BD, genetic factors have received the most
attention (Tsuchiya, Byrne, & Mortensen, 2003). The study of children with
psychopathologically ill parents has been employed with good success over the past 30 years and
has helped clinicians examine the early signs and course of a disorder as well as to identify
potential individuals for early intervention (Goodwin & Jamison, 2007). The familial risk posed
by parents with BD to their children is well documented and, aside from schizophrenia, exceeds
the heritability of all other major mental illnesses (Chang & Steiner, 2003; Farone, Tsuang, &
Tsuang, 1999; McGuffin et al., 2003). Even though the fraction of risk attributed to genetic
factors is approximately 50% or less, contextual factors also may be associated with increased
risk for developing BD (Berrettini, 2000). After all, children living with a bipolar parent
experience both the genetic predisposition along with the environmental impact of living with
such a parent. Researchers, therefore, have examined environmental risks, such as demographics
(i.e., gender, ethnicity, SES), factors related to birth, family dysfunction, medical issues, and
diet.
Historically, researchers have recognized and consistently attributed a higher rate of BD
among the relatives of pediatric onset bipolar disordered children (Faraone, Glatt, & Tsuang,
2003; Tsuchiya et al., 2003). Family history of BD as a risk factor has been considered since
Kraeplin (1921) and revisited in 1960 by Anthony and Scott as one of the 10 important
diagnostic criteria. In 1979, Davis also pointed to family history. However, prior to the 70s no
formal studies of children with manic-depressive parents were conducted (Geller & Luby, 1997).
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Offspring studies have steadily increased since the late 70s and have shed light on the early
development and onset of BD. Chang and Steiner (2003) delineate the benefits of such studies
along four dimensions. First, high risk populations may serve to demonstrate early symptoms of
prodromal BD. Second, longitudinal observation and assessment may reveal the nature of the
natural progression of childhood-onset bipolar disorder. Third, the reduction and/or elimination
of the presence of drug or alcohol use which typically confounds or changes the presentation of
BD in older populations. Fourth, these children are unique in having been raised by and/or
exposed to a parent with bipolar disorder. The environmental effects of having a parent with
bipolar disorder can therefore be studied as well.
Since 1997, studies have continued to consistently report about a 50% incidence of some
psychiatric disorder in cross-sectional assessment of child and adolescent bipolar offspring
(Chang, Steiner, & Ketter, 2000; McMahon et al., 1994; Taylor & Abrams, 1973; Weissman et
al., 1984). Estimates range from four- (Lapalme Hodgins, & LaRoche, C., 1997) to five(Hodgins et al., 2002) times greater risk for children of parents with bipolar disorder (BD) to
develop a mood disorder compared to children of parents without psychiatric disorders.
Transmission of BD has been well established by twin studies and pedigree analyses (Geller, B.,
& Luby, J. 1997). For instance, Kelsoe (1997) demonstrated a 67% concordance rate of bipolar
disorder for monozygotic twins and a 25% concordance rate for dizygotic twins. In addition,
having a first-degree relative with bipolar disorder may confer a 6.5% risk of developing bipolar
disorder, and a 10% risk for developing a major depressive episode, compared to one and five
percent respectively for controls (Kelsoe, 1997).
Several studies utilizing the Child Behavior Checklist (CBCL) demonstrated a high
degree of heritability (Althoff et al., 2005; Mick, Biederman, Pandian, and Faraone, 2003).
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Youngstrom (2007) notes that in samples where PBD is rare (i.e., general population), the
majority of individuals with such a profile do not actually have a BD diagnosis; however, a
heritable behavior pattern not isolated to PBD may be entirely consistent with a polygenic model
of illness. That is, there may be a specific gene “. . . conferring risk for the ‘bipolar profile’ of
behaviors captured by the CBCL, and this gene might often be present in individuals with PBD.
At the same time, the gene also may convey risk for aggressive behavior and occur in the context
of other disorders, such as conduct disorder (CD) or ADHD (Youngstrom, 2007).”
As concordance rates in identical twin studies do not approach 100%, it has been
proposed that BD develops in a child with genetic predisposition in response to external
stressors. The kindling model suggests mood disorders are created by an interplay between a
susceptible genetic diathesis and environmental stressor, which “. . . causes actual biological
changes at the genetic level that over time lead to the crossing of a neurobiological threshold for
a mood episode (Chang & Steiner, 2003)”. It is believed each successive episode of mania or
depression reinforces the biological changes thereby leading to more frequent and spontaneous
episodes. So aside from providing a genetic risk to their offspring, the presence of the parent
who intermittently may become manic, dysfunctional, or neglectful must be considered a
significant influence on the developing child (Chang, Blasey, Ketter, & Steiner, 2001).
As early as 1985, Laroche and colleagues reported marital discord and exposure to
parental illness before age 3 years were positively correlated with offspring psychopathology.
More recently, Aln and Torgersen (1993) associated marital discord with elevated risk for earlyonset BD. Families with a bipolar parent have less cohesion and organization and more conflict
than families considered “typical” (Chang et al., 2001). Three studies discussing stressful life
events and PBD suggested an exposure to such events occurring within a short period prior to the
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first onset (e.g., within 6 months) was associated with an increased risk for BD (Ambelas, 1987)
and psychotic mania (Bebbington et al., 1993; Mathew, Chandrasekaran, & Sivakumar, 1994).
In some research, environments which manifest a high frequency and intensity of
criticism, hostility, and or emotional over-involvement from a caregiver are operationalized as
“high expressed emotion” (EE; Miklowitz , 2007). Individuals with BD who return home to
high-EE families following an acute episode are two to three times more likely to relapse in the
subsequent 9 months than are persons who return to low-EE environments (Barrowclough &
Hooley, 2003; Miklowitz et al., 2003). Miklowitz (2007) further describes the model:
…the causal and reactive roles of parental EE (Expressed emotion) in mood disorders
begins with a child who has temperamental disturbances (e.g., irritability, low frustration
tolerance, mood instability, high anxiety) or compromised cognitive functioning. These
early disturbances partially reflect the child’s genetic vulnerability to bipolar or other
psychiatric disorders. The child is paired with a parent who, by virtue of his or her own
neurobiology and social history, reacts to the child’s behavior with frustration and
hostility (expressed as frequent criticisms of the child) or with guilt and anxiety
(expressed in overly protective behaviors). Repeated exposure to criticisms, anxiety, or
over-involvement during the period when a child is developing a sense of identity may
contribute to self-doubt, self-criticism, and core beliefs about relationships as aversive
and conflict-ridden. These schemata for the self may interfere with the child’s
acquisition of emotional self-regulatory skills, as reflected in depression, anxiety,
aggression, and the inability to tolerate negative states of affect. In turn, his or her
negative counterreactions fuel high-EE attitudes and behaviors in parents, which
recursively contribute to the child’s emotional and cognitive vulnerabilities. (p. 193)
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This type of model is particularly important when it comes to the discussion of psychoeducation
and its role in helping to equip families in both the prevention and treatment of offspring with
BD. Better understanding these biopsychosocial mechanisms will further enhance the
effectiveness of psychosocial interventions through psychoeducation, family therapy, and
cognitive behavioral therapy.
A literature review focusing on environmental associations by Tsuchiya and colleagues
(2003) focused on 95 studies which examined the first onset of BD compared with a nonpsychotic non-affective reference population, and contained a description regarding an exposure
to the specific risk factor prior to the first onset of BD. Results indicated there was not a
demonstrated, statistically conclusive difference in lifetime or period prevalence of BD across
multiple domains, including ethnicity, birth order, and high socioeconomic status of parent or
child. In fact, the selected studies often came up with confounding and often opposite results.
For example, two studies (Fogerty et al., 1994; Szadocsky et al., 1998) concluded the lifetime
prevalence for a manic episode to be higher in males whereas others reported higher rates in
females (Helgason, 1977; Brewin et al., 1997; Lloyd & Jones, 2000) or no difference at all (e.g.,
Spicer, Hare, & Slater, 1973; Weeke et al., 1975; Daly, Webb, & Kaliszer, 1995).
On the other hand, Papolos (2003) conducted a retrospective study of parental reports of
chronological symptom development in children later diagnosed with bipolar disorder. Results
of the study indicated 42% of the sample had prodromal separation anxiety disorder, 55%
reported arousal disorders of sleep (night terrors, restless leg syndrome, bruxism), and 70%
reported marked sensitivity to sensory stimuli in infancy and early childhood. Papolos concluded
because panic disorder is highly comorbid with adult bipolar disorder, the foregoing studies
suggest
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. . . if indeed the temperamental trait of behavioral inhibition represents a low threshold
for arousal, and separation anxiety disorder in children is a precursor to both panic
disorder and bipolar disorder, it is possible that both trait and several DSM-IV conditions
may share a common genetic diathesis with variations on a theme. (p. 91)
Comorbidity
Because of overlapping symptoms with other psychiatric disorders, it often is difficult to
differentiate PBD from other childhood problems. Numerous diagnoses both resemble and
coexist with PBD. The most common comorbidities identified in youths meeting criteria for BD
are ADHD, anxiety disorders, oppositional defiant disorder (ODD), and conduct disorder (CD;
e.g., Geller et al., 2003; Geller and Luby, 1997; Kowatch, Youngstrom, Danielyan, & Findling,
2005; Lewinsohn et al., 2003b). PBD also may be associated with higher risk of meeting criteria
for other conditions, such as enuresis or eating disorders (Weckerley, 2002). In a review of
research on rates of comorbidity of PBD with other disorders, it was reported that rates ranged
between 11% and 75% for ADHD, 46.4% and 75% for ODD, 5.6% and 37% for CD, 12.5% and
56% for anxiety disorders, and 0% and 40% for substance abuse disorders (Pavuluri et al., 2005).
These comorbidities with more easily identifiable disorders have often led to long latencies
between the emergence of bipolar disorder symptoms in childhood and its clinical diagnosis
(Papolos, 2003). The ease of misdiagnosis is highlighted by the work of Biederman and
colleagues (1996) who found 96% of children who met the criteria for BD did so for ADHD;
however, only 16% of ADHD patients met the criteria of mania/hypomania. Similarly, in
another study it was reported that of children presenting bipolar symptoms, approximately 90%
of prepubertal and 30% of adolescent subjects were classified as ADHD (Geller & Luby, 1997).
This significant comorbidity makes prognosis and treatment all the more difficult for children
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with BD. Rates of comorbidity vary according to the age of the child, sample selection, and
methods used to ascertain the symptomatology (Pavuluri et al., 2005).
The rate of comorbid ADHD was initially reported to be extremely high and in excess of
90% (Biederman et al., 1996; Geller et al., 2003). Other investigations using different referral
patterns or interview procedures have found closer to 60% of youths with BD also meet criteria
for ADHD. The lower rates are more similar to the rates of comorbid ADHD diagnosed
clinically in youth treated for BD (Youngstrom, Youngstrom, et al., 2005b). If ADHD were an
unrelated illness that affects roughly 5% of the general population, then it also should manifest in
roughly 5% of BD cases (Youngstrom, 2007). What accounts for the much higher rate of coincidence? ADHD often involves distractibility, high motor activity, talkativeness, and impulsive
behavior, all of which can look like manic behaviors (Klein et al., 1998). The high rate of
comorbidity might be inflated by research interviewers or clinicians who do not sufficiently
determine whether the symptom is most attributable to a mood disorder or another condition
(Youngstrom, 2007). Other investigators argue, comorbid ADHD may represent a distinct
subtype of BD, which point to patterns of heritability and the fact that youth with comorbid
ADHD and BD often show greater impairment and worse course (Biederman et al., 1996a;
Faraone, Biederman, Mennin, Wozniak, & Spencer, 1997a).
In many cases, prepubertal and early adolescent BD may be differentiated from ADHD
due to the presence of persistent mania. Symptoms such as impulsivity, hyperactivity, irritability
and distractibility are shared by both BD and ADHD (Emslie et al., 1994; Geller et al., 2002;
James & Javaloyes, 2001), whereas the presence of grandiosity, elated mood, flight of ideas,
hypersexuality, and decreased need for sleep are more common to PBD (Geller et al., 2002).
Wozniak, Biederman, Mundy, and colleagues (1995) found 94% of a sample of 43 children aged
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12 or younger evaluated with current or previous mania also met DSM-III-R criteria for ADHD,
while only 19% with a diagnosis of ADHD also met criteria for current or previous mania.
Geller et al. (2004) hypothesize that ADHD in children and adolescents with BPD may be a
separate diathesis, a reflection of mania plus normal childhood developmental behaviors, shared
genetic vulnerabilities, and/or the result of unknown overlapping criteria for both diagnoses.
One measure, the Adult Mania Rating Scale, was used with a group of prepubertal children and
was found useful in delineating between children with mania from those with hyperactivity
(Fristad, Weller, & Weller, 1992). It also has been suggested that the two disorders can be
distinguished by examining the history of the child to determine the persistence and earlier onset
of ADHD versus the lack of euphoria or depressed mood of PBD (James & Javaloyes, 2001).
Children with BD also may be more irritable compared to children classified with ADHD.
Until about two decades ago, it was commonly assumed ADHD remitted during the
transition to adolescence. However, recent studies of children with ADHD at puberty have
brought this view into question. Generally, antisocial behavior, substance misuse, and academic
failure become more prominent during adolescence in individuals with ADHD (Patton, 2007).
Given the high morbidity and disability resulting from BD and ADHD individually, it is thought
their co-occurrence results in a more severe clinical picture. Correlates of comorbid PBD and
ADHD include higher rates of other disorders like conduct disorder, oppositional defiant
disorder, and psychiatric hospitalization (Biederman et al., 1996). An Italian study (Masi et al.,
2006) of 98 referred patients (mean age 13.7 SD 3 years) with a diagnosis of BD by the Schedule
for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime
version were followed for 6 months. Thirty-seven BD patients (37.8%) presented a lifetime
diagnosis of comorbid ADHD. The mean age of onset of ADHD was 3.7 (SD 1.1) years, and the
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mean age of onset of BD was 10.0 (SD 3.2) years. Bipolar subjects with comorbid ADHD were
predominantly male, younger, and had an earlier onset of BD (8.1 versus 11.1 years). BipolarADHD patients presented more frequently a chronic rather than an episodic course of BD, with
an irritable rather than an elated mood. They showed higher rates of oppositional defiant
disorder/conduct disorder, lower rates of panic disorder, and less frequently received
antidepressant medications. Finally, ADHD comorbidity was associated with a greater
psychosocial impairment. ADHD comorbidity is frequent in juvenile BD and can influence age
of onset, phenomenology, comorbidity, and course of BD.
ADHD may be associated with a lower age at onset of BD. Sachs and colleagues (2000)
assessed adult bipolar subjects (n=56). Those with a history of childhood ADHD were age and
sex matched with bipolar subjects without a history of childhood ADHD. The age at onset of the
first affective episode was lower for the subjects with bipolar disorder and a history of childhood
ADHD (mean = 12.1 years, SD=4.6) than for those without a history of childhood ADHD
(mean=20.0 years, SD=11.3). ADHD in children of bipolar probands might identify children at
highest risk for development of bipolar disorder.
The differential diagnosis between PBD and ODD and CD also can be difficult due to the
overlap in symptomology (Kovacs & Pollock, 1995; Geller et al., 1998; Geller, Zimerman,
Williams, et al., 2000; Wilens et al., 2003). Almost all children younger than age 12 who meet
criteria for ODD or CD meet criteria for ADHD and PBD (Reeves et al, 1987). Rey (1993)
reported that one-third of all community-based children with any psychiatric condition had a
diagnosis of or met criteria for ODD, that symptoms of ODD appear to be stable over time, and
that ODD has a developmental profile and sex distribution different from those of CD. Outbursts
of anger, antisocial behavior, substance abuse, hypersexuality, and adolescent turmoil often are
67
associated with adolescent BD and misdiagnosed as CD (Cassano et al., 2000; Emslie et al.,
1994), although there are instances of comorbidity too (Carlson, 2005). Bowring and Kovacs
(1992) contend that a mental status examination and a detailed patient history enabled
differentiation between the two disorders. The diagnostic history may reveal a sudden onset of
severe behavioral disturbances with PBD whereas with conduct disorder the duration of
disturbances may have been evident over several years (James & Javaloyes, 2001). A further
possibility for delineation lies in determining the nature of the troubling behaviors.
Mischievousness and not vindictiveness distinguishes a manic child’s behavior from one who
has conduct disorder, whose behavior is typically more hurtful of others (Weller et al., 1995).
Weller et al. (1995) also noted children with conduct disorder do not have psychotic symptoms,
push of speech or flight of ideas as do children with mania.
Psychopharmacology
Untreated, BD typically follows a progressive and deteriorating course (Geller et al.,
2004). Unfortunately, even with empirically supported treatments, clinicians may not utilize
them and families with BD children may not be able to access them (Lofthouse & Fristad, 2004).
Lewinsohn, Klein, and Seeley (1995) found only 41% of young adults with BP-II and
cyclothymia and 27% with subsyndromal bipolar symptoms utilized mental health treatments.
Fortunately, in the past 10 to 15 years, specific pharmacological treatments for children with BD
have emerged, including the first randomized controlled treatment studies of lithium (Geller et
al., 1998) and quetiapine augmentation of divalproex (DelBello, Schwiers, Rosenberg, &
Strakowski, 2002).
As with adult BD, psychopharmacological treatment is considered by many as the first
line treatment for PBD (Walsh, 1998; Weckerley, 2002). Typically, clinicians extrapolate from
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adult findings when making decisions about the suitability of mood stabilizers for children
(McClure, 2002). On the basis of adult pharmacology for BD, it is recommended when choosing
first-line medications for treatment of mania, clinicians take into account the type of BD (e.g.,
mixed, rapid cycling, uncomplicated), pattern of illness, family history of BD, gender, and
individual side-effect profile (McClure, 2002). Currently, the compounds most likely to be
helpful in treating PBD also have the potential for serious side effects and probably should not be
prescribed to children unless one is fairly confident in the diagnosis and the potential for benefit
(Youngstrom & Duax, 2005). Although adolescents are treated with a variety of agents,
including antipsychotics, stimulants, mood stabilizers, SSRIs, and tricyclic antidepressants, due
to the lack of studies using children and the poor quality of the few conducted studies the
efficacy of such medications to treat children with BD has yet to be established (Bhangoo et al.,
2003; Bowden & Rhodes, 1996). For instance, according to the American Academy of Child and
Adolescent Psychiatry (AACAP (1998) practice parameters, mood stabilizing compounds, such
as lithium carbonate (Lithium) and valproate (Depakote), may be useful in the treatment of
prepubertal BD. However, the effects of these agents in the childhood population are poorly
understood, and the Food and Drug Administration (FDA) has not yet approved use of lithium
for treatment of children under 12 years of age or valproate for those under 18 (McClure,
Kubiszyn, and Kaslow, 2002; Pavuluri et al., 2005b).
Approximately sixty percent of adult patients with bipolar disorder respond to lithium
and anticonvulsants (McElroy & Keck, 2000), and those who do not respond to lithium typically
respond to anticonvulsants (Rea et al., 2003). Available studies suggest lithium is relatively safe
for use in preadolescents (McClure et al., 2002) and has been found to be 40 to 60% effective in
treating children and adolescents (Emslie et al., 1994; Kafantaris, 1995; Strober, Morrell,
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Lampert, & Burroughs, 1990; Weller et al., 1986). Side effects, such as gastrointestinal
problems, headache, tremor, enuresis, fatigue, ataxia, and leukocytosis, however, are common
with younger children typically experiencing more such effects than older children (Ryan,
Bhatara, & & Perel, 1999). Other side effects occur less frequently, although preschoolers
treated with lithium may be at higher risk for neurological side effects than other children (Geller
et al., 1998). Results of open-label trials examining the efficacy of lithium in children with BD
have yielded positive findings. DeLong and Aldershof (1987) found that of BD youth treated
with lithium for 2 months, 73.7% showed improvement, and 66% continued to benefit during
long-term treatment. Results were comparable for children under and over 14 years of age. In a
more recent open label trial, Kowatch and colleagues (2005) treated 8-18-year old outpatients
who had acutely manic BD with lithium for 2 months and found evidence of improvement in
38% of the individuals. Improvement rates were comparable for children treated with
carbamazepine (38%) and valproate (53%). Despite these findings, a number of children clearly
fail to respond to lithium treatment, and controlled studies are needed to evaluate the extent to
which, and for whom, lithium is effective. The efficacy of lithium use with adolescents
comorbid for BD and substance abuse was demonstrated in the only placebo-controlled trial to
date (Geller et al., 1995). Although lithium has been found to be effective in treating mania in the
pediatric population, physicians remain hesitant to prescribing the drug because of decreased
tolerability (Bowden & Rhodes, 1996), risk of lithium toxicity, and difficulty in maintaining a
therapeutic dosage among children and adolescents (McIntosh & Trotter, 2006). As a result,
physicians and prescribing clinicians are beginning to explore the use of newly manufactured
and recently approved medications (e.g., Risperdal, Seroquel) to treat pediatric PBD.
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Carbamazepine and valproate are anticonvulsants commonly used to treat BD and other
affective disorders. Walsh (1998) reported these medications have the same level of
effectiveness in reducing the frequency of manic cycles as does Lithium (Bowden, 1998;
Janicak, Davis, Preskorn, & Ayd, 1993); whereas, other studies have suggested Carbamazepine
is inferior to Lithium (Bowden & Rhodes, 1996) and that there may be an increased risk of
agitation and aggression by taking the medication (Popper, 1995). Preliminary research by Keck
and colleagues (1992) and Walsh (1998) has suggested valproate may be more effective in
addressing rapid cycling compared to carbamazepine. Both valproate and carbamazepine have
been used widely in children, primarily for treatment of seizures. Although their safety and sideeffect profiles are well documented, little is known about their efficacy for the treatment of
prepubertal BD, and no controlled studies with either medication have been published (McClure
et al., 2002). Carbamazepine, in particular, is poorly understood with regard to treating acute
mania, and unlike Valproate, its efficacy has not yet been established in adults (McClure et al.,
2002). Other approved anticonvulsant medications, like lamotrigine, gabapentin, topiramte, and
tiagabene have been considered as potential mood stabilizers for children with PBD but their use
is not recommended as such until controlled studies demonstrate their efficacy and safety
(Davanzo & McCracken, 2000).
Atypical antipsychotic medications, such as risperidone (Risperdal) and olanzepine
(Zyprexa), have received attention as potential agents for childhood BD. The FDA has recently
approved olanzepine for treatment of adult mania, and in a recent open trial, olanzepine
significantly decreased manic symptoms in a sample of 23 youth (5 – 14 years of age) with BPD
(Frazer et al., 2001). Weight gain, however, was a problem for many of the treated children. In a
chart review of BD outpatients who were 4 – 17 years of age (61%<12 years old), Frazier and
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coworkers (1999) found risperidone (typically along with other medications) led to
improvements in manic symptoms and aggression over 1-34 months. No serious adverse effects
were reported, although 18% of the sample gained weight, and 18% experienced mild sedation.
In a recent case study, Chang and Ketter (2000) reported improvement of manic symptoms in
three cases of acute mania in 9 – 12 year olds given olanzepine in combination with lithium or
Valproate.
Combination pharmacotherapy (polypharmacy) such as using lithium and anticonvulsants
along with various combinations of newly developed medications appears to be an increasing
trend, especially when different combinations of mood stabilizers, stimulants, and antipsychotics
have been shown effective (Bhangoo et al., 2003; Davanzo & McCracken, 2000; Kafantaris,
Coletti, Dicker, Padula, & Kane, 2001; Kowatch, Sethuraman, Hume, Kromelis, & Weinberg,
2003). In particular, during manic episodes, it is not uncommon for both antipsychotics and
mood stabilizing medications to be prescribed (Emslie et al., 1994). Typically, mood stabilizers
(e.g., Depakote, Lithium, Tegretol, Topamax) are considered the first line of pharmacological
intervention and, if necessary, are followed by anti-psychotic medications (e.g., Abilify, Clozaril,
Geodon, Risperdal, Seroquel) to help reduce aggressive or psychotic symptoms (Lofthouse et al.,
2004). After a child’s mood has been stabilized with a mood stabilizer, low dose anti-depressant
medications may be used to reduce depressive and anxiety symptoms. Psychostimulants also
may reduce ADHD symptoms of inattention, impulsivity, and hyperactivity; however, there is
concern stimulant medications (Carlson & Mick, 2003; DelBello et al., 2002), tricyclic
antidepressants (Geller, Fox, & Fletcher, 1993), or selective serotonin reuptake inhibitors
(Ghaemi, Hus, Soldani, & Goodwin, 2003; Papolos, 2003) may induce manic symptoms and
therefore must be monitored carefully (Bhangoo et al., 2003; Carlson, 2005; Lofthouse et al.,
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2004b; Youngstrom, 2007). Although it has proven difficult to demonstrate evidence of
pharmacotoxicity in research studies (Carlson, 2003; Carlson & Mick, 2003), even the “best-case
scenario” suggests selection of inappropriate pharmacological interventions exposes patients to
all of the potential risks, with little potential for benefit (Youngstrom, 2007). There appears to
be increasing support for the use of polypharmacy, but it should be kept in mind only a limited
number of studies have been published demonstrating their capacity to produce the desired
results. Further complicating the issue is evidence that adolescents become medication resistant,
resulting in multiple trials of medications (Bhangoo et al., 2003).
Psychosocial Treatment
Pediatric bipolar disorder is associated with significant morbidity and mortality,
nevertheless effective psychosocial treatment strategies remain underdeveloped and understudied
(Fristad, Gavazzi, & Mackinaw-Koons 2003a). Even thought lithium carbonate, anticonvulsants
and antipsychotic agents, mood stabilizers, and stimulants demonstrate efficacy in the
stabilization and treatment of PBD, the prevention of recurrences and control of symptomatic
fluctuations through pharmacological intervention alone has been less than adequate (Rea et al.,
2003). For instance, 60% of patients have recurrences within two years after an acute episode
and approximately 50% experience significant inter-episode symptoms (Miklowitz, George,
Richards, Simoneau, & Suddath, 2003).
Even though current practice parameters indicate pharmacotherapy should be considered
the first line of treatment, a growing body of evidence suggests psychoeducational (Firstad,
Gavazzi, & Mackinaw-Koons, 2003), family therapy (Miklowitz & Otto, 2006), cognitive
behavioral therapy (Feeny, Danielson, Schwartz, Youngstrom, & Findling, 2006; Pavuluri et al.,
2004), and other psychosocial interventions have significant value as adjunctive treatments. A
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large amount of published research supports the use of cognitive and behavioral interventions
when treating children with unipolar depression (Dujovne, Barnard, & Rapoff, 1995), and it has
been demonstrated pharmacotherapy can be effectively augmented by psychosocial interventions
whose objectives include decreasing family stress and improving psychosocial functioning,
compliance with medication, identifying “triggers” and early warning signs of mood
destabilization to help prevent relapse, and the patient’s ability to cope with environmental
stressors (Miklowitz, 1996; Sachs, Guille, & McMurrich, 2002). Unfortunately, too few studies
have been published regarding the effectiveness of such interventions with PBD populations
despite the fact that the critical features necessary to develop effective psychosocial interventions
for children with BD have been delineated (Fristad, Goldberg-Arnold, & Gavazzi, 2003;
Lofthouse & Fristad, 2004). Without proven assessment and psychosocial treatment techniques,
there is a tremendous unmet need for helping families to make sense of their struggles and to
address them constructively (Youngstrom, 2007).
In 2004, a systematic review of the literature assessing the effectiveness of psychological
interventions for adult BD was conducted (Vieta & Colom, 2004). The authors concluded
cognitive, cognitive-behavioral, and schema-focused therapies were the most effective
psychosocial interventions to address the depressive features of adult BD. They also reported
there was little research to support the use of these therapies in addressing the manic or
hypomanic symptoms of adult BD. Instead, pharmacological treatments appear most beneficial
in addressing these symptoms. Scott and Colom (2005) examined 32 outcome studies which
occurred between 1960 and 1998 describing the combined use of psychologic and pharmacologic
treatments. Most of the reports addressed group (45%) or family approaches (45%). Less than
half were randomized, controlled trials; however, it was clear that in many of the studies,
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individuals receiving adjunctive psychologic treatments had better subjective and objective
clinical and social outcomes than individuals receiving usual psychiatric care consisting mainly
of treatment with mood stabilizers and outpatient support, and that many of these differences
reached statistical significance.
In 1996, the National Institute of Mental Health recommended the creation of adjunctive
psychosocial interventions as a primary research focus for PBD (Prien & Rush, 1996). A variety
of studies have demonstrated an association between socioenvironmental stressors and
remission-relapse cycles thereby suggesting psychosocial interventions may be advantageous
(Morris, Miklowitz, & Waxmonsky, 2007). These symptom exacerbating relations include
levels of familial expressed emotions (Goldstein, Miklowitz, & Richards, 2002), low parental
warmth (Geller et al., 2002), and stressful life events which disrupt the individual’s social
rhythm (Malkoff-Schwartz et al., 2000). It has been suggested adjunctive psychosocial
intervention objectives should prevent relapses and reduce inter-episode symptoms by enhancing
patients’ stress-coping abilities and encourage psychopharmacological compliance through
psychoeducation and support (McClure et al., 2002; Miklowitz et al., 2003). Adjunctive family
therapy, individual cognitive-behavioral therapy, and interpersonal and social rhythm therapy,
are associated with increased stabilization of symptoms compared to interventions solely relying
on medication and active clinical management (Miklowitz et al., 2003; Rea et al., 2003).
“Expressed emotion” (EE) emerged as a term from a series of studies that focused on
relapse rates in adults diagnosed with schizophrenia (Fristad et al., 2003). High EE may include
critical comments, hostility, and emotional over involvement, and is a general predictor of poor
outcome across diagnostic categories (Butzlaff & Hooley, 1998). Given the severe clinical
manifestations of BD in children, reducing EE in their family unit has the potential to
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significantly reduce symptom severity and improve therapeutic outcomes. The evidence is clear
that parents of children with disabilities have many unmet needs and equipping those families to
shift from “emotion focused coping” to “problem focused coping” may be a very useful strategy
(Sloper, 1998).
Increased disagreement between caregivers on child behavior management issues has
been linked to lower levels of family problem-solving, higher rates of child problem behaviors,
and diminished parental effectiveness (Fristad, Gavazzi, & Mackinaw-Koons, 2003). Because
children with bipolar disorder tend to have a heightened sensitivity to conflict (Miklowitz &
Goldstein, & Nuechterlein, 1995) it may be speculated that the likely increase of parental tension
caused by disagreements over appropriate treatment and methods to manage symptoms of BD
(Hellander et al., 2003) may have a deleterious impact on the child’s recovery. Fristad and
colleagues (2003) initiated an approach utilizing “multifamily psychoedcuation groups”(MFPG),
which showed promise during the piloting phase. During the treatment program, families meet
for 8, 90-minute sessions in multifamily psychoeducation groups (MFPG). Each session was
highly formatted with specific content to be taught and skills to be practiced. The sessions would
begin and end with a family component and included middle sessions for individual work.
Parents also received workbooks containing materials presented in the session as well as copies
of the children’s activities. Family projects were assigned to be completed during the week and
were designed to reinforce concepts taught during the session. Most of the therapeutic techniques
utilized in MFPG were not unique to this intervention. What is unique, however, is the way in
which teaching families about the child’s illness and treatment options (including how to work
effectively with the mental health system and school system), followed by training families in
communication exercises, cognitive-behavioral interventions, and social problem-solving
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strategies focused on the children’s mood symptom management was integrated.
Family focused interventions for BD tend to be psychoeducational in orientation.
Common elements include teaching families how to recognize the signs and symptoms of the
disorder, developing strategies to intervene early to new episodes, assuring consistency with
medication schedules, managing family members’ affective reactions to the illness, its prognosis,
and its expected treatments, and developing coping strategies relevant to their unique situation
(Miklowitz, 2007). Miklowitz and colleagues’ (2003) family-focused therapy (FFT) approach
resulted in patients experiencing significantly fewer relapses, reduced mood disorder symptoms,
better medication adherence, and longer survival intervals than patients undergoing crisis
management, a less intensive psychoeducational intervention, during a two year period. FFT is a
21-session psychoeducation program administered in conjunction with pharmacotherapy over
nine months following an episode of mania and consists of education for patients and their
caregivers about the disorder, communication enhancement training, and problem solving skills
training. Miklowtiz’s results are similar to other randomized trials of psychosocial interventions
with individuals and families which demonstrated a decreased relapse risk in bipolar disorder by
30% (Perry, Tarrier, Morriss, McCarthy, & Limb, 1999) to 40% (Lam, 2002) during intervals
that range from 12 to 24 months. Key features of the Family-Focused Treatment (FFT) approach
include:

Commences shortly after an acute episode of mania, depression or mixed
disorder.

Involves the patient and one or more relatives.

Conducted in 21 sessions over 9 months (weekly for 3 months, biweekly for 3
months, monthly for 3 months)
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
Consists of three consecutive modules:
1.
Psychoeducation: didactic information and interactive discussion about the
symptoms of bipolar disorder, early warning signs, relapse prevention
plans, roles of risk and protective factors, and the importance of
medication adherence (7 sessions)
2.
Communication enhancement training: behavioral rehearsal of effective
speaking, listening, and negotiating skills, with homework practice (7-10
sessions)
3.
Problem-solving skills training: identify and define specific family
problems, brainstorm solutions, evaluate the advantages and disadvantages
of each solution, choose one or a combination of solutions, develop
implementation plans, and homework between sessions (4-5 sessions).
Pavuluri et al. (2004) developed a child and family focused cognitive behavioral therapy
specifically designed for children with BD – Child- and Family-Focused Cognitive-Behavioral
Therapy. The therapy integrated cognitive-behavioral therapy and interpersonal principles of
psychotherapy, modified the conventional behavior therapy and emphasized empathic validation.
In addition to addressing the needs of the child, their model also helped parents become aware of
their own unhelpful cognitions and to learn new tools in order to serve as ‘coaches’ for their
affected offspring. For example, the use of psychoeducation can help parents (and teachers)
better understand the biological basis of mood swings often displayed among children with BD.
By recognizing that difficulties with regulation of affect may have a biological basis, parents
may recognize the unintentional aspects of BD and be more likely to respond empathically. The
psychoeducation aspect of this model also taught parents how to monitor a child’s mood and
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address rapid cycling. In addition, the parents learned anger-management skills they could
implement with their children to help in affect regulation. Preliminary results indicated a good
symptomatic response and parent satisfaction.
Another promising psychosocial treatment to be used in conjunction with
pharmacological intervention was proposed by Danielson, Feeny, Findling, and Youngstrom
(2004). The model was based in part on successful treatment models for adult BD and included
12 sessions lasting approximately 60 minutes with corresponding homework assignments for
both the adolescent with BD as well as caregivers. Sessions topics included: psychoeducation,
medication compliance, mood monitoring, anticipating stressors, problem solving, identifying
and counteracting negative thinking, sleep maintenance, assertiveness, and family
communication. Given the model’s approach and content, it is easy to see how a school
psychologist with understanding of BPD could be involved in the intervention.
Finally, Otto, Reilly-Harrington, Kogan, Henin, and Knauz (2009) developed a treatment
manual for BPD that may be able to be adapted for adolescents. They initially focused on
cognitive restructuring and activity management strategies. As treatment progresses, they focus
on enhancing an individual’s emotional-social problem-solving skills (Otto, Reilly-Harrington,
& Sachs, 2002). Otto and colleagues (2002, 2009) also recommend the use of vivid metaphors
and stories to assist clients in recognizing the specific aspects of BPD, teaching emotional
regulation, and when training specific cognitive skills. Similar treatment programs are being
studied such as the multisite NIMH-funded Systematic Treatment Enhancement Program for
Bipolar Disorder, which is studying the efficacy of various psychotherapy approaches (Otto et
al., 2002).
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School-Based Identification
Emotional disorders in general, and PBD in particular, create significant barriers to
learning and limit the acquisition of academic, vocational, and social skills (Merrell & Walker,
2004; U.S. Department of Health and Human Services, 1999). Some estimates suggest over 20%
of school-age children would qualify for a psychiatric diagnosis and have mental health needs so
severe as to require attention, treatment, and supports (Hoagwood & Erwin, 1997). A 2001 report
of the U.S. Department of Education estimated, nationwide, 5% of school-age children have
mental health impairments resulting in extreme functional limitations, and 11% have mental
health impairments that cause significant functional limitations. It is likely children with
emotional disorders are under-identified within the local educational system and too few receive
the necessary mental health services. This may be due, in part, to the belief by some school
personnel and systems that they are not responsible or accountable for the mental health needs of
students (Walker, Ramsay, & Gresham, 2004).
School systems have identified and classified children with disabilities since the
introduction of Public Law 94-142 in 1975. Public Law 94-142, later reauthorized in 1990 and
1997 as Individuals with Disabilites Act (IDEA), and then as the Individuals with Disabilities
Improvement Act (IDEIA) in 2004, provides federal guidelines to assign students to 13 special
education categories (e.g., specific learning disability, mild cognitive impairment). IDEIA
provides broad definitions of disability categories which represent enduring educational
problems requiring alternative, specialized services. Because the decision-making criteria are so
general, categories include students with decidedly heterogeneous problems and diverse
educational needs (Wodrich, Pfeiffer, & Landau, 2008). Even though the United States
government has formalized the identification of an emotional disorder (IDEIA, 2004), there
80
remain discrepancies across the country in the definition used to describe the disorder and the
special education services provided the identified child. States also lack systematic and
standardized procedures for screening and evaluating children with emotional problems (Rudy &
Levinson, 2008).
The IDEIA classification system is significant for doctoral-level, licensed psychologists
who work with students outside of school as well as for certified school psychologists working
within the school environment. A complicating factor is that the special education scheme has
limited heuristic application because it was contrived for educational administrative purposes
whereas the DSM-IV-TR (and upcoming DSM-V) is committed to a medical nosological schema
with little concern for school issues (Gresham & Gansle, 1992; Wodrich, Pfeiffer, & Landau,
2008). Although a school psychologist may be familiar with DSM-IV-TR diagnostic criteria as
well as trained to make differential diagnoses through use of the standard psychiatric taxonomy,
they are required to work with students within the IDEIA framework. Nevertheless, working
knowledge of DSM diagnoses may help school psychologists not only to better conceptualize
school-based emotional disorders but also to provide a descriptive system for collaboration and
communicating with mental health professionals and other non-school service providers
(McConaughy & Ritter, 2005).
School psychologists play a key role in assessing ED to determine eligibility for special
education. In practice, school psychologists often become involved with children exhibiting
emotional or behavioral problems before they are formally referred for an evaluation
(McConaughy & Ritter, 2005). For example, the school psychologist may have already
collaborated with the child’s teachers to define problem behaviors and/or develop classroom
interventions or counseling may have been provided to the child or their families. School
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psychologists are to be concerned that children with emotional disorders receive “comprehensive
assessment and intervention services” in a manner valuing collaboration and recognizing the
critical role of the family and other community service providers (NASP, 2005; Ringeisen,
Henderson, & Hoagwood, 2003).
The IDEIA (2004) definition of ED states that it is a condition characterized by one or
more of the following characteristics over a long period of time and to a marked degree that
adversely affects educational performance: (a) an inability to learn that cannot be explained by
intellectual, sensory, or health factors; (b) an inability to build or maintain satisfactory
interpersonal relationships with peers or teachers; (c) inappropriate types of behaviors or feelings
under normal circumstances; (d) a general pervasive mood of unhappiness or depression; and (e)
a tendency to develop physical symptoms or fears associated with personal or school problems.
The definition includes children who are schizophrenic but excludes children who are socially
maladjusted, unless they also are ED. The federal definition of ED has been the target of much
criticism (Coleman & Webber, 2002; Gresham, 2012; Kauffman, 1997). For instance, Gresham
(2012) contends that the criterion reveals immediate complications within the definition as well
as between other disorders. For example, Criterion A of the definition also could apply to the
category of specific learning disabilities; Criterion B implies that ED primarily involves social
skills deficits; and C and D appear to suggest ED involves internalizing disorders, whereas E
seems to imply ED cannot include externalizing behavior problems. Other criticisms include the
exclusion of children identified as socially maladjusted and the meaning and measurement of
such terms as “long period of time,” “marked degree,” and “adversely affects educational
performance” (IDEIA, 2004). Professionals and advocacy groups have long criticized the IDEIA
definition as being overly restrictive and not supported by legal precedent or educational and
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clinical research (Forness, 1992; Skiba & Grizzle, 1992). Obviously, the IDEIA (2004) definition
is “ambiguous, circular, and logically contradictory” (Gresham, 2005).
This definition is so broad it may encompass children with severe mood disorders
apparent by overt behaviors (e.g., PBD) to less conspicuous, more internal symptoms (e.g.,
anxiety) (Wodrich et al., 2008). Even though students with emotional disturbances are similar in
that their problems are longstanding, significant, and markedly detrimental to educational
success, students with ED are so diverse it often is very difficult to generalize the type, intensity,
and duration of necessary interventions and accommodations. Consequently, it would seem, an
ED designation provides professionals with extremely limited planning information (Wodrich et
al., 2008). Perhaps more troubling is the failure to designate a child with a disability under the
current IDEA system due to the lack of connection between research on the characteristics and
histories of students who persist with genuine disabilities and administrative categorization
(Berninger, 2006). Use of the DSM-IV-TR may provide a solution to IDEA’s problem of
heterogeneity and give psychologists a better way to classify students (Wodrich et al., 2008).
For example, a broad, indistinct categorization of ED could be replaced with several distinctive
clinical ones with the potential of rooting caregiver response and intervention in a more specific,
research-based manner. However, use of the DSM-IV-TR criteria for diagnostic and
classification purposes poses its own set of limitations including poor coverage of academic and
developmental disorders, inadequate listing of school-based symptoms, and an under
appreciation of the unique demands imposed by the academic setting and process (Wodrich et
al., 2008).
It also is important to note the federal definition of ED specifically excludes students who
are characterized as “socially maladjusted (IDEIA, 2004).” This exclusion is based on the
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scientifically unsubstantiated belief that students with disorders of conduct are responsible for
their behavior and thus do not have a “true disability” compared to students with internalizing
behaviors (e.g., anxiety, depression, fearfulness; Gresham, 2012). This is of some concern since
children potentially identified as ED and those with PBD in particular may demonstrate chronic
behavior problems often associated with “social maladjustment” including noncompliance,
aggression, and disrespect toward authority figures (Coleman & Webber, 2002). Because ED is
a category used to describe students whose behavior deviates from their peers in terms of degree
rather than kind, the category is considered to be fraught with confusion (Gresham, 2012).
In the early 1990’s, the National Mental Health and Special Education Coalition
attempted to substitute a new definition of “emotional or behavioral disorders (EBD)” for the
IDEA definition. The coalition’s definition was and continues to be endorsed by the National
Association of School Psychologists and, if applied, may go a long way to reducing much of the
confusion (Forness & Knitzer, 1992):

Emotional or Behavioral Disorder (EBD) refers to a condition in which behavioral
or emotional responses of an individual in school are so different from his/her
generally accepted, age appropriate, ethnic or cultural norms that they adversely
affect performance in such areas as self-care, social relationships, personal
adjustment, academic progress, classroom behavior, or work adjustment.

EBD is more than a transient, expected response to stressors in the child’s or
youth’s environment and would persist even with individualized interventions,
such as feedback to the individual, consultation with parents or families, and/or
modification of the educational environment.
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
The identification of EBD must be based on multiple sources of data about the
individual’s behavioral or emotional functioning. EBD must be exhibited in at
least two different settings, at least one of which is school related.

EBD can co-exist with other disabilities.

This category may include children or youth with schizophrenia, affective
disorders, anxiety disorders, or who have other sustained disturbances of behavior,
emotions, attention, or adjustment.
This definition also recognizes children with emotional disorders are a diverse group with
difficulties existing along a spectrum of intensity, duration, and frequency of occurrence. Many
states have adopted the definition of ED, while others have posited their own definitions
modeled on the federal definition, and a few states do not require categorical classifications for
special education (McConaughy & Ritter, 2002). SPs trained around the U.S. will need to learn
and follow their own states’ unique definitions, rules, and regulations.
Special Education Identification
Response to intervention
Current assessment practices in most U.S. schools for identifying children in need of
special education services are structured around a Response to Intervention (RTI) framework.
RTI is based on the idea of determining whether an adequate or inadequate change in academic
or behavioral performance has been achieved as a result of an intervention. The model is often
conceptualized as three tiers moving from the three-tiered model from universal conditions for
all students (Tier 1), to targeted interventions of varying degrees of intensity (Tier 2), to very
intensive interventions for individual students (Tier 3). This model assumes an academically or
behaviorally struggling child will receive the best intervention available and feasible within a
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given setting. If the child shows an inadequate response to a research-based intervention
delivered with fidelity, then they should be eligible for additional assistance, including more
intense interventions, specialized assistance, and special education and related services.
RTI is built upon the foundation of identifying children as early as possible who are at
risk of behavioral difficulties so early response may minimize, if not, eradicate, negative
outcomes. Schools often wait until it is too late to intervene effectively on children’s emotional
difficulties (Walker, Nishioka, Zeller, Severson, & Feil, 2000). Early identification of problem
behaviors through the use of screenings and subsequent interventions should help prevent the
escalation of these problems or at least help the child receive clinical help as early as possible.
Assessment team issues
A further complication may be the perspective taken by team members relative to the
nature and/or cause of the disorder. This is particularly influential when it comes to decisions of
treatment and intervention. McConaughy and Ritter (2002) describe four general perspectives on
the nature of EDs. One perspective views psychopathology as the basis for the child’s
difficulties and suggests that both genetic and environmental factors contribute to the
individual’s emotional, behavioral, and social difficulties. This perspective uses a classification
system to describe and label problematic behavior problems. Additionally, it acknowledges that
familial and environmental factors may contribute to the development of child psychopathology.
Examples include mental illness in a parent, substance abuse, low socioeconomic status, and life
stress (Jensen, Bloedau, Degroot, Ussery, & Davis, 1990). This view would seem to be most in
line with the current conceptualization of PBD. A second perspective assumes a lack of
psychopathology and assesses the reciprocal interactions between individuals’ behaviors and
their environments. Within the school context, the focus is on the school environment and the
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children’s interaction patterns with peers, teachers, and administrators. The third perspective
attempts to identify the functional relationships between environmental events and problem
behaviors and assumes all behavior serves some function for children. Changing behavior,
therefore, focuses on antecedent events precipitating behaviors, consequences reinforcing
behaviors, and interventions that alter antecedents, consequences; or both. Finally, the fourth
perspective emphasizes the effectiveness of interventions and defines disorders by the extent to
which the students’ behaviors prove resistant to interventions. The degree to which the
assessment team emphasizes each of these four perspectives will likely be influenced by the
purpose of the assessment. In the case of students suspected of PBD, the multidisciplinary team
may need to “rule out” certain of the above perspectives through the assessment process. For
example, in many schools before a child can be referred for assessment of a possible ED an
intervention (perspective 4) and/or FBA (perspective 3) must be administered.
It is apparent school-based assessment of EDs may have several purposes. Rudy and
Levinson (2008) suggest the possibility of four unique purposes. The assessment may be
designed to help teachers cope with behavior problems that are manifested in regular education
classroom settings. If this is the case, then it is likely the assessment team will adopt either the
behavioral-environmental interaction or the intervention-focused perspective since both may
offer the most effective classroom strategies for teachers. A second purpose may be to help
children reduce their problem behavior and improve their competencies and skill. Once again,
the behavioral-environmental interaction or the intervention-focused perspective may be the
most effective perspective to adopt. If the purpose is to determine whether a child is eligible for
special education services, then the team will be making classification and eligibility questions.
Therefore, the team should probably take the child psychopathology perspective as the basis for
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the assessment. Finally, the assessment may be intended to determine whether children and their
families need to be referred for mental health services outside of the school setting. Again, the
team will likely consider adopting a psychopathology perspective of ED. As part of the
multidisciplinary team, it may be necessary for the SCHOOL PSYCHOLOGISTnot only to
clarify the specific purpose but to understand that more than one purpose may need to be
addressed before a decision is made. Depending on the purpose of assessment, the school
psychologist may emphasize each of the four perspectives to different degrees (McConaughy &
Ritter, 2002).
Assessment best practices
The goal for assessment should be to identify students’ needs and to assist in developing
and implementing interventions when they are warranted (NASP, 1993). The school
psychologist’s assessment of emotional disorders can serve several purposes within the school
system. These include (1) helping teachers cope with behavior problems in regular education
classrooms; (2) helping students to reduce their problems and improve their competencies; (3)
determining whether a student is eligible for special education services; and (4) Referring
children (and perhaps families) for mental health services outside of the school setting
(McConaughy & Ritter, 2005). Through assessment, the school psychologist may be involved
with reviewing referral and screening information, consulting with teachers and other school
staff, planning and conducting assessment procedures, interpreting assessment data and
preparing reports, and linking assessment data to intervention planning, implementation, and
evaluation. The National Association of School Psychologists position statement on students
with emotional and behavioral disorders provides four general characteristics of an effective
identification process (NASP, 2005), 1) Comprehensiveness, 2) multiple sources of information,
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3) appropriate assessment methods, and 4) a comprehensive formulation of the relevant issues.
Comprehensiveness.
Screening. Screening for emotional difficulties should occur as early in the child’s school
career as possible and should be efficient, practical, and evidence based (Davis, Young,
Hardman, & Winters, 2011; President’s Commission on Excellence in Special Education, 2002;
U.S. Department of Health and Human Services, 1999). Systematic screening is not designed to
make a Special Education determination or a definitive diagnosis. Instead, screenings are
intended to lead to research-based interventions to ameliorate the behaviors of concern. Early
interventions have a greater chance of being effective than do interventions administered later
(Walker, Severson, & Feil, 1995). Screening procedures require an understanding of various
decision rules and associated statistics to make correct decisions and avoid incorrect
determinations (Gresham, 2012). Bennet and colleagues (1999) contend the issue in screening is
knowing whether the degree of predictive accuracy is high enough to justify the use of a
particular method. A further means of increasing the value of screening is to utilize a multiple
gating procedure (Severson & Walker, 2002), which involves a series of progressively more
extensive and precise assessments (“gates”) that provide for multimethod and multisource
assessment of children’s difficulties. Unfortunately, few screening tools have been specifically
designed and researched to identify at-risk elementary school students with either externalizing
or internalizing behaviors.
Walker and Severson (1992) developed the Systematic Screening for Behavior Disorders
(SSBD) for use in elementary schools. The SSBD is proactive and incorporates three stages.
The screening takes into consideration both teacher judgments and direct observations to identify
students at-risk for an ED. The first stage involves teacher nomination. The teacher filling out a
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Critical Events Inventory and a short adaptive and maladaptive behavior checklist for each of the
nominated students follows this. Students whose scores exceed the established cut off are then
candidates for Stage 3, which involves a 15-minute interval observation across settings (e.g.,
classroom, playground).
Other screening methods include the Strength and Difficulties Questionnaire (SDQ;
Goodman, 1997); the Behavior Assessment System for Children, Behavioral and Emotional
Screening System (BASC-2 BESS; Kamphaus & Reynolds, 2007); and the Student Risk
Screening Scale (SRSS; Drummond, 1994). The SDQ contains 25 questions and the BASC-2
BESS has 25 – 30 items. Although the possibility of completing either of these tools is minimal,
it seems unrealistic to expect teachers to complete either one of them for every student and
unnecessary for students who are clearly not at risk (Davis, et al., (2011). A solution to these
issues may be to use a teacher nomination form like the SSBD to identify students at-risk and
then confirm the student’s risk status by administering a standardized instrument like the SDQ or
BASC-2 BESS. The SRSS asks the teacher to check which of seven behaviors (if any) are
characteristic of each student and can provide an overview of an entire class in about 10 – 15
minutes. However, the SRSS only identifies students with externalizing concerns.
The assessment of a child suspected of an ED and/or PBD should provide an objective
and observable description of the student’s difficulties. This stage of assessment may be likened
to a problem solving approach similar to the behavioral consultation model presented by Bergan
and Kratochwill (1990). In that model, consultation has four stages: problem identification,
problem analysis, plan implementation, and treatment evaluation. In the case of beginning to
identify a child suspected of an ED, the stages are similar: identify behavioral excesses, deficits,
or both; analyze the antecedent and consequent events surrounding these excesses and deficits;
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differentiate acquisition and performance deficits, implement an intervention plan; and evaluate
the effects of the intervention plan. This approach to and process of identifying and analyzing
behavior is a core principle of an RTI approach (Brown-Chidsey & Steege, 2005; Gresham,
2005).
Functional behavior assessment. Functional behavior assessment (FBA) procedures are
recommended to gather information about the child’s behavior in relationship to the instructional
and social environment (Knoster & McCurdy, 2002). The FBA adheres to a problem-solving
process that is designed to identify the function of problem behaviors for the child, which then
leads to interventions. FBA involves the assessment and linking of external environmental
conditions to specific behaviors so these behaviors can be predicted and controlled (Ervin,
Ehrhardt, & Poling, 2001). The use of FBA and positive behavioral intervention planning (BIP)
was first included in and required by the 1997 amendments to the Individuals with Disabilities
Education Act. The use of FBA as a critical component in designing interventions for problem
behaviors has a long history of empirical support (Carr, 1993; Gresham,Watson, & Skinner,
2001; O’Neill,Horner, Albin, Storey, & Sprague, 1997; Steege, Mace, & Brown-Chidsey, 2007;
Witt, Daly & Noell, 2000). Once the function of behavior is determined, this information is used
to design interventions to reduce problem behaviors and to facilitate positive replacement
behaviors (Knoster & McCurdy, 2002; O’Neill et al., 1997; Witt et al., 2000). When suspecting a
child may have an ED such as PBD, FBA not only provides evidence on whether a given set of
behaviors can be changed or are likely to be organic, but also provides a multimethod strategy
involving direct observations, interviews, records review, and behavior ratings about a given
student’s behaviors. In conducting an FBA as part of the comprehensive individual evaluation,
evidence is provided regarding whether the student demonstrates an ED and is in need of special
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education and related services (Rudy & Levinson, 2008).
Observation. Direct observation is an expected best practice as well as an essential
component of FBAs. Observations should occur across settings, times, and contexts. Two
broach categories of observation recording systems include empirical and narrative recording
(Breen and Altepeter, 1990). Time sampling, continuous event recording, and interval recording,
are examples of empirically based observation and require operationally and predefined
behaviors to be meaningful. In contrast, narrative recordings require the school psychologists to
observe and transcribe student’s behaviors throughout a designated period. Examples include
descriptive time sampling, daily logs, and antecedent-behavior-consequence analysis
(Mcconaughy & Ritter, 2005).
Context and history. Environmental factors also must be taken into consideration, such as
the student’s relationship between the instructional, social and community environment and the
specific people and systems that impact the difficulties demonstrated by the student. Although it
is likely the student’s perceived shortcomings and weaknesses have initiated the referral for
assessment, the strengths and available resources of the student, family, teacher(s) and school
setting, also should receive attention. This is especially important as these may be useful to the
development of intervention plans.
Historical data should include the duration of the difficulties, their relationship to specific
developmental or situational stressors and any previous attempts to resolve the student’s
difficulties. According to NASP (2005) gathering historical background information should
include:
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
Intensity: The severity of the difficulties as they affect academic achievement,
social skills, and interpersonal relationships within the family, community and
school settings;

Pervasiveness: The extent to which difficulties occur in different situations within
the school, family or community settings;

Persistence: The extent to which difficulties have continued despite the use of
well-planned, empirically-based and individualized intervention strategies
provided within the least restrictive environments.

Developmental and cultural functioning: The student’s current developmental
status and the extent to which the student’s behavior is different from the behavior
expected for children of the same age, culture, and ethnic background.
There is tremendous value in gathering a thorough family history. Tsuchiya and
colleages (2003) conducted a meta-analysis reviewing over 100 articles discussing more than 30
different risk factors potentially associated with PBD. It was concluded that only family history
of BD was robust enough to merit clinical interpretation. An earlier meta-analysis (Hodgins et
al., 2002) found on average, 5% of children with a biological parent affected by BD already met
criteria for a BD themselves at the time of the research assessment. It also was reported that
having a bipolar parent doubled a child’s risk of developing psychopathology in general, and
tripled the risk of developing mood disorders. Obviously learning whether or not there is a
history of BD is a critical piece of information; however, Youngstrom (2007) cautions that
clinicians should remember that (1) family history of bipolar illness increases risk of
psychopathology, and especially BD; (2) the vast majority of children with a parent diagnosed
with BD still do not have PBD themselves; and (3) they often show other, nonbipolar behavioral
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problems. Additional concerns include how prone “historical” diagnoses are to error and the
added burden placed on family members by conducting a more systematic and structured
interview. Although one solution may be to ask parents to fill out a brief screening measure,
such as the Mood Disorder Questionnaire (MDQ; Hirschfeld et al., 2000), the sensitivity of such
measures are at best moderate (around .4 to .6) and insufficient at detecting bipolar II and
“bipolar spectrum” (Miller, Klugman, Berv, Rosenquist, & Ghaemi, 2004).
Academic functioning. All multidisciplinary evaluations require some type of assessment
of the child’s current level of academic performance to establish the need for special education
services. Group or individually administered standardized achievement tests, curriculum-based
assessment, review of grades, and portfolio assessments are all examples of assessment methods.
Scales such as the BASC-2 Teacher version (Reynolds & Kamphaus, 2006) can yield
information concerning student’s academic achievement and adaptive behaviors.
Multiple sources of information
Multiple informants. Children’s behavior often varies from setting to setting, and
information should be obtained from a variety of sources. Best practice requires that information
be gained from the children’s caregiver/parent and teachers(s) as well as from direct assessment
of the child (McConaughy & Ritter, 2005). Parents can provide specific information regarding
the history of the presenting problem, other problem areas, developmental progression,
feasibility of interventions, family resources, and stressors (Rudy & Levinson, 2008). Aside from
family members, school psychologists also should, when feasible, use information from
community treatment providers, teachers and other school personnel, social service workers, and
school records, medical records, or other relevant records.
It is important for the multidisciplinary team to remember that no one informant observes
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all aspects of a child’s behavior and that each observer is limited by factors such as context,
perceptions, and biases. A typical strategy used in assessment of ED/BPD is to administer a
behavior checklist to parents, teachers, and youth (Quinn & Fristad, 2004). The thought on this
practice is that different informants will provide additional, unique information above and
beyond what can be learned from a single respondent (Achenbach, McConaughy, & Howell,
1987; Muschkin & Malone, 2007) and that a greater volume of information will lead to greater
diagnostic accuracy (Youngstrom, Joseph, & Greene, 2008). Agreement between informants,
however, is expected to be moderate at best (Achenbach et al., 1987). Some researchers have
found results from multiple informants often provides contradictory information that is at best
difficult to interpret, and worst, not useful in making a determination (Achenbach et al., 1987;
Ruffalo & Elliott, 1997). Reasons for this expected discrepancy are that a child’s behavior may
be situationally specific (Ruffalo & Elliott, 1997; Thuppal, Carlson, Sprafkin, & Gadow, 2002)
or that informants may have different characteristics and abilities that affect their ability to
accurately describe the behaviors they see in children (Cai, Kaiser, & Hancock, 2004; De Los
Reyes & Kazdin, 2005). However, differing perspectives do not need to be interpreted as “right
and wrong”, but underscores the need for multiple informants to acquire an accurate picture of a
child’s behavior. While some (Thuppal et al., 2002) researchers have found it useful to
incorporate teacher report of child behavior, others have suggested the teacher report is markedly
less valuable than parent report when identifying PBD (Hazell, Lewin & Carr, 1999;
Youngstrom, Findling, & Calabrese, 2003). In general, large discrepancies between parent,
teacher, and youth ratings of behavior problems in PBD have been reported across a number of
studies (Hazell et al., 1999; Kahana, Youngstrom, Findling, & Calabrese, 2003; Youngstrom,
Findling, & Calabrese, 2003). On the whole, however, parent report has been shown to be
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significantly better than teacher report or youth self-report in identifying PBD in children (Hazell
et al., 1999; Kahana et al., 2003; Youngstrom et al., 2005).
Interviewing. Interviews play a significant role in the assessment of PBD/ED in both
clinical and school settings (Busse & Beaver, 2000; McConaughy, 2000a, 2000b). Structured
interviews typically improve the reliability and validity of information acquired and often are
used with multiple informants. Some structured diagnostic formats can be time-consuming and
may feel unnatural to the participants due to their rigid pattern of questioning. An example is the
NIMH Diagnostic Interview Schedule for Children, Version 4 (Shaffer, Fisher, Lucas, Dulcan, &
Schwab-Stone, 2000). Other formats use standard question formats but allow for more flexibility
to create a more conversational style. Examples include the Child Assessment Schedule
(Hodges, Gordon, & Lennon, 1990) and the Schedule for Affective Disorders and Schizophrenia
for School-Age Children (Ambrosini, 2000). An unstructured interview format may be used and
can be individually designed to assess specific areas of problematic functioning. However, use
of unstructured interviews should be cautioned because they may not address separate relevant
issues such as other problem areas, the child’s strengths, and previously attempted interventions
(Rudy & Levinson, 2008). Additionally, unstructured interviews may make it difficult to
compare information received from multiple informants (McConaughy &. Ritter 2002).
Semistructured interviews provide a minimal amount of structure while providing a flexible
format and the potential to compare obtained data. A semistructured approach may be the most
appropriate for interviews with children (McConaughy & Achenbach, 1990). Children under the
age of 10 years are likely to be unreliable reporters of their own behavior (Edelbrock, Costello,
Dulcan, Kalas, & Conover, 1985); however, time spent with younger children may provide an
opportunity to observe behavioral tendencies and interaction styles, impulsivity and
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distractibility, displays of anxious or depressed behaviors, and a range of emotions. Once
rapport is established the child may be asked about the problem as well as their thoughts on
family, school, social, and personal factors (Breen & Altepeter, 1990).
Appropriate assessment methods
The potential effects of identifying a child as having an emotional disorder necessitate the
use of instruments that have empirically demonstrated high reliability and validity. Norms
should be representative, current and appropriate for the individual being assessed in terms of
age, culture/ethnicity, and gender. Both indirect and direct assessment methods should be used as
appropriate. Indirect methods may include behavior checklists, structured interviews, rating
scales, and other appropriate assessment techniques. Assessments that are specific to one
emotional or behavioral dimension (e.g., ADHD) should not be used in isolation, but should be
part of a more comprehensive assessment of multiple emotional and behavioral domains (NASP,
2005). Direct methods may include behavior observation, standardized self-reports from a child,
curriculum-based assessment, and analysis of work samples.
It also is likely SPs will need to take a categorical as well as an empirically based
approach to determine if the child’s behavior is due to psychopathology, such as PBD.
Categorical classifications provide specific criteria to describe symptoms of a disorder. If all of
the specified symptoms are met, or present, the individual is considered to have the disorder.
Examples include the DSM-IV-TR (APA, 2000) and current special education classification
systems (Rudy & Levinson, 2008). In the empirically based assessment approach, problems are
rated quantitatively according to frequency, duration, and intensity. Ratings yield standard scores
and percentiles for evaluating a child’s behaviors compared to peers and delineate clinical cutoff
points for differentiating between criterion groups. Examples include the Behavior Assessment
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System for Children (BASC-2; Reynolds & Kamphaus, 2006), Reynolds Child Depression Scale
(W. M. Reynolds, 1989), the Behavioral and Emotional Rating Scale (Epstein & Sharma, 1998),
and the Achenbach System of Empirically Based Assessment (ASEBA; Achenbach, 1991a). The
ASEBA includes the Child Behavior Checklist (CBCL; Achenbach, 1991b), which is designed to
obtain parents’ ratings of emotional or behavioral problems of children aged 4 – 18. Best
practice in assessing EDs requires that a standardized rating scale should be obtained from at
least one parent and one teacher. If feasible, it is beneficial to acquire ratings from both parents,
more than one teacher, and a self-report from the child. The results of the standardized rating
scales should be integrated with information gained from other assessments methods (e.g.,
interviews, observations, etc.; Mcconaughy & Achenbach, 1990).
Comprehensive formulation of issues
After the data has been gathered, the findings must be integrated into a written report.
Simply stating the child qualifies for ED is insufficient. The report should provide clear and
specific descriptions of the child’s emotional problem as reported by the measures used
(McConaughy & Ritter, 2002). The results of the assessment should provide working
hypotheses about a child’s behavioral and emotional functioning, developmental history, areas of
significant impairment in school (academic achievement, adaptive behavior, social skills, and
interpersonal relationships) and impairment outside the school setting (vocational skills, and
function within the community). The presence of social maladjustment along with emotional and
behavioral disorders should be noted for planning interventions (McConaughy & Ritter, 2002;
Merrell & Walker, 2004).
School Based Support
Students identified by schools as emotionally disturbed (ED) exhibit significant learning
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problems (Epstein, Kinder, & Bursuck, 1989; Gresham, Lane, MacMillan, & Bocian, 1999;
Kauffmann, 2001; Ruhl & Berlinghoff, 1992; Sutherland and Wehby, 2001) and they have been
unsuccessful in gaining the skills necessary to achieve academically and socially (Kauffman,
Cullinan, & Eptein, 1987; Patterson, DeBeryshe, & Ramsey, 1989; Trout et al., 2003) resulting
in negative school and life outcomes. According to the 25th Annual Report to Congress on the
Implementation of the Individuals with Disabilities Education Act (U.S. Department of
Education, 2003), children with ED earn lower grades than any other group of children with
disabilities. They fail more courses and minimum competency examinations and are retained at
the same grade level more frequently than children who have other types of disabilities. The
average grade point average of children identified with ED is 1.7, compared with 2.3 for all
students receiving special education services, and 2.6 for all students in regular education.
Children identified with ED also fail one or more courses annually, drop-out at a rate exceeding
59%, and miss an average of 18 to 20 days of school per year, all of which are significantly
higher than any other group of children. Forty percent of ED students, whether they graduate or
drop out, will not participate in additional education, vocational training, or full-time, nonminimum wage employment (Edgar, 1987; Wagner et al., 1993). More than one-half of all
students with ED are arrested within five years of leaving school and among dropouts with ED
the figure exceeds to a shocking 70% (Wagner et al., 1993). Students diagnosed as BD and
identified as ED are often judged by others to be disruptive, insubordinate, uncooperative, and
exhibiting behaviors that interfere with learning (Landrum, 1992; Jolivette, Stichter, &
McCormick, 2002). Compared to their non-ED or –BD peers, students identified as ED tend to
be less engaged; more likely to display off-task behaviors; more impulsive, disengaged, and
inattentive; more likely to have poor relationships and lower self-esteem (Swaggart, 1998;
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Szymanski & Zolotor, 2001). Osher, Osher, and Smith (1994) summarized the situation which
persists nearly twenty years later: "Educating students identified as seriously emotionally
disturbed is one of the most stressful, complex, and difficult challenges facing public education
today, and perhaps one of our greatest failures" (p. 7).
School-based prevention and intervention practices have become essential for reducing
the incidence of mental health problems that interfere with learning and social development
(Dwyer, 2004). In response to the need for expanded mental health services for children,
research on the use of universal (i.e., targeting all students) and selective (i.e., targeting students
at risk) school-based interventions for mental, emotional, and behavior problems has grown
considerably over the past decade (Hoagwood et al., 2007; Stormont, Reinke, & Herman, 2010;
Weissberg, Kumpfer, & Seligman, 2003). Despite the increased availability of evidence-based
interventions and the importance of targeting the school setting, the widespread adoption and
implementation of evidence-based practices and interventions to both promote children’s mental
health and intervene with children with specific issues has not occurred (DuPaul, 2003;
Kratochwill, 2007; Schaughency & Ervin, 2006).
A large obstacle to providing students with ED the services they need, is that the
educational professionals most likely to impact the students’ behavior and mental health needs
on a daily basis may not have the resources or knowledge to do so (George, George, Gersten, &
Grosenick, 1995; Kratochwill & Shernoff, 2004; Vannest, Temple-Harvey, & Mason, 2009).
Teachers face increasing challenges of educating and managing students with ED and
consistently report a felt need for additional training in the areas of working with children
exhibiting externalizing problems, effective classroom management and behavioral
interventions, and engaging and effectively working with families of special needs children
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(Jacobson, 1998; Reinke et al., 2011). One study reported 89-percent of teachers agreed schools
should be involved in addressing mental health needs of children yet only 34-percent felt they
had the skills necessary to support these children (Reinke et al., 2011). Given the robust
literature about effective classroom management practices, it is disconcerting that so many
teachers feel unprepared to manage challenging student behaviors. According to the same study,
teachers expressed a desire for school psychologists to play a greater role in screening,
conducting assessments, and teaching social emotional lessons in the classroom. School
psychologists working within school districts wanting to utilize evidence-based practices could
serve as consultants supporting teacher-implemented programs and practices as well as provide
much desired professional development (McClelland, Morrison, & Holmes, 2000; Ringeisen et
al., 2003). Professional development should range from providing knowledge on the
characteristics of a child with BD (i.e., inappropriate emotional response, rapidly changing
moods in a short period of time, etc.) to how to monitor mood changes and/or the effects of
medication (Kowatch et al., 2005; Senokossoff & Stoddard, 2009).
Translating educational and behavioral research into best classroom and special education
practices is of national concern (Abbott, Walton, Tapia, & Greenwood, 1999). The research-topractice gap is well documented and continues to limit student outcomes and presents significant
obstacles for students with an ED (Cook et al., 2003; Szymanski & Zolotor, 2001). For example,
Shores, Gunter, and Jack (1993) suggested teachers of students with an ED seldom use effective
practices, and the lack of such practices magnifies the deficits of these students (Sutherland &
Wehby, 2001). Even though there has been extensive research identifying effective practices in
the area of SPED with the potential to dramatically improve student outcomes (Greenwood &
Abbott, 2001), implementing and sustaining these effective strategies over time has proven
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extremely challenging (Abbott et al., 1999; Fitzpatrick & Knowlton, 2007; Klingner, Ahwee,
Pilonieta, & Menendez, 2003; Spooner & Browder, 2003). In addition, sometimes teachers do
not use techniques identified as effective because of a lack of treatment acceptability, distrusts of
empirical research, and a low regard for the characteristic of research-based as an important
selection criterion for adopting intervention practices (Boardman, Arguelles,Vaughn, Hughes,
and Klingner, 2005; Landrum, Cook, Tankersley, & Fitzgerald, 2002 ). Conversely, other
popular, professionally recommended programs are grounded in little or no research supportive
of their use with students identified as having an ED (Fitzpatrick & Knowlton, 2009). For
example, practitioners for decades have incorporated the popular level system into their behavior
management programs as a way of encouraging students with an EBD to acquire appropriate
social, behavioral, and academic skills (Farrell, Smith, & Brownell, 1998). However, Smith and
Farrell (1993) argued that little—if any—research exists to support the effects of level systems
for this student population.
Self-management & -monitoring strategies
Two strategies supported in intervention research dating back to the 60s and early 70s
(McDougall, 1998) are self-management and self-monitoring. Self-management strategies have
been effectively implemented across all grade levels from preschool (Connell, Carta, & Baer,
1993) and elementary school (Fantuzzo & Polite, 1990), and have been successful for students
with ED (Nelson, Smith, Young, & Dodd, 1991). Shapiro et al. (1998) suggested selfmanagement can be conceptualized on a continuum from external agent control (authority) to
student internal control (evaluation). Thus, the goal of self-management is to refocus and engage
students with disruptive and other behavior problems toward independent behavior control
(Shapiro et al., 1998). Further, as students with disabilities learn how to effectively use and apply
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self-management strategies, the responsibility for external behavior-management systems shifts
from authority management to student accountability (King-Sears, 1997). Students with
disabilities who have been taught self-management interventions have successfully generalized
their behaviors to other situations and settings (King-Sears, 1997), reduced disruptive behaviors
in both general and special education classrooms (Rhode, Morgan, & Young, 1983), and
increased appropriate social interactions within and outside the school setting (Strain, Kohler,
Storey, & Danko, 1994). These positive results also have reduced the demands on teacher time
(Snyder & Bambara, 1997).
Self-monitoring involves the student’s recognizing and recording designated target
behavior(s). Often, one’s awareness and counting of target behaviors serve as useful
interventions by themselves (McDougall, 1998). Self-monitoring has an extensive research base
showing its effectiveness with students with disabilities (Reid, 1996; Webber, Scheuermann,
McCall, & Coleman, 1993), including those with behavioral difficulties (Shapiro and Cole,
1994). Several studies have shown self-monitoring improved classroom behavior of students in
special education programs (Hughes, Korinek & Gorman, 1991; Nelson et al., 1991). The
intervention is often recommended and used by practitioners to enhance the acquisition and
maintenance of specific skills (Allinder, Bolling, Oats, & Gagnon, 2000) because selfmonitoring has been shown to increase desired student outcomes (Harris, 1986; Maccini &
Hughes, 1997; Studwell & Moxley, 1984), increase appropriate school behaviors, and decrease
inappropriate behaviors (Keel, Dangel, & Owens, 1999; Webber et al., 1993). Gable and
Hendrickson (2000) suggested self-monitoring strategies have contributed to the long-term
stability of appropriate social responses of students who are inept at reading social situations.
Classroom accommodations
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Responding to the need for expanded mental health services for children, research on the
use of universal (i.e., targeting all students) and selective (i.e., targeting students at risk) schoolbased interventions for mental, emotional, and behavior problems has grown considerably over
the past decade (Hoagwood et al., 2007; Stormont, Reinke, & Herman, 2010; Weissberg et al.,
2003). Schools provide excellent settings for targeting children’s mental health, their academic
performance, and the important connection between them (Greenwood, Kratochwill, &
Clements, 2008). However, despite the increased availability of evidence-based interventions
and the importance of targeting the school setting, the widespread adoption and implementation
of evidence-based practices and interventions to both promote children’s mental health and
intervene with children with specific issues has not occurred (DuPaul, 2003; Kratochwill, 2007;
Schaughency & Ervin, 2006). However, a number of potentially beneficial clinical and
educational recommendations for school difficulties are available and have been used with
success to help students with emotional or behavioral difficulties/disorders to improve their
academic performance (c.f. Baxendall, 2003; CABF, 2012; Crundwell & Killu, 2007;
Greenwood, Delquadri, & Hall, 1984; Heward, 1994; Levendoski & Cartledge, 2000; McIntosh
& Trotter, 2006; Reinke et al., 2011; Vannest et al., 2009).
Academic flexibility
Erratic academic performance can be expected at times and may stem from poorly
modulated affect. The erratic academic performance may be characterized as periods where
assignments are on time, fully completed, and completed with enthusiasm with periods where
assignments are late, partially completed (or not completed at all), and completed with low
motivation. As symptoms of PBD wax and wane, teacher’s may need to modify their
expectations regarding the amount, content of, and time allowed for activities, assignments, and
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tests. Academic adjustments may include altering pace of delivery, increased organizational
support, creating assignments, which build on the student’s strengths. Based on the child’s
fluctuations in mood, attention, energy, and motivation, it may be necessary to accept late
assignments. Side effects of medication may include increased thirst and urination, drowsiness,
and sluggishness. Allowing unlimited access to fluids and restroom, and establishing a private
signal to covertly communicate these needs to the teacher may be beneficial. Minimizing
distractions and surprises, and maintaining a stable environment with consistent expectations,
provides students with structure and predictability, and reduces the level of undesirable reactivity
to instructional demands. Modify the pace of instruction, opportunities to practice, work
demands, activity level, and degree of interactions with peers.
Students with BD may benefit from consistent and structured routines within the home
and school settings. This includes routinizing daily activities, following a classroom discipline
program, responding to poor affective regulation with flexibility, developing assignment
completion checklists, and informing students in advance of any changes in the classroom or
daily school schedule. Teach students to develop short- and long-term goals due to difficulties in
regulating emotion and impact on work production and task completion. Use daily planners,
visual organizers, to-do lists, and assignment completion checklists.
During manic episodes children and adolescents often display episodes of inflated selfesteem or grandiosity. Parents and teachers need to be taught to recognize these episodes and
how to effectively address them. Students may overly commit to projects and extracurricular
activities or pursue projects that have little chance of being completed. Teachers and parents can
help redirect students during periods of inflated self-esteem so they avoid being embarrassed
later when they realize they have over committed. Teachers may wish to modify time constraints
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to ease feelings of pressure/anxiety and decrease difficulties with performance expectations.
Provide additional instructions, act as a scribe, monitor progress and frustration levels and use
technology that provides output modifications.
Sleepiness
A common symptom of students with BD is a poor sleep pattern. Extreme difficultly
falling to sleep, frequently wake-up during the night, and engaging in activity during the night
are not uncommon. At school, students may be tired, irritable, complain of being tired, and fall
asleep in class. It is important for teachers to not assume that because students fall asleep in class
that the parents are to blame or the students are being oppositional. If students with BD are
consistently tired during the school day, then possible interventions may include a shortened
school day and/or Internet courses so they can complete the work outside the school setting.
Episodes of intense emotion
Intense emotions such as sadness, rage, and tearfulness, may unexpectedly occur.
Making prior arrangements for the child to access a safe, private place to go may help in them
regaining control and helping other students avoid being distracted. Again, establishing a private
signal for the child to covertly communicate their need to take a brief time-out during class may
not only improve response time but also teach the child self-management skills. If an FBA has
not occurred previously, then the teacher may want to arrange for one to identify potential
triggers and setting events that precede a student’s loss of control. An FBA also helps to develop
a behavior plan to teach the child new ways to prevent or cope with stressors and frustrations.
For instance, if episodes are due to boredom, provide enrichment activities; if they are due to
hunger or low blood sugar, allow the child to eat a mid-morning/afternoon snack; and if episodes
occur during particularly difficult activities, reduce demands to a level the child can manage. It
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also is recommended that a crisis plan be put into place. Use strategies such as categorization and
“bid ideas” (Ellis, Farmer, & Newman, 2005), concept mapping, graphic organizers, and guided
notes. Deliver feedback (Konold, Miller, & Konold, 2004) to provide ongoing support to acquire
skills due to lack of engagement during class time. For example, helping students regulate their
anxiety and irritability by providing a picture schedule of the day’s sequence of activities helps
to preplan individualized schedules. Also, advanced notice of changes in classroom or daily
activities and development of a plan for “down time” during naturally unstructured periods of the
day can be helpful in decreasing anxiety among children with PBD.
Cross-system communication
Develop methods for parents and teachers to communicate daily about problems and
positive behaviors. Work with parents to develop consistent and structured routines across the
home and school environments. Identify an emergency contact person who can pick the child up
if parents are not available. Partnering with parents may allow the SCHOOL
PSYCHOLOGISTto provide additional support to the family unit by monitoring medication,
reporting on symptom severity, connecting family with community services, and educating on
behavior management techniques and coping skills. Provide ongoing education to school
personnel regarding the disorder. Build teams to work with students with bipolar disorder to
provide more consistency, effectiveness, and flexibility
Social Deficits
The development of coping mechanisms and problems solving strategies, understanding
self-directedness and personal responsibility may be provided and/or facilitated by school
personnel in an individual or group counseling environment. Recognize social skills difficulties
and have the child work with the guidance counselor, school psychologist, or school social
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worker regularly to improve those skills. Foster an environment of inclusiveness in the classroom
through open discussion, providing appropriate peer mediation and support (Bowers et al., 1999;
Fowler et al., 1986), protect students from ridicule or rejection, and setting the occasion for
positive, collaborative working relationships.
Transition planning
Prepare for transitions back to school following hospitalization or after an upsurge in
symptoms that precludes success in negotiating an entire school day. It also may be necessary to
arrange for temporary homebound instruction followed by gradual transition back to school if
needed or arrange for partial days at school. Develop a crisis management plan for the following
areas: explicit instructions to manage the unsafe behavior (i.e., who does what, when and where),
identification of a safe place for the student to go and who will provide appropriate supervision,
alternative backup plans if the safe place does not work, recovery procedures for all involved
following the crisis (e.g., distress and debrief the class with the student involved.
Dealing with medication side-effects
Most require multiple medications to alleviate symptoms of mania, depression, and
comorbid conditions (Lofthouse & Fristad, 2006). Cognitive dulling may be a result of some
medications, making it necessary to provide more time to complete assignments, increased
teacher-feedback and support, decreased workload, and avoiding student embarrassment by not
calling on to answer questions unless s/he volunteers. Physical side effects may include visual
blurring, slowed motor function, increased urinary frequency, nausea, or flatulence.
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Training for School Psychologists
Many different personnel, including guidance counselors, social workers, teachers,
principals, schools nurses, and community resource personnel play a role the design,
implementation, management, and evaluation of mental health services in public schools
(Nastasi, Vargas, Bernstein, Pluymert, 1998). School psychologists are an important part of the
delivery of school-based mental health services and may be the ideal persons to take on key roles
in mental health services because of their training, desirability for the job, and functions within
the school (Nastasi, et al., 1998).
According to NASP (2008), in the year 2004 – 05, the number of credentialed school
psychologists in the US numbered approximately 38,000. However, taking into account
graduates entering the field, attrition, and retirements, the estimated number of credentialed
school psychologists in the year 2008 was approximately 35,4000 (Curtis et al., 2004).
Approximately 80% of NASP regular members are practicing school psychologists in their
primary employment (Curtis et al., 2008). If this figure applies to non-NASP members, then
there are an estimated 28,500 practicing school psychologists in the U. S. in 2008. About 83%
of school psychologists, including those who serve as administrators, have their primary
employment in public schools (Curtis et al., 2008), which is up from 77.5% in 2002 (Curtis et al.,
2002). The number of practitioners credentialed by state departments of education is
approximately 94%, while nearly 31% are licensed through a state board of psychology (Curtis
et al., 2008). The number of practicing school psychologists with doctoral degrees is estimated
to be around 25%.
Curtis, Grier, and Hunley (2004) estimate an ongoing shortage of practicing school
psychologists. The ratio of school psychologists to students ranges between 1,482 (Curtis et al.,
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2008) to 1,671 (U.S. Department of Education, 2008) per student. NASP (2000) recommends a
school psychologist to student ratio of 1 to 1,000. Dividing the total student enrollment of
49,113,000 (U.S. Department of Education, 2008) by 1,000 yields 49,113 school psychologists
(NASP, 2008). Thus, approximately 19,700 additional school psychologists were needed during
the time of these estimates to meet the recommended ratio. It is doubtful this discrepancy has
changed much in the past four years since approximately 1,750 new school psychologists
graduate and entered the field each year (Curtis et al., 2004).
As of the year 2012, NASP estimates there to be approximately 200 school psychologytraining programs across the United States. The American Psychological Association grants
accreditation to 62 school psychology doctoral training institutions with two of those programs
no longer accepting students (American Psychological Association, 2012). NASP (2000b)
standards establish the specialist level (60 graduate hours or 90 graduate quarter hours) for entry
to professional practice. The APA (1987) policy establishes the doctoral degree for entry in the
field. Preparation of school psychologists has changed dramatically over the past 30 years.
Specialist level of training, whether or not they actually held a specialist or doctoral degree, has
grown from approximately 70% of the field in 1970 (Farling & Hoedt, 1971) to 86.5% in 2000
(Curtis et al., 2002). School psychologists actually holding a specialist degree or higher,
increased from 5.2% to 58.5% during the same period of time. The number of school
psychologists increased the greatest during the 1980s (Reschly, 2000) and their preparation was
greatly influenced by the adoption of standards for both credentialing and training by NASP in
the 1970s (Curtis et al., 2004). Although masters-level practitioners remain in the field, masterslevel training programs have almost disappeared. According to Thomas (1998), master’s level
programs declined from 16% in 1986–1987 to only 4% by 1996–1997 while specialist level
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programs had increased to 66.1% and doctoral programs to 29.5% by 1996–1997. Consequently,
it would appear that the percentage of school psychologists prepared at the specialist level or
higher will continue to increase gradually in the years ahead, with those prepared at the masters
level eventually constituting a very small percent of the field (Curtis et al., 2004).
Accredited institutions, whether affiliated with NASP, APA, or both, must practice by an
established set of guidelines to ensure quality training for students in school psychology.
According to the APA (2008), graduates must be capable of “diagnosing or defining problems
through psychological assessment and measurement and formulating and implementing
intervention strategies” and receive training which includes “theories and methods of assessment
and diagnosis, effective intervention, consultation and supervision, and evaluating the efficacy of
interventions.” NASP also places an emphasis on preparation in the areas of assessment,
intervention, counseling, and consultation. The NASP training standards require school
psychologists to acquire “knowledge of behavioral, mental health, collaboration, and other
consultation models and their application to particular situations. School psychologists should
provide or contribute to prevention and intervention programs that promote the mental health and
physical well-being of students” (NASP, 2000). The NASP Blueprint for Training and Practice
III (Ysseldyke et al., 2006) made an even stronger statement: “School psychologists should be
the leading mental health experts in schools who are knowledgeable about development in social,
affective, and adaptive domains”.
A study conducted by Curtis, Grier, Abshier, Sutton, and Hunley (2002) revealed nearly
one-third of the respondents completed 25 or fewer initial special education evaluations during
1999 – 20000, demonstrating a decreasing trend in the number of special education evaluations
compared to previous years. However, school psychologists indicated they spent nearly 80% of
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their time completing special education evaluations, with 41% of that time being spent in
assessment activities, 25% in report writing, 25% in meetings, and 8% in other activities. The
authors concluded that more time was spent by school psychologists in conducting initial special
education evaluations and reevaluations and other special education related activities than in all
other professional functions combined.
As noted, mental health services currently do not represent a priority in schools even
though they likely have resources, in the person of the school psychologist, with the desire and
training to be involved in the delivery of mental health services. In the face of slow, systemic
reform, it may be necessary for school psychologists to be proactive and to seek roles allowing
them to deliver some level of mental health services. Power, McGoey, Heathfield, and Blum
(1999) proposed school psychologists encompass the domains of intervention, program
development, training, and applied research. Given their training, a school psychologist should
be in an excellent position to assist with interventions for children with mental health problems
by conducting FBAs, collaborating with other team members to develop strategies, and
providing technical assistance in the implementation of interventions (Power et al., 1999). In
addition, school psychologists can provide continuing education of other professionals within the
school setting.
Nastasi et al. (1998) identified seven roles school psychologists can fulfill in the delivery
of mental health services in schools, including:
1. Prevention specialists who help teachers and school administrators foster the
development of competent individuals;
2. Child advocates who assist schools in establishing mechanisms for identifying
and treating students with psychiatric disorders;
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3. Direct service providers to help children with emotional disorders such as
depression and bipolar disorder; and help to families who are at risk or have
disabilities;
4. Trainers of teacher consultants to extend the scope of consultation services in
schools;
5. Health care service providers;
6. System-level interventionists, and
7. Organizational facilitators in school reform and interagency collaboration.
School psychologists must be competent to fulfill the role of mental health service provider and
to “recognize their strengths and limitations of their training and experience, engaging only in
practices for which they are qualified” (NASP, 2010). It also is expected that if a school
psychologist is lacking in a needed competency s/he should consult with other professionals,
make referrals, or acquire more training.
Central to all of this is the role of the school psychology program. Recently, researchers
stated school psychology programs have not quite embraced the school-based mental health
services (SMHS) model and “ . . . need to decide whether, in fact, they desire to educate and
train students in the delivery of school-based mental-health services” (Perfect & Morris, 2011). It
is likely some school psychology programs will need to restructure current curricula to fulfill this
mandate (Perfect & Morris, 2011). Perfect and Morris suggest training programs wanting to
better equip their graduates to provide SMHS may wish to consider courses in therapeutic and
crisis intervention, and psychopharmacology – areas of skill and knowledge essential to work
with students with PBD and/or ED classification. Further research is needed to better understand
to what degree current school psychologists possess the competency necessary to effectively
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work with a PBD population.
Chapter Summary
Reviewed in this chapter were the current research related to pediatric bipolar disorder.
A brief historical overview of PBD served as a foundation to better understand the challenges
and ongoing complications associated with the diagnosis. Research on rates of prevalence and
the current diagnostic criteria as understood in the literature and including the adult criteria
outlined in the DSM-IV (American Psychiatric Association, 2000) were provided. The unique
expressions of early onset mania and childhood depression, comorbid disorders,
neuropsychological features, and etiological factors were each examined. Review of
psychopharmacological and psychosocial therapeutic responses to the child with PBD were
followed by an examination of school-based identification processes, including IDEIA and
NASP definitions of ED, RtI, FBA, and assessment best practices.
Finally, research regarding
the degrees, training, and experience held by school psychologists was investigated with respect
to recommendations from PBD and SMHS literature.
Based on the review of literature, it is proposed that additional experience, training, and
knowledge in the area of PBD would result in more accurate assessments and more meaningful
interventions. It is necessary to gain a greater understanding of school psychologists’ current
practices, levels of knowledge and experience. The current survey will assess school
psychologists’ knowledge, training, and methods for evaluating and providing interventions for
children with PBD. The data acquired should assist training programs develop curricula
necessary to equip school psychologists to competently provide support to students with
emotional disorders in general and PBD in particular.
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Chapter 3
Method
Overview
The current study investigated practicing school psychologists’ depth of knowledge,
breadth of experience and training, current assessment practices, and variety of direct services
provided to students with PBD. An electronic survey (See Appendix A) was adapted from a
similar online survey of school psychologists entitled “Autism: Assessment and Intervention
Practices of School Psychologists and the Implications for Training in the United States”
(Rasmussen, 2009). A link to the PBD survey was emailed to school psychologists currently
practicing full-time in the public school setting.
Participants
The demographic characteristics and practices of school psychologists have been
examined through numerous surveys by both independent and professional organizationsponsored investigators (e.g., Curtis, Chesno-Grier, Hunley, 2004; Curtis et al., 2002; Fisher,
Jenkins, & Crumbley, 1986; Hosp & Reschly, 2002). For this investigation, a list of school
psychologists from public school districts across eighteen states was generated through an
Internet search. Current estimates suggest there are approximately 29,000 school psychologists
in U.S. Public Schools (Charvat, 2005). Concerning online survey sample sizes with large
populations such as this, Ritter and Sue (2007) suggest that a sample size of 384 is necessary to
assure a maximum 5% margin of error at the 95% confidence level. However, Dillman (2000)
suggests a sample size of 240 participants may be enough to achieve a commensurate level of
confidence with a population similar in size. Although this study is based on a non-probability
sample, it was, nevertheless, determined to acquire 384 qualifying surveys to increase the
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likelihood of generalizability. A total of 1005 school psychologists were invited to participate
and a 38% response rate was pursued. This response rate is similar to previous surveys of school
psychologists (see Chafouleas et al., 2002) but may be considered low according to some
researchers (Curtis et al., 2002, 2004; Fricker & Schonlau, 2002; Hosp & Reschly, 2002.).
Although Van Horn, Green, and Martinussen’s (2009) meta-analysis of 308 survey
administrations with a similar population of mental health practitioners resulted in an average
response rate of 49.6%, in general response rates to surveys by various means (e.g., phone, postal
mail, email) have been in decline across various professional populations (Curtin, Presser, and
Singer, 2005; Dey, 1997; Larson & Poist, 2004).
The total sample size was acquired by an Internet search of school districts across
eighteen states. Historically, in the absence of membership lists from state or national school
psychology associations, researchers have obtained mailing lists from state departments of
education to conduct surveys (Lewis, Truscott, & Volker, 2008; Meachem & Peckham, 1978).
School districts’ and their website addresses were obtained in this manner and resulted in 1062
email addresses of which 57 were rejected leaving 1005 sent emails. After the initial mailing,
126 emails were returned due to delivery failure and removed from the email list for subsequent
emails. This procedure was followed for the second and third mailings resulting in a total of 862
emails successfully reaching the intended school psychologist.
Only full-time, school psychologists practicing in a school district were included in the
study. Fagan and Wise (2000) describe a full-time practicing school psychologist as an
individual maintaining a current school psychology license or certificate who spends at least 30 –
40 hours per week providing psychological services including assessment, intervention,
consultation, psychoeducation, and other direct services to students. Participants were asked to
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provide their gender, degree(s) earned, professional affiliation(s), years of experience,
geographical location of current assignment, and whether or not they were a National Certified
School Psychologist (NCSP). In addition, participants were asked to estimate how many
psychoeducational evaluations they completed in a year, to describe the age ranges of students
typically assessed, and to approximate the percentage of their time spent in Special Education
related services. According to Curtis (1999), the majority of school psychology practitioners are
trained at the non-doctoral level (20.6%). More specifically, a little more than 40% obtained a
master’s degree and 36% held a specialist degree. Sixty-two percent of those surveyed by Curtis
held the NCSP certification and nearly 80% of respondents indicated their preparation had been
at the 60-hour/specialist level or higher before entering the profession. In addition, nearly onethird of school psychologists have been in the field more than 15 years and approximately 17%
with more than 20 years of experience. Concerning the current study, means and percentages of
demographic data are reported in Chapter 4.
Procedures
The Internet is quickly becoming the preferred mode of communication for many
Americans (Duffy, 2000; Wijndaele et al., 2007) and researchers across disciplines are noting the
value of and relying upon data collected online (e.g., McMahon et al., 2003; Raziano,
Jayadevappa, Valenzula, Wiener, & lavizzo-Mourey, 2001). Wijndaele and colleagues (2007)
demonstrated the internal consistency, equivalency, as well as test-retest reliability of
computerized versions of the same paper-and-pencil questionnaires were comparable.
Additional benefits of online research include reduced response time (Lazar & Preece, 1999),
lowered cost (Granello & Wheaton, 2004), flexibility and control over format (Dillman et al.,
1999; Lazar & Preece 1999), higher percent of questions answered completely and accurately
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(Dykema, Jones, Piche, & Stevenson, 2013; Messer, Edwards, & Dillman, 2012) and increased
recipient acceptance of the format particularly for individuals who are college educated
(Cartwright et al., 1999; Franceschini, 2000). However, a number of disadvantages have been
identified which are associated with web-based surveys. In particular, web-based research may
result in lower response rates compared to traditional mail surveys (Dykema et al., 2013;
McLeod, Klabunde, Willis, & Stark, 2013; Schaefer & Dillman, 1998). Respondents possessing
inadequate computers and software (Dillman, Tortora, & Bowker, 1999), lacking control over
the testing situation (Buchanan & Smith, 1999), and fearing a loss of privacy and confidentiality
(Frankel & Siang, 1999), are among the suggested reasons for this dilemma.
The present study initially contacted participants through an invitation email letter
explaining the importance of the survey and the purpose it served, addressing the issues of
confidentiality and anonymity, and informing the respondent of the approximate time needed to
complete the survey (See Appendix B). Prospective respondents were invited to access the
survey by following a web link provided in the body of the email. The initial webpage included
a detailed description of the study, what information would be collected, and how the data would
be used and stored. After respondents read this information and agreed to participate, they were
allowed to access the survey through a provided link. By selecting this link, participants
formally acknowledged voluntary participation and informed consent. Anonymity of
respondents was maintained by not linking entries with URL or email addresses. Because followup contacts have been shown to improve response rate (e.g., Fox, Crask, & Kim, 1988; Salant &
Dillman, 1994; Sue & Ritter, 2007; Yammarino, Skinner, & Childers, 1991), two reminders were
sent through email at selected intervals (i.e., five and ten business days after the initial contact;
see Appendices C and D)
118
As an incentive to respond, recipients were informed a donation of $2.00 would be made
per completed survey not to exceed a total of $750.00 to the NASP Children’s Fund. The
Children’s Fund is a tax-exempt, non-profit, independent charity, which disperses monies for
purposes consistent with the priorities of NASP. Those priorities include advocating for the
welfare of children and adolescence, promoting optimal learning environments, and developing
meaningful academic and social-emotional interventions (NASP, 2013). In addition,
respondents had an opportunity to indicate interest in receiving an executive summary of the
survey’s findings. Requests by participants to receive a summary of the study's results was
handled separately from the survey and required participants to contact the lead researcher by a
provided email. Participants were informed their request would be treated as confidential and
destroyed once the request for a summary was fulfilled.
Instrumentation
The survey for this study was modeled after similar tools used to investigate the
assessment and interventions practices of school psychologists (Hosp & Reschly, 2002;
Messmer-Wilson, 2006; Rasmussen, 2009; Smith, 1999) and was composed of four sections.
Section one utilized a series of multiple-choice, fill-in-the-blank, and forced option questions, to
ask participants to provide demographic information including level of education, type of degree,
professional affiliation(s), years of experience, and whether or not an NCSP.
Section two investigated the general knowledge and perceptions of respondents in the
area of PBD through the use of Likert scales, multiple-choice, and forced choice questions.
Current misconceptions and facts about PBD were taken from current research and used to
investigate school psychologists’ understanding of PBD, including its features, differential
diagnoses, and comorbid disorders.
119
The third section also used Likert scales, rank order, forced choice, as well as multiplechoice and fill-in-the blank formats to assess school psychologists’ current assessment and
intervention practices in their school. Specific areas addressed included time spent in various
Special Education activities, role in the determination and classification process, personal
assessment practices, and the provision of interventions and supports for students and their
families.
The final section used a series of multiple-choice and Likert scales asking school
psychologists to describe self-perceptions of preparedness to provide services for students
identified with an emotional disturbance as well as levels of self-confidence pertaining to the
assessment and identification of PBD and related mood disorders.
Due to the original nature of this survey, validity and reliability are unknown. However,
a doctoral level school psychologist, licensed clinical psychologist, and special education tenured
professor reviewed and critiqued the initial draft of the survey as well as to evaluate the survey’s
online presentation. Considerable changes were made in content and format based on the
reviewers’ feedback before being sent to participants.
Statistics
Research Question 1.What is the general level of knowledge of school psychologists in
the area of PBD?
a.
What is the general understanding and perceptions of school psychologists in
regard to the diagnostic category of PBD?
b.
What is the general understanding and perceptions of school psychologists
concerning the differential diagnosis, comorbidity, and signs and symptoms of
PBD?
120
c.
Is there a difference in the levels of knowledge in the area of PBD when
considering a practitioner’s level of education (e.g., Masters, Specialist, PhD), as
well as whether or not nationally certified (i.e., NCSP)?
Descriptive statistics (i.e., means, frequencies, and standard deviations) were calculated for
questions related to participants’ levels of knowledge. To further compare the groups, a one-way
analysis of variance utilizing the mean percentages correct on questions measuring knowledge
level also were applied for each of the conditions provided they were found to be independent. It
was expected that those with more training and experience would have a higher percentage of
correct answers.
Research Question 2. What are the general practices of school psychologists with regard
to the identification of children suspected of having an emotional disorder?
a.
How much time in general do school psychologists spend providing the following
special education services: assessment for special education services, counseling
students, providing academic and/or behavioral interventions, providing
functional behavioral analyses, consulting with teachers, and doing research.
b.
What is the primary role of school psychologists in the determination and
classification of an emotional disorder?
c.
What instruments and methods do school psychologists use when evaluating
children suspected of an emotional disorder?
d.
What is the level of involvement of school psychologists in pre-referral activities
of children suspected having an emotional disorder?
e.
What services are typically provided for students identified with an emotional
disorder?
121
f.
When considering the types of interventions and special education services
provided for students identified with an emotional disorder, is there a difference
in the above-mentioned practices between doctoral and non-doctoral school
psychologists, those school psychologists who are nationally certified, or between
school psychologists with greater and lesser amounts of experience?
Means and standard deviations were calculated and reported for questions inquiring about school
psychologists’ current practices. Concerning whether or not level of education or years of
experience results in any significant difference in practices, a one-way analysis of variance was
applied. It was expected that those with more training and experience would have a greater level
of involvement in counseling, providing interventions, consulting with teachers, taking part prereferral activities, and providing specific services fro students with an emotional disorder.
Research Question 3. What types of training have school psychologists received in the
area of PBD identification and intervention, and do those with more formal training understand
the symptomology of PBD better than those with informal training?
Research Question 4. How prepared do current school psychologists feel to consult,
assess, and intervene in cases suspected of PBD and what is the level of personal confidence
related to their involvement in these activities?
For both questions 3 and 4, means and standard deviations were calculated to investigate
the types of training held by school psychologists, their perceptions of their preparedness, and
their level of confidence in working with children with PBD. The group of school psychologists
determined to have formal/advanced training will be compared to those with “minimal” training
on their responses regarding their perceived preparedness. An ANOVA will be applied to
determine if those with formal training feel more prepared to deliver the services of consultation,
122
assessment and intervention.
The IBM Statistical Package for the Social Sciences – 22nd Edition (SPSS-22) will apply
the described statistics.
123
Chapter 4
Results
Response Rate
A total of 1,005 school psychologists’ email addresses were acquired from an Internet
search across eighteen states. Three emails were sent to each participant over the course of 10
business days. The total number of emails failing to be delivered and returned to the sender over
the course of the mailings was 143. Reasons for rejection included invalid or expired email
addresses, problems with email servers, or no longer serving as a full-time school psychologist.
Because returned emails were removed from subsequent mailings it is likely participants
received the original and two follow-up contacts. Although 862 emails were not automatically
returned, the actual number of received emails is likely lower due to junk email folders and spam
blockers. Of the 307 who agreed to the terms of the study, 258 finished the survey. Examination
of those who did not complete the survey indicated 41% dropped out before completing the
section on demographics, which may indicate those respondents did not fit the required criteria
to participate.
In total, 258 surveys were completed for a response rate of 29.93%. Of these completed
surveys, 7 respondents were removed because they reported not working at least 25 hours in a
school setting, leaving 251 participants for continued analysis completed the surveys. Although a
sample size of 384 was desired, some researchers (Dillman et al., 2009; Dykema, Jones, Piche, &
Stevenson, 2013; Ritter & Sue, 2007) suggest a minimum sample size of 240 may be adequate to
achieve a representative sample from large populations.
124
Demographics
Questions 1 through 11 of the survey focused on demographic information. Based on the
251 participants who reported their highest degree earned, 77.7% indicated they held either a
Masters or Specialist degree, 20.3% held doctoral degrees (i.e., PhD, EdD, PsyD), and 2.0%
indicated they held some other certification (e.g., Certificate of Advance Study, Certificate of
Advanced Graduate Study) as their highest training acquired. Concerning membership in
professional organizations, 60.2% (n=151) belonged to NASP, 10.0% (n=25) to APA, and 7.6%
(n=19) belonged to both NASP and APA with 37.1% (n=93) indicating they belonged to no
national organization. In addition, 50.6% (n=127) reported they belonged to a State
organization. A total of 113 respondents (45.2%) indicated they were a National Certified
School Psychologist and of the 108 indicating the approximate number of years considered an
NCSP, 71.3% held the NCSP distinction for fifteen years or less (see Table 1).
Table 1
Approximate Number of Years Considered an NCSP
Category
n
Percent
1 to 5
38
35.2
6 to 10
24
22.2
11 to 15
15
13.9
16 to 20
7
6.5
21 to 25
9
8.3
26 or more
15
13.9
Total
108
100.0
125
Concerning years serving as a school psychologist, nearly two-thirds (64.1%) had served in the
school system fifteen years or less with nearly a quarter of respondents (24.6%) serving 21 years
or longer (See Table 2). The majority of respondents (83.1%) were female, which is slightly
above the overall proportion practicing school psychology primarily in a school setting
(Approximately 74.0%; Curtis, 1999; NASP, 2008). Participants also were given an opportunity
to describe the geographical location of their current job to which 248 responses indicate 19.4%
serve in an urban area, 42.7% in a suburban area, and 36.3% in an area considered rural. In
addition, survey software made it possible to determine the state from which the participant was
responding as well as to infer representation from each of the four NASP designated regions (See
Appendix C). Of the twenty states represented, nearly 36% were located in the NASP Northeast
Table 2
Approximate Number of Years Serving as a School Psychologist
Years
n
Percent
1 to 5
52
21.0
6 to 10
67
27.0
11 to 15
40
16.1
16 to 20
28
11.3
21 to 25
25
10.1
26 or more
36
14.5
Total
248
100.0
126
Region, 34% from the Southeast Region, 16% from the Central Region, and nearly 14% from the
Western Region. Respondents were asked to estimate the number of psychoeducational
evaluations personally completed during a school year. Of the 231 valid responses, the Mean
estimate was 51.16, with a Median of 50.00 and an SD of 36.138. Respondents’ estimates of the
percentage of time spent in special education related services indicated nearly 88% spend at least
half or more of their time each week in activities such as assessing students, writing reports, and
attending case conferences (See Table 3).
Table 3
Estimated Percentage of Time Spent in Special Education Related Services
Time spent
n
Percent
Less than 10%
1
0.4
10 – 25%
6
2.4
26 – 50%
23
9.2
51 – 75%
73
29.2
76 – 90%
88
35.2
More than 90%
59
23.6
Total
250
100.0
Research Question 1. What is the general level of knowledge of school psychologists in the area
of PBD?
Research Question 1a. What is the general understanding and perceptions of school
psychologists in regard to the diagnostic category of PBD?
127
Perceptions of PBD (Survey Questions 12 – 17, 20)
Through the use of a Likert scale, participants were asked to indicate to what degree they
agreed or disagreed with 9 statements about PBD (See Table 4).
PBD is currently under diagnosed in the United States. Nearly half of respondents
(46.8%) disagreed in some manner with this statement with only 21.6% agreeing (M=3.32; SD=
1.05).
The diagnosis of PBD should be based on the DSM adult symptomology. The vast
majority of respondents (81.9%) indicated disagreement with this statement, with only 8%
finding agreement. No other statement in this section garnered as much strength of opinion
(M=4.17; SD 0 .974).
Most children exhibiting symptoms of PBD will develop into adults with Bipolar
Disorder. Nearly a third of respondents (32.7) were undecided about this statement, while 46%
either mildly or strongly agreed (M=2.710; SD=0.958).
Children should not be diagnosed with Bipolar Disorder. Although approximately half
of respondents (49.4%) disagreed to some degree with this statement, 29.6 percent expressed a
level of agreement (M=3.23; SD=1.170).
Behavioral approaches to reducing problematic behaviors due to PBD are relatively
ineffective without the concurrent use of medications. Concerning this statement, a little over
half of respondents (54.4) mildly or strongly agreed with a quarter of participants (24.4)
expressing overall disagreement (M=2.60; SD 1.07).
It is appropriate to prescribe antipsychotic medications to children exhibiting symptoms
of mania. Perhaps surprisingly, just over three percent strongly disagreed with this statement,
with nearly one third undecided and almost half of respondents expressing mild or strong
128
agreement (M=2.68; SD 0.961).
The majority of adults diagnosed with Bipolar Disorder exhibited symptoms of mania as
children. Very few respondents felt strongly either way about this statement (M=2.68;
SD=0.862) with 36.7% mildly agreeing, 41.1% undecided, and 13.7% mildly disagreeing.
Table 4
Participant Perceptions and Opinions about PBD
Valid Percent
Statement
Strongly
Mildly
Un-
Mildly
Strongly
Agree
Agree
decided
Disagree
Disagree
4.0
17.6
31.5
32.8
14.0
2.0
6.0
10.0
36.5
45.4
7.7
38.3
32.7
18.1
3.2
8.5
21.1
21.1
36.8
12.6
12. PBD is currently under
diagnosed in the United
States.
13. The diagnosis of PBD
should be based on the
DSM adult
symptomology.
14. Most children exhibiting
symptoms of PBD will
develop into adults with
Bipolar Disorder.
15. Children should not be
diagnosed with Bipolar
Disorder.
129
Table 4 (cont.)
Valid Percent
Statement
Strongly
Mildly
Un-
Mildly
Strongly
Agree
Agree
decided
Disagree
Disagree
13.2
41.2
21.2
20.4
4.0
7.2
42.0
29.2
18.4
3.2
6.4
36.3
40.6
13.5
2.0
16. Behavioral approaches to
reducing problematic
behaviors due to PBD are
relatively ineffective
without the concurrent
use of medications.
17. It is appropriate to
prescribe antipsychotic
medications to children
exhibiting symptoms of
mania.
20. The majority of adults
diagnosed with Bipolar
Disorder exhibited
symptoms of mania as
children.
130
Research Question 1b. What is the general understanding and perceptions of school
psychologists in regard to the differential diagnosis, comorbidity, and signs and
symptoms of PBD?
Signs and Symptoms (Survey Questions 18 – 19, 21)
Participants were asked to indicate agreement or disagreement concerning two statements
about PBD through the use of a Likert scale. A third question required selection of a correct
response amongst four distractors. The correctness of their answers was determined on current
research. Therefore, the first statement is false, the second is true, and the correct selection for
the third statement was “euphoria” (See Table 5).
Table 5
Respondents’ Understanding of PBD Signs and Symptoms
Valid Percent
Statement
Strongly
Mildly
Un-
Mildly
Strongly
Agree
Agree
decided
Disagree
Disagree
6.8
44.2
33.7
12.4
2.8
1.2
13.7
55.4
21.3
8.4
18. The course of mania in
children is typically of
short duration and
episodic.
19. Children diagnosed with
PBD are expected to
have a significantly
higher VIQ than PIQ
131
The course of mania in children is typically of short duration and episodic. Of the 251
respondents, 15.2 percent were correct in disagreeing with this statement. The remaining 84.8
percent were either undecided or incorrect (M=2.60; SD 0.897).
Children diagnosed with PBD are expected to have a significantly higher Verbal IQ than
Performance IQ. Similar to the previous statement, nearly 15% of respondents were correct in
agreeing with this statement and 85.1 percent responded incorrectly (M=3.22; SD 0.830).
Of the following symptoms, which do you think is most likely to be exhibited by children
with PBD? Only 5.6% selected the most correct response “euphoria”. Nearly thirty percent of
respondents selected “hyperactivity” with 57.7% selecting “irritability”, 3.2% “grandiosity”, and
4.4% “flight of ideas”.
Differential Diagnosis (Survey Questions 22 - 31)
Participants were provided a four-point Likert scale and asked to describe how difficult it
is to differentiate PBD from other disorders. The scale ranged from Very Easy (1) to Very
Difficult (4). The means scores and standard deviations for those ten disorders are summarized in
Table 6.
The two disorders reported to be the most difficult from which to differentiate PBD were
ADHD with a mean score of 2.96 (SD=0.725) and Oppositional Defiant Disorder with a mean
score of 2.97 (SD=0.712). Autism and Asperger’s Disorder were reported by participants to be
two of the easiest disorders from which to differentiate PBD with mean scores of 1.70
(SD=0.665) and 1.87 (SD=0.698), respectively.
132
Table 6
Mean Level of Difficulty in Differentiating Disorders from PBD
Disorder
M
SD
Autism
1.70
0.665
Asperger’s Disorder
1.87
0.698
Attention Deficit/Hyperactivity Disorder
2.96
0.725
Conduct Disorder
2.88
0.733
Oppositional defiant disorder
2.97
0.712
Childhood Depression
2.94
0.636
Thought Disorder
2.90
0.647
Anxiety Disorder
2.84
0.659
Pervasive Developmental Disorder NOS
2.04
0.759
Comorbidity (Survey Questions 32 – 50)
A list of seven disorders (Autism spectrum disorders, attention deficit/hyperactivity
disorder, conduct disorder, oppositional defiant disorder, obsessive compulsive disorder,
childhood depression, and though disorder) was given to participants who were asked to estimate
the percentage of individuals with PBD who also receive a diagnosis of one or more of the listed
disorders. Attention deficit/hyperactivity disorder (mode=51, M=63.84) and oppositional defiant
disorder (mode=76, M=55.96) were indicated by participants to be the disorders most commonly
found comorbid in those diagnosed with PBD. The least common comorbid condition reported
by participants was autism spectrum disorders (mode=11, M=18.82; see Table 7)
133
Table 7
Participant Estimates of the Percentage of Individuals with PBD and Comorbid Conditions
Disorder
N
Minimum Maximum Mode
M
SD
Autism Spectrum Disorders
198
0
92
11
8.82
16.636
Attention Deficit/
243
0
97
51
63.84
23.991
235
0
100
76
48.79
26.075
Oppositional Defiant Disorder 238
0
95
76
55.96
25.465
Obsessive Compulsive
225
0
85
11
26.39
20.311
Childhood Depression
239
0
100
21
51.96
27.450
Thought Disorder
239
0
100
51
46.70
26.355
Hyperactivity Disorder
Conduct Disorder
Disorder
Due to PBD’s significant number of shared symptoms with ADHD, participants were
provided a list of 12 symptoms (irritability, impulsivity, grandiosity, hyperactivity, distractibility,
elated mood, flight of ideas, decreased need for sleep, talkativeness, high motor activity,
inattention, rapid cycling) and asked to select only those items most common to and indicative of
PBD. The three symptoms participants reported most indicative of PBD were rapid-cycling
(85.6%), irritability (82.4%), and elated mood (80.0%). According to respondents, distractibility
(19.2%) and inattention (19.6%) were thought to be the least symptomatic of PBD (see Table 8)
134
Table 8
Selected Symptoms Most Common to and Indicative of PBD
Disorder
N
Percent
Irritability
206
82.4
Impulsivity
75
30.0
Grandiosity
179
71.6
Hyperactivity
71
28.4
Distractibility
48
19.2
Elated Mood
200
80.0
Flight of Ideas
163
65.2
Decreased Need for Sleep
149
59.6
Talkativeness
98
39.2
High Motor Activity
73
29.2
Inattention
49
19.6
Rapid-cycling
214
85.6
Research Question 1c. Is there a difference in the levels of knowledge in the area of
PBD when considering a practitioner’s level of education (e.g., Masters, Specialist,
PhD), as well as whether or not nationally certified (i.e., NCSP)?
To determine whether a school psychologists’ level of education related to level of
knowledge about PBD, each respondent’s answers to survey Questions 18, 19, and 21 were
scored according to current research. The statement made for Question 18 (The course of mania
in children is typically of short duration and episodic.) is considered to be false, while the
135
statement for Question 19 (Children diagnosed with PBD are expected to have a significantly
higher Verbal IQ than Performance IQ) is considered to be correct. The Likert scale responses
were scored so that high scores corresponded to being more correct while low scores indicate a
less correct response. Concerning survey question 21 (Of the following symptoms, which do you
think is most likely to be exhibited by children with PBD), the only selection considered correct
was “euphoria” with all other responses being considered incorrect. Based on the information
provided by participants concerning the level of training they had received, the groups (Masters
degree level of training vs. Doctoral level of training) were compared on their response to the
above questions to determine if their level of education or designation as an NCSP had a
predictable effect on their correct understanding of particular symptoms of PBD.
The Levene’s F Test was used to test the assumptions of homogeneity of variance with
the level of significance set a priori (α=.05). Across compared variables, the null hypothesis for
the assumption of homogeneity of variance was met (See Table 9). There is, therefore, an
increased confidence in the reliability of the ANOVA, which indicated there was no significant
relationship between level of education (See Table 10) or NCSP designation (See Table 11) on
the correctness of responses to survey questions 18, 19, and 21.
Table 9
Results of Levene’s Test Level of Education and NCSP on Knowledge
Level of Education
Q18. Course of mania in
F
.106
NCSP
p
.745
F
1.919
children
136
p
.167
Table 9 (cont.)
Level of Education
Q19. Higher Verbal IQ
NCSP
F
p
F
p
.840
.360
.134
.715
.027
.870
1.881
.172
than Performance IQ
Q21. Most likely
symptom
Table 10
Tests of Between-Subjects Effects Highest Degree Earned
Sum of
Partial
Squares
μ2
F
p
η2
Q18. Course of Mania in Children
.019
.019
.024
.877
.000
Q19. Verbal and Performance IQ
.127
.127
.183
.669
.001
Q21. Most likely symptom
.000
.000
.007
.935
.000
Table 11
Tests of Between-Subjects Effects NCSP
Sum of
Partial
Squares
μ2
F
p
η2
Q18. Course of Mania in Children
.460
.460
.574
.449
.002
Q19. Verbal and Performance IQ
.043
.043
.061
.804
.000
Q21. Most likely symptom
.025
.025
.465
.496
.002
137
Research Question 2. What are the general practices of school psychologists with regard to the
identification of children suspected of having an emotional disorder?
Research Question 2a. How much time in general do school psychologists spend
providing the following special education services: assessment for special education
services, counseling students, providing academic and/or behavioral interventions,
providing functional behavioral analyses, consulting with teachers, and doing research.
General Practice (Survey Question 52)
Participants were asked to provide an estimate of time spent in a variety of Special
Education activities. Not surprisingly, the most time spent by respondents was in providing
assessment for services (mode=50, M=49.74, SD=21.321). The three activities in which
respondents spent the least amount of time were academic intervention (mode=10, M=7.61,
SD=7.660), functional behavior analysis (mode=5, M=6.75, SD=5.416), and research (mode=.0,
M=1.98, SD=3.616; see Table 12).
Table 12
Participant Estimates of the Percentage of Time in Special Education Activities
Disorder
Assessment for Special
Minimum Maximum Mode
0
95
50
M
49.74
SD
21.321
Education Services
Counseling Students
0
60
.0
8.83
10.581
Academic Intervention
0
35
10
7.61
6.660
Behavior Intervention
0
45
10
10.70
7.824
Functional Behavior Analysis
0
40
5
6.75
5.416
138
Table 12 (cont.)
Disorder
Consultation with Teachers
Research
Minimum Maximum Mode
0
60
10
0
20
.0
M
14.22
SD
9.352
1.98
3.616
Research Question 2b. What is the primary role of school psychologists in the
determination and classification of an emotional disorder?
Role (Survey Question 53)
Respondents were asked to select one of three provided statements, which most
accurately reflected their primary role in the determination, and classification of an emotional
disturbance. The vast majority of the 250 respondents (98.8%) reported they participated as part
of a multidisciplinary team to determine the special education eligibility of students with a
possible emotional disorder. Less than one percent (N=2, .8%) indicated they sat on the
multidisciplinary team making eligibility decisions but did not participate in conducting the
evaluations.
Research Question 2c. What instruments and methods do school psychologists use
when evaluating children suspected of an emotional disorder?
Instruments and Methods (Survey Questions 54 – 55)
A list of ten common assessment procedures was provided and participants asked to use a
4-point Likert scale ranging from “always” to “never”, to describe the frequency with which they
employed each activity when receiving a referral for a possible emotional disturbance. Two
individuals did not respond to this question due to their non-involvement in the assessment of
students with an emotional disturbance. More than 75% of the remaining 249 respondents
indicated they always reviewed school records (95.2%), reviewed academic work (83.2%), and
139
conducted a teacher interview (75.9%). Approximately two-thirds of participants reported they
always reviewed medical records (69.1%), utilized classroom observations (66.8%), recorded a
developmental history (66.4%), and interviewed the student (66.3%). Eighty percent of
respondents never observe the referred student in his or her home environment and 12.2% never
interview caregivers. Table 13 details the results.
Table 13
Frequency of Use of Evaluation Procedures
Valid Percent
Method
Always
Often
Sometimes
Never
Review of school records
95.2
4.4
.4
.0
Review of medical records
69.1
23.3
7.2
.4
Review of academic work
83.2
13.6
3.2
.0
Classroom observation of student
66.8
22.8
10.4
.0
2.0
1.6
16.3
80.0
Functional Behavioral Analysis
29.8
21.8
40.3
8.1
Developmental history
66.4
15.2
10.8
7.6
Caregiver interview
51.2
21.1
15.4
12.2
Student interview
66.3
23.7
9.6
.4
Teacher interview
75.9
20.9
3.2
.0
Home observation of student
Utilizing a similar Likert scale as the previous question, participants involved in
assessing students for a possible emotional disturbance were asked to indicate how often they
personally used specific measures during the assessment process. The three assessment
measures always used by the majority of participants included behavior rating measures (86%),
140
cognitive ability measure (65.5%), and an academic achievement measure (59.8%). Nearly 46%
of participants indicated they never administered a neurologically based evaluation and 42.5%
never utilized a projective measure. Table 14 details the results.
Table 14
Frequency of Use of Assessment Measures
Valid Percent
Method
Always
Often
Sometimes
Never
Cognitive ability measure
65.5
24.1
9.6
Academic achievement measure
59.8
18.0
12.1
Neuropsychological Evaluation
7.0
13.9
33.2
45.9
Adaptive behavior rating measure
14.9
21.3
55.4
8.4
Behavior rating measure
86.0
12.0
2.0
.0
Attention Scale
30.0
32.8
34.0
3.2
Anxiety Scale
25.8
23.4
39.5
11.3
Depression Inventory
25.8
20.6
41.1
12.5
Projective measure
13.8
10.9
32.8
42.5
.8
10.0
Research Question 2d. What is the level of involvement of school psychologists in prereferral activities of children suspected having an emotional disorder?
Pre-referral Involvement (Survey Question 56)
Respondents also were asked to consider their level of involvement in three activities
occurring before a student was referred for special education services due to a possible emotional
disturbance. Over half of all respondents indicated they were either often or always involved in
research based interventions (66.2%), functional behavior analysis (57%), and consultation with
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teachers (91.7%), before students are referred for a formal evaluation for a possible emotional
disturbance (see Table 15).
Table 15
Level of Involvement in Three Pre-Referral Activities
Valid Percent
Method
Always
Often
Sometimes
Never
Research Based Intervention
29.9
36.3
24.7
9.2
Functional Behavior Analysis
23.9
33.1
31.9
11.2
Consultation with Teacher
59.0
32.7
6.4
2.0
Research Question 2e. What services are typically provided for students identified with
an emotional disorder?
Services Provided (Survey Question 57)
Participants were asked to describe the frequency they provided a variety of services
often needed by students identified with a mood disorder and receiving special education
services for an emotional disturbance. The services respondents indicated least likely, if ever, to
occur included monitoring the effects of prescribed medication(s) (80%), providing caregiver
support (80.4%), consulting with the student’s doctor (76.3%), and providing small group
support for the student (79.6%). Describing their frequency as often or always, respondents were
most likely to consult with teachers concerning instructional strategies and academic
accommodations (74%), to develop behavior modification plans for school use (64.6%) and to
consult with the teacher to implement and monitor the effectiveness of behavior modification
plans (73.1). See Table 16 for further details.
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Table 16
Frequency of Provision of Services for Students with an Emotional Disorder
Valid Percent
Method
Always
Often
Sometimes
Never
4.4
15.7
41.0
39.0
Consult with student’s doctor
2.8
20.9
60.2
16.1
Social skills training for student
5.6
21.9
41.8
30.7
Provide caregiver support
3.6
16.0
51.2
29.2
.8
5.2
56.6
37.3
19.6
44.8
28.8
6.8
26.8
47.2
23.6
2.4
28.1
45.0
22.9
4.0
6.0
21.5
44.2
28.3
Monitor effects of prescribed
medications(s)
Develop behavior modification plans for
home use
Develop behavior modification plans for
school use
Consult with teacher concerning
instructional strategies and academic
accommodations.
Consult with teacher to implement and
monitor effectiveness of behavior
modification plans.
Provide individual counseling for
student
Provide small group counseling/
support for student
3.2
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17.2
39.2
40.4
It was of some interest to know if there was a significant difference in the abovementioned practices between doctoral and non-doctoral school psychologists, NCSP designated
school psychologists, as well as between school psychologists with greater and lesser amounts of
experience in schools. The Levene’s F Test was used to test the assumptions of homogeneity of
variance with the level of significance set a priori (α=.05). Across compared variables, the null
hypothesis for the assumption of homogeneity of variance was met with the exception of one
variable (See Table 17). Application of the ANOVA indicated there was no significant
relationship between level of education (See Table 18), NCSP designation (See Table 19), or
years of experience (See Table 20) on the provision of services.
Table 17
Results of Levene’s Test Levels of Education, NCSP, Years of Service on Practice
Level of Education
NCSP
F
p
F
Monitor effects of medications
.274
.601
Consult with student’s doctor
.446
Social skills training
Years of Service
p
F
p
.025
.874
1.058
.385
.505
1.487
.224
.241
.944
.243
.622
.021
.886
1.856
.103
Care giver support
.001
.972
.050
.823
1.407
.222
Behavior modification home
.250
.618
3.123
.078
1.239
.292
Behavior modification school
.287
.593
.061
.806
1.321
.256
Consult with teacher academics
1.63
.202
.292
.589
.885
.492
Consult with teacher behavior
.017
.896
.000
.995
1.647
.148
Individual counseling
.250
.617
1.531
.217
.854
.513
1.200
.274
5.182
.024
.474
.796
Group counseling
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Table 18
Tests of Between-Subjects Effects Highest Degree Earned
μ2
F
p
η2
Monitor effects of medication
1.695
2.418
.121
.010
Consult with student’s doctor
.539
1.140
.287
.005
Social Skills training
.352
.467
.495
.002
Care giver support
.905
1.524
.218
.006
Behavior modification home
.005
.013
.911
.000
Behavior modification school
.169
.238
.626
.001
Consult with teacher academics
.035
.057
.811
.000
Consult with teacher behavior
.146
.216
.642
.001
Individual counseling
.278
.376
.541
.002
Group counseling
.729
1.075
.301
.004
μ2
F
p
η2
Table 19
Tests of Between-Subjects Effects NCSP
Monitor effects of medication
.510
.726
.395
.003
Consult with student’s doctor
1.455
3.090
.080
.012
Social Skills training
1.096
1.486
.224
.006
Care giver support
.252
.424
.516
.002
Behavior modification home
.839
2.337
.128
.009
Behavior modification school
.383
.544
.462
.002
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Table 19 (Cont.)
μ2
F
p
η2
Consult with teacher academics
.029
.048
.826
.000
Consult with teacher behavior
.005
.007
.932
.000
Individual counseling
.058
.079
.779
.000
Group counseling
.482
.726
.395
.003
F
p
η2
Table 20
Tests of Between-Subjects Effects Years of Service
μ2
Monitor effects of medication
.490
.692
.630
.014
Consult with student’s doctor
.266
.561
.730
.012
Social Skills training
.664
.880
.495
.018
Care giver support
.326
.552
.737
.011
Behavior modification home
.267
.734
.598
.015
Behavior modification school
.565
.787
.560
.016
Consult with teacher academics
.273
.446
.816
.009
Consult with teacher behavior
.242
.354
.880
.007
Individual counseling
.701
.949
.450
.019
Group counseling
.448
.651
.661
.013
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Research Question 3. What types of training have school psychologists received in the area of
PBD assessment and intervention and do those with more formal training understand the
symptomology of PBD better than those with informal training?
Training (Survey Question 58)
Respondents were asked to indicate the type of training they had received specific to
three categories: emotional disturbances, pediatric bipolar disorder, and adult/adolescent bipolar
disorder. A significant number (86.9%) of the 251 school psychologists responding to this query
had completed formal course work in emotional disturbances in their training program. The
majority of respondents also reported having an internship or residency experience (68.9%) as
well as had attended a workshop presentation or in-service training (79.3%) addressing the topic
of emotional disturbances. To create a clearer picture of the training experiences of participants,
a dichotomy of formal and informal training was created. School psychologists who indicated
they had completed either formal course work or an internship or residency program were
grouped into a formal training group and those school psychologists who indicated their only
training in emotional disturbances was through workshops or in-service trainings were placed in
an informal training group. When considered in this way, 91.2% had received formal training in
emotional disturbances, while 7.6% reported having only informal training.
Concerning the training experiences of participants pertaining specifically to PBD, only
16.3% indicated they had completed formal coursework in a training program and a mere 10.4%
reported having any internship or residency experience. Less than half of the respondents
(43.0%) had learned about PBD through a workshop or in-service training. As done previously,
respondents were coded dichotomously. This procedure revealed 21.2% had formal training in
PBD with 29.6% having informal training. The remaining 49.2% indicated having had no
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training at all concerning PBD. For more details, see Table 21.
Table 21
Types of Training across Areas of Concern Reported by School Psychologists
Emotional
Disturbances
Level of training
N
PBD
Adult/
Adolescent BD
Percent
N
Percent
N
Percent
Formal course work
218
86.9
41
16.3
94
37.5
Internship or residency
173
68.9
26
10.4
50
19.9
Workshops or in-services
199
79.3
108
43.0
130
51.8
Once the Levene’s F Test established homogeneity of variance, an ANOVA was applied to
determine whether or not there was a significant relationship between the types of training
related to PBD with level of correctness on survey questions 18, 19, and 21. The level of
significance was set a priori (α=.05). Application of the ANOVA indicated there was no
significant relationship between types of training and level of knowledge concerning specific
symptoms of PBD.
Research Question 4. How prepared do current school psychologists feel to consult,
assess, and intervene in cases suspected of an Emotional Disorder?
Preparation and Confidence (Survey Questions 59 – 60)
Participants were asked to describe their quality of preparedness to provide a variety of
services including consultation to parents and teachers, assessment of EDs within the Special
Education framework, and interventions for both academic and behavior concerns. A Likert
Scale was used for response purposes: 1 = Not Prepared at All, 2 = Minimally Prepared, 3 =
Somewhat Prepared, and 4 = Very Prepared. Independent responses were given to each of the
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five areas which yielded the following means: Teacher Consultation M=3.50, SD=.641; Parent
Consultation M=3.33, SD=.730; Assessment M=3.81, SD=.436; Academic Intervention M=3.37,
SD=.676; Behavior Intervention M=3.49, SD=.635.
In total, 251 school psychologists reported on their level of preparation to provide teacher
consultation services for students identified with an emotional disorder and 58% reported they
felt very prepared, 34.8% reported they were somewhat prepared, and 7.2 percent reported
minimally prepared or not prepared at all. Concerning levels of preparation to provide parent
consultation, 46.6% percent of the 251 respondents reported they felt very prepared, 41.8%
reported they felt somewhat prepared, with 9.6% and 2.0% reporting they felt minimally
prepared or not prepared at all respectively. When describing levels of preparedness to provide
academic interventions, 90% of respondents indicated they felt very or somewhat prepared to do
so. Similarly, 93.9% of respondents reported feeling very or somewhat prepared to provide
behavioral interventions. A significant majority of participants (83.3%) indicated they were very
prepared to provide assessment services with another 15.5% feeling somewhat prepared. Only
1.2% of respondents reported they were minimally or not prepared at all (See Table 22).
Table 22
School Psychologists’ Reported Preparedness for Providing Services to Students with an
Emotional Disturbance
Valid Percent
Level of
Preparedness
Very prepared
Teacher
consult.
Parent
consult.
Assessment
Academic
Interv.
Behavior
Interv
58.0
46.6
83.3
46.6
56.6
34.8
41.8
15.5
45.4
37.3
Somewhat
prepared
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Table 22 (Cont.)
Valid Percent
Level of
Preparedness
Teacher
consult.
Parent
consult.
Assessment
Academic
Interv.
Behavior
Interv
Minimally
prepared
6.8
9.6
0.8
6.4
5.2
0.4
1.6
.8
Not prepared at
all
0.4
2.0
Note: The values represent mean percentages.
Recognizing that mood disorder diagnoses are not typically provided by School
Psychologists within school systems, respondents were asked to describe their level of
confidence when it came to identifying signs and symptoms of PBD, making a differential
diagnosis between PBD and other more common disorders, as well as having knowledge of
current medications to treat childhood mania and depression. A Likert Scale was used for
response purposes: 1 = Not At All Confident, 2 = Somewhat Confident, 3 = Confident, and 4 =
Very Confident. Independent responses were given to each of the four areas which yielded the
following means and standard deviations: Identifying signs and symptoms M=2.21, SD=.822;
Making a differential diagnosis M=1.91, SD=.793; Knowledge of current medications for mania
in children M=1.68, SD=.780; Knowledge of current medications for depression in children
M=2.01, SD=.817 (Table 23).
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Table 23
School Psychologists’ Reported Levels of Confidence with PBD
Valid Percent
Level of
confidence
Signs/
Symptoms
Differential
Diagnosis
Knowledge
of Meds –
Mania
Knowledge
of Meds Depression
Very confident
8.4
4.4
3.2
6.0
Confident
21.9
14.3
10.0
15.9
Somewhat confident
53.0
49.8
39.0
51.4
Not at all confident
16.7
31.5
47.8
26.7
Chapter Summary
A total of 1,005 school psychologists’ email addresses were acquired from an Internet
search across eighteen states and email contact was attempted with each of these school
psychologists. An estimated 143 emails were returned due to failure of delivery; however, the
actual number of received emails is likely lower due to junk email folders and spam blockers. In
total, 258 surveys were completed for a response rate of 29.93%. Of these completed surveys, 7
respondents were removed because they reported not working at least 25 hours in a school
setting, which left 251 valid survey responses.
Concerning their highest degree earned, nearly 78% of respondents indicated they held
either a Masters or Specialist’s degree, with just over 20% indicating they held a doctoral level
degree. The remaining 2.0% indicated they held some other school psychology certification as
their highest training acquired. Concerning membership in professional organizations, over half
(60.2%) belonged to NASP, ten-percent to APA, and 7.6% belonged to both organizations.
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Over a third of respondents indicated they held no membership in a national school psychology
organization. A total of 113 respondents (45.2%) indicated they were a National Certified School
Psychologist and of the 108 indicating the approximate number of years considered an NCSP,
nearly three quarters (71.3%) held the NCSP distinction for fifteen years or less. The majority of
respondents (83.1%) were female and regarding the number of years participants had served as a
school psychologist, 64.1% had worked in a public school system for fifteen years or less and
24.6% had served longer than 20 years. Participants also were given an opportunity to describe
the geographical location of their The largest percentage (42.7%) of participants indicated they
worked in a suburban area, while 36.3 percent described their area as rural and 19.4% as urban.
The vast majority (88%) of respondents’ estimated spending at least half of their time was spent
in activities typically associated with special education.
A strong majority (81.9%) of respondents indicated the diagnosis of PBD should not be
based on the DSM criteria for adults, implying some understanding that the childhood disorder
may express itself differently symptomologically. Other statements concerning PBD, however,
did not have this level of agreement amongst participants. Although nearly thirty percent
(29.6%) of respondents reported PBD was not an appropriate diagnosis for children, nearly half
(46%) expressed some level of agreement that most children exhibiting symptoms of PBD would
likely develop into adults with Bipolar Disorder. Only 21.6 percent of respondents thought it
inappropriate to prescribe antipsychotic medications to children exhibiting symptoms of mania
while a similar amount (24.4%) indicated behavioral approaches to addressing PBD behaviors
would not benefit from the concurrent use of medications.
Overall, the vast majority of respondents responded incorrectly to specific statements
about the signs and symptoms of PBD. The course of mania in children was misidentified by
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approximately 85 (84.8%) percent and a similar number (85.1%) did not understand the
differential diagnostic significance of a child with PBD having a higher Performance than Verbal
IQ. An even greater number of respondents (94.4%) were unable to select the most likely
symptom exhibited by children with PBD. A univariate ANOVA indicated there was no
significant relationship between one’s level of education or NCSP designation on the likelihood
of responding correctly to these indicators. Participants not only reported the most difficult
disorders to differentiate from PBD were ADHD and ODD, but also indicated those same
disorders were the most likely to be comorbid with PBD. When asked to distinguish ADHD
from PBD symptomologically, rapid-cycling (85.6%), irritability (82.4%), and elated mood
(80.0%) were identified to be most indicative of PBD, while distractibility (19.2%) and
inattention (19.6%) were thought to be the least symptomatic of PBD.
Participants were asked to estimate the amount of time spent on a variety of special
education activities. Quite easily, the most time spent on a weekly basis was in the provision of
assessment services (M=49.74, SD=21.321) while providing academic interventions (M=7.61,
SD=7.660), functional behavior analysis (M=6.75, SD=5.416), and research (M=1.98,
SD=3.616) were the activities participants were least likely to spend time performing. Nearly all
(98.8%) of the participants indicated they participated as part of a multidisciplinary team to
determine the special education eligibility of students with a possible emotional disorder. During
their assessment process, it was reported by respondents they always or often provide the
following procedures: review of school records (99.6%), medical records (92.4%), and academic
work (96.8%), classroom observation (89.6%), developmental history (81.6), and teacher
interview (96.8%). However, only 3.6% utilize home observations and just over half (51.6%) a
functional behavior analysis.
153
The three assessment measures always used by the majority of participants included
behavior rating measures (86%), cognitive ability measure (65.5%), and an academic
achievement measure (59.8%). Nearly 46% of participants indicated they never administered a
neurologically based evaluation and 42.5% never utilized a projective measure. Respondents
also were asked to consider their level of involvement in three activities occurring before a
student was referred for special education services due to a possible emotional disturbance. Over
half of all respondents indicated they were either often or always involved in research based
interventions (66.2%), functional behavior analysis (57%), and consultation with teachers
(91.7%), before students are referred.
Concerning the frequency with which respondents provided a variety of services for
students with an emotional disorder, respondents always or often consulted with teachers
concerning instructional strategies and academic accommodations (74%), developed behavior
modification plans for school use (64.6%) and consulted with the teacher to implement and
monitor the effectiveness of behavior modification plans (73.1). However, respondents indicated
they were least likely, if ever, to monitor the effects of prescribed medication(s) (80%), provide
caregiver support (80.4%), consult with the student’s doctor (76.3%), or provide small group
support for the student (79.6%). Application of an ANOVA procedure indicated there was no
significant difference in the above-mentioned practices between doctoral and non-doctoral
school psychologists, NCSP designated school psychologists, or between school psychologists
with greater and lesser amounts of experience in schools.
A highly significant amount of respondents had received formal training, either through
training programs and/or internships, in emotional disturbances (91.2%) whereas only 21.2% had
formal training in PBD. A significant relationship between the types of training related to PBD
154
with level of correctness on survey questions 18, 19, and 21 was not found.
Not surprisingly, when asked about perceived levels of preparedness, 83.3 percent of
respondents indicated they felt very prepared to provide assessment services. Respondents
indicated they only felt somewhat or minimally prepared to provide teacher consultation
(41.6%), parent consultation (51.4%), academic intervention (51.8%) and behavior intervention
(42.5%). Concerning PBD in particular, nearly three quarters of respondents reported they were
only somewhat or not at all confident with the signs and symptoms (69.7%), making a
differential diagnosis (81.3%), or having knowledge of the medications currently used to treat
childhood mania (86.8%) or depression (78.1%).
155
Chapter 5
Discussion
Chapter Overview
The purpose of this study was to investigate school psychologists’ level of knowledge
and breadth of experience and training pertaining to PBD. Of added interest were the current
assessment practices and variety of direct services provided to students with PBD and/or ED as
defined by current special education federal guidelines. The study was divided into four sections
not including those questions pertaining to demographic information. First, the perceptions and
general knowledge of school psychologists in the area of PBD was assessed with specific focus
on their understanding of differential diagnosis, comorbidity, and signs and symptoms.
Additionally, whether or not the educational level of school psychologists impacted the level of
knowledge in the area of PBD was examined. Comparisons also were made between those
identified as nationally certified (NCSP) and those who were not. Next, the general practices of
school psychologists regarding the assessment and identification of children suspected of having
an ED were explored to determine how well these methods aligned with current understanding of
best practices. This included questions regarding the types of services provided before and after
special education identification, such as counseling, academic and behavioral interventions, and
teacher consultation, as well as questions about the methods and instrumentation used when
evaluating students referred for an emotional disorder. Similar to section one, a comparison was
made between the level of involvement and types of practices of more highly trained school
psychologists. Section three inquired about the types of training school psychologists received
specifically in the area of PBD and ED identification and intervention and if the different types
of training translated into a noticeable difference in school psychologist practices. The last
156
purpose of this study was to explore how prepared and confident school psychologists feel to
provide consultation, assessment, and intervention in cases of PBD and ED.
Knowledge
Perceptions of PBD
Participants were provided a variety of statements representing common thoughts and
perceptions about PBD. Only the question concerning whether or not participants thought the
diagnosis of PBD should be based on the DSM adult diagnostic criteria amassed what could be
considered a significant consensus. Nearly 82% of respondents expressed some level of
disagreement concerning the use of the DSM adult criteria for BD with children. Although most
school psychologists may believe different criteria should be applied to children suspected of
PBD, there may not be any clear idea on what those criteria should be. In addition, as will be
described later, there appears to be scant knowledge about what the current research describes as
the unique features of PBD.
When asked if PBD is currently under-diagnosed, the majority of respondents were either
undecided or disagreed. Despite there being a historical view PBD has been misdiagnosed in
favor of more familiar disorders such as ADHD, ODD, and CD (Morselli & Elgie, 2003; Papolos
& Papolos, 2006) or undiagnosed due to cultural reluctance to identify mental health disorders in
the young (Egger & Emde, 2011), when asked if PBD is currently under-diagnosed in the United
States the majority of school psychologists were either undecided or disagreed. It would be
beneficial for future research to explore the reason(s) school psychologists hold this view. Does
there remain reluctance on the part of school psychologists to identify children with a mental
health disorder in general and PBD in particular? Or perhaps, practitioners fear the lack of
distinct, pediatric-specific, diagnostic criteria is leading to misdiagnosis? Considering only 30%
157
thought PBD should not be diagnosed and 46% thought it was likely PBD was a precursor to
adult BD, there is some indication the reason for practitioners’ uncertainty about the utility of the
diagnosis may be more due to diagnostic confusion than to disbelief in the disorder. If so,
training institutions may want to examine their curriculum concerning pediatric psychopathology
to confirm the information being taught about PBD is reflective of current research.
School psychologists expressed a primarily mild or undecided view about the efficacy of
psychopharmacological and behavioral treatment of PBD. Perhaps this is an expression of an
understandable reluctance to utilize psychotropic medications with a child population;
nevertheless, current research continues to recognize the necessity for including a
psychopharmacological response as the first line of treatment for mania in children as well as an
essential element for supporting psychosocial interventions (McClure, 2002; Weckerly, 2002).
Furthermore, mood-stabilizing compounds such as Lithium and Depakote have long been
recognized by the AACAP to be useful in treating PBD, even though the effects of such agents
on children are not fully understood nor in many instances approved by the FDA (Pavuluri et al.,
2005b). Most school psychologists lack the licensure and training necessary to prescribe
medications; however, they are often in positions to provide guidance to caregivers wrestling
with treatment options, consultation with teachers dealing with unwanted behaviors related to
medicinal side effects, and observation of the student’s day to day response to psychotropics.
This indecision on the part of practitioners may be further evidence many school psychologists
have not availed themselves to the current literature on the treatment of childhood mania and
depression. It is also possible school psychologists either believe they are not in a position to
provide this type of care or acknowledge they are ill-equipped to do so. Regardless of the
reason, the ability of a school psychologist to provide meaningful consultation to teachers and
158
caregivers or to monitor side effects of medications used to treat PBD are limited by this
confusion.
As noted earlier, retrospective studies in adults with BD indicate up to 60% experienced
the onset of their BPD before 20 years of age (Pavuluri et al., 2005a; Soutullo et al., 2005) with
10%-20% reporting the onset before 10 years of age (Egeland et al., 2003). Caution must be
exercised when considering ex post facto information, yet there seems to be some evidence
supporting the idea many adults diagnosed with BD exhibited symptoms of mania as children.
Most survey respondents are either uncertain or lean in the direction of thinking a child with
PBD is likely to continue exhibiting symptoms into adulthood; however, the implications of this
“lean” as well as the benefit of asking this particular question remain unclear.
Signs and Symptoms
For over twenty years researchers have made a distinction between adult and childhood
expressions of BD (Carlson, 1995, 2005; Geller, Tilman, Craney, & Bohofner; Weller et al.,
1995). For instance, it is known adults are more likely to present with discrete cycles of mania,
hypomania, and depression, and tend to have an episodic and acute course. Children on the other
hand tend to exhibit mania and depression in a more chronic and continuous manner. Geller and
colleagues in 1995 coined the term “complex cycling” to describe PBD as a pattern of brief
cycles embedded within a more prolonged episode. It is also widely held by the research
community that mood shifts in children are more likely to be expressed as mixed states – the
simultaneous exhibition of both manic and depressive symptoms (Geller et al., 1995; Lofthouse
et al., 2004). Therefore, it is a bit disconcerting most school psychologists were unaware of this
distinction (85.1%). The consequences of this confusion may include: (a) missed opportunities
to intervene early; (b) misidentification of a mental health disorder as either ADHD or a
159
behavioral issue; (c) failure to employ best practices when providing interventions of a child with
an emotional disorder. Such consequences, whether experienced singularly or as a whole, will
only exacerbate the distress of a child with PBD.
Biederman and colleagues (1996) demonstrated the ease of misdiagnosing PBD as
ADHD and reported nearly all (96%) children who met the criteria for PBD did so for ADHD,
whereas only 16% of ADHD patients met the criteria of mania or hypomania. A similar finding
by Geller & Luby (1997) reinforced the historical difficulty of differentiating the two disorders
as well as the likelihood a child presenting bipolar symptoms is likely to be classified as ADHD.
However, two key features of mania in children, elevated and/or irritable mood, are not shared
with ADHD (Lofthouse, Mackinaw-Koons, & Fristad, 2004). Since the year 2000, the National
Association of School Psychologists has provided a list of symptoms to be used when identifying
an altered mood, including inflated self-esteem, grandiosity, pressured speech, racing thoughts,
and risk-taking. Although the majority of school psychologists identify “irritability” as the most
likely symptom they will observe, it is not known how school psychologists are defining the
term. The term “irritability” is shared with several other disorders, which may make it very
difficult to differentiate PBD primarily based on that symptom. There also is evidence
symptoms of euphoria, pressured speech, and grandiosity, in children are more specific to mania
than other associated symptoms such as aggression, irritability, distractibility, or increased motor
activity (Geller et al., 2000; Geller et al., 2002b). Only a small number of school psychologists
indicated they would be expecting signs of euphoria (5.6%), grandiosity (3.2%), or flight of ideas
(4.4%) in a child with PBD. Instead, they expected to observe hyperactivity (29.1%) and
irritability (57.7%). Unfortunately, it is not known if this indicates a failure to understand
differentiating symptoms or if the problem lies in how the question is asked. For example, school
160
psychologists were asked what they expected to see in a child with PBD and not “what is the best
symptom to differentiate PBD from other disorders.”
Understandably, nearly a third of school psychologists identified hyperactivity as the
other symptom they expected to observe. Therefore, it is uncertain how school psychologists
differentiate between the hyperactive symptomology associated with ADHD and the hyperactive
symptomology often associated with PBD.
Because hyperactive symptomology is
symptomatically shared by both PBD and ADHD, it is essential school psychologists be better
informed on those symptoms unique to PBD. As mentioned previously, the presence of
grandiosity, elated mood, flight of ideas, and decreased need for sleep are more common to PBD
but may not be as readily identified.
It also has been suggested that the two disorders can be distinguished by examining the history of
the child to determine the persistence and earlier onset of ADHD versus the lack of euphoria or
depressed mood of PBD (James & Javaloyes, 2001).
School psychologists who want to improve their ability to understand mental health
disorders, to effectively respond to students with a mood disorder, and to communicate with the
medical practitioners treating a child diagnosed with PBD, need to better understand the
biological basis of childhood pathology (Davis, 2006). Neuropsychological research provides
insight into the brain networks that could be disrupted in PBD and the functional impairments
underling the behavioral and emotional dyscontrol characteristic of the disorder (Doyle et al.,
2005). One of the most commonly reported neuropsychological findings in children with PBD is
that children with PBD typically possess a significantly higher WISC Verbal IQ (VIQ) than
Performance IQ (PIQ). Given the formal training school psychologists have in cognitive
assessment as well as the near universal popularity of the WISC across school districts (Flanagan
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& Kaufman, 2009), this differential characteristic could be invaluable. Unfortunately, only a
small portion (15%) of school psychologists appear to know of this indicator, even though it has
been known since 1983 and repeatedly supported by the literature to the current day.
Differential Diagnosis and Comorbidity
Several other disorders not only share symptoms but also often coexist with PBD. In a
review of research on rates of comorbidity of PBD with other disorders, it was reported that rates
ranged between 11% and 75% for ADHD, 46.4% and 75% for ODD, 5.6% and 37% for CD,
(Pavuluri et al., 2005). The ease of misdiagnosing PBD as some other disorder is further
illustrated by the work of Biederman and colleagues (1996) who found 96% of children who met
the criteria for BD did so for ADHD; however, only 16% of ADHD patients met the criteria of
mania/hypomania. Similarly, in another study it was reported of the children presenting bipolar
symptoms, approximately 90% of prepubertal and 30% of adolescent subjects were classified as
ADHD (Geller & Luby, 1997). This significant comorbidity makes prognosis and treatment all
the more difficult for children with BD. Respondents seem to recognize the likelihood of
comorbidity with PBD and correctly indicated the most likely comorbid disorder would be
ADHD.
Participants were given a list of twelve symptoms and asked to indicate which symptoms
were more indicative of PBD than of ADHD. Rapid-cycling, irritability, and elated mood were
the symptoms school psychologists thought would be most indicative of PBD. These results
may provide some encouragement and confidence that school psychologists can adequately
differentiate PBD from ADHD; however, the survey question and participants’ responses may
just as likely indicate they are very familiar with the symptoms of ADHD and knew which
symptoms did not belong.
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Effects of Training and NCSP Designation
Participants were placed in one of two groups depending on their reported level of
education. Those with a Masters degree level of training were in one group and those with a
Doctoral level of training were placed in another. Surprisingly, based on the current data, the
level of training received by school psychologists does not appear to significantly impact their
understanding of PBD. In other words, those with additional formal training were no more likely
to possess correct knowledge about PBD compared to those with less training.
The NCSP process was created by NASP to establish a nationally recognized standard to
be used as a measure of professionalism for interested agencies as well as to promote the
continuing professional growth and development of NCSPs (NASP, 2014). This includes
NASPs commitment to the import of school mental health services, which states:
The National Association of School Psychologists (NASP) advocates for the provision of
coordinated, comprehensive, culturally competent, and effective mental health services in
the school setting, which include prevention and early intervention services as well as
therapeutic interventions. These services should emphasize competence enhancement,
prevention of mental illness, education, early intervention, and coordination of intensive
interventions to adequately address student mental health needs (NASP, 2014)
Given the national interest and federal mandate for school psychologists to provide frontline
mental health support as well as NASP’s commitment to mental health, one might expect NCSPs
to have greater knowledge and confidence when it comes to PBD than those without the
designation. However, according to the current data, meeting the qualifications for and the
reception of the NCSP designation makes little to no difference in a practitioners ability to
identify the symptoms of PBD. These results, if confirmed in further research, should be of some
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concern to training institutions as well as professional organizations.
General Practice
Time Spent in Special Education Activities
Historically, of all the services provided by school psychologists the greatest amount of
time is spent providing assessment services (Hosp & Reschly, 2002). Assessment provides a
process to identify a student’s needs and to assist in developing and implementing interventions
(NASP, 1993). Given this understanding of the role of a school psychologist, it is not surprising
the average practitioner participating in the current survey reports spending half of their time in
the Special Education identification process. Compared to the other listed activities, respondents
spend much more time in assessment for special education services than providing counseling,
interventions, consultation, or behavior analysis.
In 1997, Hoagwood and Erwin estimated over 20% of school-age children qualified for a
psychiatric diagnosis and the requisite attention, treatment, and support, which come with such
mental health needs. The U.S. Department of Education provided a more conservative estimate
of 11% of school aged children were likely to have mental health impairments resulting in
extreme functional limitations. Of course, as has been noted previously, the evidence suggests
that such a percentage is low due to under-identification of mental health disorders in children
(Walker, Ramsay, & Gresham, 2004). All of this begs the question, if school psychologists are
spending at least half of their time in performing assessments, then do they have the time, let
alone training, to provide other essential services? It could be assumed that those who spend less
time in assessment spend more time in related services, yet based on the current study very little
time is invested in counseling, academic and behavior intervention, functional behavior analysis,
or consultation, all of which are necessary to provide best practice support.
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Role of Practitioner
School psychologists typically serve as a regular participant on multidisciplinary teams
responsible for determining the special education eligibility of students with a possible emotional
disturbance. The role of the school psychologist in the case conference is not simply to provide a
summary report of the assessment, but to lend their expertise in determining what is best for the
student. Nearly all (98.8%) of the respondents reported they regularly participated as part of a
multidisciplinary team making special education service determinations.
Evaluation methods and instruments
When assessing a child for ED school psychologists should follow IDEIA or their
licensing state’s guidelines. The purpose of the evaluation is to identify students’ needs and to
assist in developing and implementing interventions when warranted (NASP, 1993). According
to NASP (2005), when assessing students with a possible emotional disturbance, school
psychologists should be comprehensive. This includes conducting observations across settings,
times, and contexts, collecting contextual, medical, and developmental information, and
assessing academic functioning. Based on the data collected, the majority of participants reported
including these methods in their evaluation practice.
Another aspect of NASPs definition of comprehensiveness is performing a functional
behavior assessment (FBA). An FBA involves the assessment and linking of environmental
conditions to specific behaviors so these behaviors can be predicted and controlled (Ervin,
Ehrhardt, & Poling, 2001). The use of an FBA was first included in and required by the 1997
amendments to the Individuals with Disabilities Education Act. By conducting an FBA, the
practitioner gathers essential evidence regarding whether the student’s problematic behaviors can
be corrected or if the problem is more organic and in need of special education and related
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services (Rudy & Levinson, 2008). According to the current study, not quite a third (29.8%) of
participants reported always utilizing an FBA as part of the evaluation process. The reason or
reasons why seventy percent of respondents are not consistently if ever applying an FBA is a
matter of conjecture and perhaps of interest for further study. Although it is possible FBA’s are
being provided by school personnel other than the school psychologist, it is more likely FBAs
are not being employed as frequently as they should which is disconcerting.
NASP also expects school psychologists to use appropriate assessment methods. The
potential effects of identifying a child as having an emotional disorder necessitate the use of
instruments that have empirically demonstrated high reliability and validity. Both indirect and
direct assessment methods should be used when warranted. Indirect methods may include
behavior checklists, structured interviews, rating scales, and other recognized assessment
techniques. Based on the current data, the majority of respondents are likely utilizing
appropriate measures during the assessment process. However, projective measures and a
neuropsychological evaluation are rarely employed.
Even though administration of a cognitive ability measure is typically not required or
expected to identify a student as ED, 89.6% respondents indicated they administer a cognitive
measure often or always. This frequent use of cognitive ability measures during the evaluation
process of a child suspected of an ED may provide an opportunity to better equip school
psychologists to knowledgably use the WISC when making a differential determination. Even if
practitioners prefer other cognitive measures, they may choose to utilize the WISC when
necessary. Because school psychologists receive a significant amount of formal training in the
administration and interpretation of standardized measures, training institutions should educate
pre-service school psychologists how to apply WISC results in this way when evaluating a child
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for PBD or ED.
Services provided
As noted previously, school psychologists possess expertise in a variety of areas and are
likely one of the most qualified persons in the school system to provide services often required
by a student with PBD or ED. Organizations like the Child and Adolescent Bipolar Foundation,
the Juvenile Bipolar Research Foundation, and authors such as Fristad and Goldberg-Arnold
(2004), and Lofthouse and Fristad (2006) implore school psychologists to provide these services
including being aware of and managing medication side effects and preparing for episodes of
intense emotion, considering alternatives to regular classrooms, and educating school-based
teams of the diagnosis and its implications on school performance. Unfortunately, the frequency
which some of these helpful services are provided may not be as often or consistent as one would
hope. For instance, according to respondents, monitoring the effects of prescribed medications,
providing individual and/or group counseling, and consulting with the student’s doctor occurs
inconsistently if at all. When examined further, neither a higher level of education nor possession
of the NCSP designation results in these activities happening more frequently. It is likely the
reasons for this inconsistency are mostly due to time constraints. However, another reason may
be many school psychologists lack the formal preparation and the confidence necessary to
provide such services. More encouraging was the indication school psychologists are more
likely than not to develop behavior modification plans, and consult with the teacher concerning
instructional and behavioral interventions.
Types of Training
When asked about the type of training received in the area of ED, 91% of respondents
reported they had received formal training either through coursework and/or an internship
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addressing ED. Less than 10% indicated their only training on this subject was through a
workshop or in-service. The quality of preparation changes considerably when participants were
asked about the type of training they had received concerning PBD in particular. A mere one
fifth (21.2%) of participating school psychologists reported having received formal training with
another third (29.6%) of respondents indicating they only had informal training via workshop or
in-service. Of greater concern is that nearly one half (49.2%) indicated they had no training at
all concerning PBD. There are a couple of implications resulting from this data.
One implication may be that school psychologists are not actively participating in
professional development opportunities. Or, perhaps, there is a dearth of quality curriculum for
those who regularly avail themselves to in-service and workshop experiences. Regardless of
one’s level of preparation, there is an expectation that the practitioner will participate in
continued professional development (CPD; Fagan & Wise, 2000). Furthermore, NASP sees
CPD as “ . . . a responsibility of all school psychologists . . . (NASP, 2014) as well as an
organizational responsibility to facilitate CPD experiences. An additional implication may be
school psychology training programs are more likely to emphasize ED as defined by IDEIA with
little to no attention given to specific clinical diagnoses such as PBD.
Preparation and Confidence
The lack of formal training in PBD mentioned above is likely a significant contributor to
participants’ overall lack of confidence in identifying signs and symptoms of PBD, making a
differential diagnosis between PBD and other more common disorders, and having knowledge of
current medications used to treat mood disorders in children. This is not surprising because
school psychologists within school systems are not required to make diagnoses of PBD nor
respond to childhood mood disorders in a clinical way. Nevertheless, because of the professional
168
and national mandate to provide mental health services by way of the school system,
professional and pre-service school psychologists should be better prepared. The existing
dichotomy between childhood mood disorders and identification of emotional disturbances is
further illustrated by the responses received concerning how prepared school psychologists feel
when providing services to students with an emotional disturbance. Nearly 93% of participants
reported an overall sense of being very or somewhat prepared to provide the services necessary
to assess, intervene, and consult, when a student is suspected of having or has been identified
with an Emotional Disturbance.
Limitations of Study
This survey was electronically sent to school psychologists across the United States.
Amidst the advantages of utilizing digital technology, there are some disadvantages. For
example, it is easy to delete an email or to forget about a survey invitation in the midst of a full
inbox. Furthermore, a smaller than expected response rate to this survey was in part due to digital
failure to deliver survey invitations (e.g., inactive email accounts).
In retrospect, the survey was too long and too broad. Despite efforts to create a survey
that was quick and easy to complete, that objective was not met. The average time to complete
the survey was 19 minutes and is likely a contributing reason why 16% of those who started the
survey did not complete it. Busy practitioners may have felt the time commitment was too great.
In the future, it may be helpful to enlist full-time practicing school psychologists to test-drive a
survey in development and not solely rely upon clinicians in private practice or those serving in
academia.
It was hoped the breadth of the survey would provide researchers as well as those
involved in the training and supervision of school psychologists with an abundance of helpful
169
information. Although the current study has collected data, which can be used to inform the
field, the current survey required too much demographic information and attempted to examine
two significant topics at the same time. In the future, shorter surveys targeting more narrow
subjects may result in deeper knowledge.
Because the topic of PBD was communicated through the introduction email as well as
the entry page of the survey, this may have been a draw for practitioners with an awareness of
and interest in PBD. Moreover, school psychologists who were unfamiliar with PBD or felt too
uninformed about the subject to have made a meaningful contribution may have lacked the
motivation necessary to complete the survey. Therefore, school psychologists responding likely
had more interest in the topic than a true cross sample of the population. Although this is a
common limitation of most surveys in general and digital surveys in particular, a briefer more
specific survey, or a clearer explanation of who could participate, may have minimized this
effect.
Another group of non-respondents may have been school psychologists who primarily
work with an adolescent population. By its very definition, PBD is addressing the mental health
concerns of a prepubescent population. Larger school districts often have more than one school
psychologist with responsibilities for assessment and intervention to be divided according to
school building or age group (e.g., elementary, secondary). It could be argued all school
psychologists should be well informed of the issues effecting students regardless of age and
therefore willing to participate in a survey focused on children; however, given the already
acknowledged constraints on school psychologists time and the frequent need to narrow one’s
expertise, it is an understandable problem.
Although it would have only added more questions to an already lengthy survey, it is
170
problematic that there is uncertainty as to how knowledgeable school psychologists are about BD
in general. For instance, several questions imply a distinction between the symptoms of PBD and
Adult/Adolescent BD and makes the assumption participants know what the diagnostic criteria is
for post-pubescent BD.
The current study was most limited by the non-random acquisition of participants.
Even though there was an attempt to select states equally across the four NASP regions, those
states were not selected randomly but by the researcher’s own sense of which state would yield
the most results. As a reminder, acquiring potential participants was done by initially trying to
identify every public school district within a state and then locating a website for each of those
districts and associated schools. This resulted in invitations to participate being sent to only
those individuals with a published email address easily located on a local school or school
district’s web page. In addition, school psychologists who work at full-time denominational and
independent schools were not included. To complicate matters further, school districts and local
schools vary on whether or not their practitioners (i.e., teachers, school psychologists, social
workers, etc.) are identified at all through a website, let alone if an individual professional email
address is provided.
Recommendations for Future Research
Even though a limitation of this study was its breadth, the data collected provides several
opportunities for further study. First, this survey asked questions concerning PBD as well as ED,
both of which are broad albeit related subjects. Future study could explore each of these topics
separately and more narrowly through the use of more specific questions. Not only would this
likely result in a reduction of interpretive error but also provide more actionable data. Second,
given the variety of expression between bipolar disorder in children and adolescents, future
171
research on PBD could focus on school psychologist’s who spend the majority of their time
working with a prepubescent population. Third, state specific studies may replicate this survey
to contrast state results with national data. For that matter, school districts may wish to explore
how they compare to the national average on assessment and intervention practices of its
practitioners. An additional benefit of this recommendation would be the increased likelihood of
acquiring a more thorough list of school psychologists by accessing state licensure records.
Fourth, several issues were raised by the data that exceeded the purpose of this study. For
example, school psychologists selected “irritability” as a primary indicator of PBD. Although
irritability is an indicator, it often expresses itself differently in children with PBD. Questions
examining what school psychologists mean when using this term, as well as others, may be
helpful for future educational opportunities. Fifth, this study may be replicated with specific
school psychology professional organizations such as NASP and APA to make further
comparisons on types of training, levels of confidence, and feelings of preparation. Sixth, not all
school psychologists work full-time in a school setting. Because approximately 20% of school
psychologists are also employed in independent private practice, non-school agencies,
universities, and community or regional mental health centers (Fagan & Wise, 2000), an attempt
could be made to explore how this population differs from those practitioners in the public
schools.
Chapter Summary
The purpose of this study was to investigate the current knowledge and perceptions of
school psychologists concerning PBD, their level of training and certification, as well as their
current assessment practices and types of services provided within the school setting. School
psychologists generally believe PBD should be determined with a different set of criteria than
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those supplied by the DSM, which is used to diagnosis adolescents and adults. This belief may
be rooted more in a school psychologist’s overall understanding of developmental differences
across many disorders and not necessarily indicative of a clear understanding of the diagnostic
differences between pre- and post- pubescent individuals with BD. When asked if PBD is
currently under-diagnosed, most school psychologists reported they either disagreed or were
undecided. Further research may reveal whether or not school psychologists hold this opinion
because they are uncertain of the diagnostic criteria, genuinely believe it is mis- or overdiagnosed, or have an aversion to diagnosing children with mental health disorders such as BD.
Given only a small minority of school psychologists expressed outright disagreement with the
diagnosis, it is likely many think PBD is potentially a viable diagnosis. However, despite a belief
in the likely efficacy of the diagnosis, practitioners were undecided about the course of PBD, the
use of psychotropic medications with children as well as the benefits of a behavioral approach to
treatment. It is likely school psychologists feel unprepared or too uninformed to hold a confident
opinion about these particular issues.
School psychologists’ knowledge of the signs and symptoms of PBD appeared to be
limited and inaccurate. Although there remain significant difficulties in accurately diagnosing
PBD, there are known indicators, which increase the likelihood of a correct differential
diagnosis. If known, these indicators will help a school psychologist during the assessment
process. When school psychologists were asked how PBD presents, the majority incorrectly
indicated the course of mania in children was acute and episodic. Euphoria is not always easily
identified; however, it is thought by many to be one of the best indicators to distinguish PBD
from other disorders. Grandiosity and flight of ideas are also symptoms used in the literature to
differentiate PBD over ADHD. Only a very small number of school psychologists indicated they
173
would be expecting signs of euphoria, grandiosity, or flight of ideas in a child with PBD.
Instead, they expected to observe hyperactivity and irritability.
Expecting to see hyperactivity is understandable since PBD and ADHD share it as a
descriptor for a suite of behaviors. Although there are qualitative differences in how
hyperactivity is commonly displayed in PBD and ADHD, it may be more beneficial for school
psychologists to look for more specific behaviors such as the presence or absence of grandiosity,
elated mood, and flight of ideas. Like “hyperactivity”, the term “irritability” is also shared when
describing other disorders. Even though the majority of participants identified irritability as a
likely symptom of PBD, knowing how they define irritability would instill greater confidence
that they understand how this symptom is often displayed in children with PBD.
School psychologists having a good understanding of the biological basis of childhood
psychopathology has long been encouraged by neuropsychologists. Ongoing neuropsychological
research into mood disorders provides valuable insights to identifying PBD. One such insight is
the tendency for children with PBD to possess a significantly higher WISC Verbal IQ than
Performance IQ. Unfortunately, despite formal training in assessing cognitive abilities, this
characteristic was not known by the vast majority of respondents.
One of the reasons PBD is often difficult to identify is not only its shared symptomology
with other disorders but the likelihood of PBD being comorbid with those disorders. When
presented with a set list of symptoms, survey participants successfully identified rapid-cycling,
irritability, and elated mood as more indicative of PBD. It is hoped these results are an
indication of respondents knowledge of PBD; however, it may simply be an indicator of how
well versed respondents were with the symptoms of ADHD.
At the beginning of this research project, it was expected that the level of a practitioner’s
174
education would result in greater knowledge and understanding of PBD. Unfortunately, based
on the data collected through this study, school psychologists holding a Doctoral degree are no
more likely to understand PBD than those with a Masters or Specialists degree. This
phenomenon also held true when comparing those participants with the NCSP designation to
those without. If future research confirms these results, it behooves organizations like NASP as
well as school psychology training institutions to seriously consider the implications.
This study confirmed the findings of previous research: the typical school psychologist
continues to spend more time providing assessment than doing anything else. Sound
psychosocial assessment is critical to the functioning of a school, and yet the mandate to also
provide care to students with mental health problems requires a host of other services. Based on
the results of this study, school psychologists may not have the time, training, or confidence to
adequately provide academic and behavioral interventions, teacher and caregiver consultation, or
other services associated with student care like monitoring medication side effects or counseling.
Despite the entreaties of researchers and organizations specializing in childhood mood disorders,
it is likely school psychologists are not providing these services as frequently as they should.
Similarly, neither a higher level of education nor possession of the NCSP designation resulted in
these activities happening more frequently.
The majority of participants provide best practice evaluation methods such as observing
classrooms, collecting medical and developmental histories, reviewing school records and
assessing academic performance. However, according to the data, there may be a failure on the
part of school psychologists to provide or at least participate in an FBA, which is an essential
piece of the assessment process for emotional disturbance. Whether this is an accurate
conclusion or not, further research should investigate the frequency with which FBAs are
175
employed along with the role school psychologists play in conducting FBAs.
Aside from projective measures or neuropsychological evaluations, the majority of
survey participants utilize appropriate measures in the assessment process. Of particular interest
was the frequent use of cognitive measures when making a determination of an ED student.
Although typically not required, this may represent an opportunity to utilize the WISC and to
examine the differences in a student’s PIQ and VIQ.
Based on the current results, most (91%) respondents have received formal training
addressing ED. However, nearly half had neither formal nor informal training pertaining to
PBD. This lack of education about PBD may be a primary reason for some of the poor results
above. It is likely this lack of training in PBD also contributes to participants’ lack of confidence
in identifying signs and symptoms of PBD as well as making a differential diagnosis between
PBD and other disorders.
This current study found reasons to be optimistic as well as reasons to be concerned
about school psychologists’ knowledge and training in the area of PBD. The level of education
and the designation of NCSP made no noticeable difference in what was known or in what was
practiced. Overall, it is apparent school psychologists would benefit from more in-depth, formal
training, as well as ongoing consultation if they are to adequately meet the national and
organizational demands to provide adequate mental health care for young students.
176
References
Abbott, M., Walton, C., Tapia, Y., & Greenwood, C. R. (1999). Research to practice: A
“blueprint” for closing the gap in local schools. Exceptional Children, 65, 339–352.
Achenbach, T. M. (1991a). Interpretive guide to the 1991 CBCL, YSR and TRF profiles.
Burlington, VT: University of Vermont, Department of Psychiatry.
Achenbach, T. M. (1991b). Manual for the child behavior checklist/4-18 and 1991 profile.
Burlington, VT: University of Vermont, Department of Psychiatry.
Achenbach, T. M., & Edelbrock, C. (1983). Manual for the child behavior check-list and revised
child behavior profile. Burlington: University of Vermont, Department of Psychiatry.
Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987). Child/adolescent behavioral and
emotional problems: Implications of cross-informant correlations for situational specificity.
Psychological Bulletin, 101, 213-232.
Akiskal, H. S. (1983). The bipolar spectrum: New concepts in classification and diagnosis. In L.
Grinspoon (Ed.), Psychiatry update: The American Psychiatric Association annual review
(Vol. 2, pp. 271-292). Washington, DC: American Psychiatric Press.
Akiskal, H. S. (2003). Validating 'hard' and 'soft' phenotypes within the bipolar spectrum:
Continuity or discontinuity. Journal of Affective Disorders 73, 105.
Akiskal, H. S., Rosenthal, R. H., Rosenthal, T. L., Kashgarian, M., Khani, M. K., & Puzantian,
V. R. (1979). Differentiation of primary affective illness from situational, symptomatic,
and secondary depressions. Archives of General Psyhciatry, 36, 635-643.
Allinder, R. M., Bolling, R. M., Oats, R. G., & Gagnon, W. A. (2000). Effects of teacher selfmonitoring on implementation of curriculum-based measurement and mathematics
computation achievement on students with disabilities [Electronic version]. Remedial and
177
Special Education, 21, 219–226.
Aln, S. R., & Torgersen, S. (1993). Mood disorders: developmental and precipitating events.
Canadian Journal of Psychiatry, 38, 217–224.
Althoff, R. R., Faraone, S. V., Rettew, D. C., Morely, C. P., & Hudziak, J. J. (2005). Family,
twin, adoption, and molecular genetic studies of juvenile bipolar disorder. Bipolar
Diosrders, 7, 598-609.
Altschule, M. D. (1976). The development of traditional psychopathology: A sourcebook.
Hemisphere Pub. Corp.: New York.
Ambelas A. (1987). Life events and mania. A special relationship? British Journal of Psychiatry,
150, 235–240.
Ambrosini, P. J. (2000). Historical development and present status of the Schedule for Affective
Disorders and Schizophrenia for School Aged Children (K-SADS). Journal of the
American Academy of Child and Adolescent Psychiatry, 39, 48-58.
American Academy of Child and Adolescent Psychiatry (1998). Summary of the practice
parameters for the assessment and treatment of children and adolescents with depressive
disorders. Journal of the American Academy of child and Adolescent Psychiatry,
37(Suppl. 10), 107-125.
American Psychiatric Association (1994). American Psychiatric Association practice guideline for
the treatment of patients with bipolar disorder. American Journal of Psychiatry,
151(Suppl), 1-36.
American Psychiatric Aassociation (1987). Diagnostic and Statistical Manual of Mental
Disorders (3rd ed., rev.). Washington, DC: American Psychiatric Association.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders
178
(4th ed., text rev.). Washington, DC: American Psychiatric Association.
American Psychological Association (2008). Guidelines and principles for accreditation of
programs in professional psychology. Washington, DC: Author.
American Psychological Association (2012). Accredited programs in School Psychology.
Retrieved July 9, 2012, from http://www.apa.org/ed/accreditation/programs/accredschool.aspx
Anderson, J., & Werry, J. S. (1994). Emotional and behavioral problems. In I. B. Pless (Ed.), The
epidemiology of childhood disorders (pp. 304 – 338). New York: Oxford University
Press.
Angold, A., & Costello, E. (2009). Nosology and Measurement in Child and Adolescent
Psychiatry. Journal of Child Psychology and Psychiatry, 50(1-2), 9-15.
Annell, A. L. (1969). Lithium in the treatment of children and adolescents. Acta Psychiatrica
Scandinavica, 45(suppl 207), 19-30.
Anthony, E. J. (1975). Childhood depression. In E. J. Anthony, & T. Benedek (eds.) Depression
and Human Existence. Boston: Little, Brown.
Anthony, J., & Scott, P. (1960). Manic-depressive psychosis in childhood. Journal of Child
Psychology and Psychiatry, 1, 53-72.
Axelson, D., Birmaher, B., Strober, M., Gill, M. K., Valeri, S., Chiappetta, L., et al. (2006).
Phenomenology of children and adolescents with bipolar spectrum disorders. Archives of
General Psychiatry, 63, 1139-1148.
Baethge, C., Glovinsky, I., & Baldessarini, R. J. (2004). Manic-depressive illness in children: An
early twentieth-century view by Theodor Ziehen. History of Psychiatry, 15(2), 201-226.
179
Baldessarini, R.J. (1970). Frequency of diagnoses of schizophrenia vs. affective psychoses from
1944 - 1968. American Journal of Psychiatry, 127, 759-763.
Barrowclough, C., & Hooley, J. M. (2003). Attributions and expressed emotion: A review.
Clincial Psychology Review, 23, 849-880.
Basso, M. R., Lowery, N., Neel, J., Purdie, R., & Bornstein, R. A. (2002). Neuropsychological
impairment among manic, depressed, and mixed-episode inpatients with bipolar disorder.
Neuropsychology, 16(1), 84-91.
Baumann, B., & Bogerts, B. (2001). Neuroanatomical studies on bipolar disorder. British
Journal of Psychiatry, 178(supp. 41), 142-147.
Baxendall, B. W. (2003). Consistent, coherent, creative: The 3C’s of graphic organizers.
Teaching Exceptional Children, 35(3), 46–53.
Bearden, C. E., Hoffman, K. M., & Cannon, T. D. (2001). The neuropsychology and
neuroanatomy of bipolar affective disroder: A critical review. Bipolar Disorders, 3, 106
150.
Bebbington, P., & Ramana, R. (1995) The epidemiology of bipolar affective disorder. Social
Psychiatry and Psychiatric Epidemiology, 30, 279–292.
Beigel, A., & Murphy, D. L. (1971). Assessing clinical characteristics of the manic state.
American Journal of Psychiatry, 128, 688-694.
Benabarre, A., Vieta, E., Martinez-Aran, A., Garcia-Garcia, M., Martin, F., Lomena, F., & et al.
(2005). Neuropsychological disturbances and cerebral blood flow in bipolar disorder.
Australian and New Zealand Journal of Psychiatry, 39, 227-234.
180
Benner, G. J., Nelson, J. R., & Epstein, M. H. (2002). The language skills of students with
emotional and behavioral disorders: A literature review. Journal of Emotional and
Behavioral Disorders, 10, 43–59.
Bennett, K., Lipman, E., Brown, S., Racine, Boyle, M., & Offord, D. (1999). Predicting conduct
problems: Can high risk children be identified in kindergarten and grade 1? Journal of
Consulting and Clinical Psychology, 67, 470–480.
Bergan, J., & Kratochwill, T. R. (1990). Behavioral consultation and therapy. New York:
Plenum Press.
Bhangoo, R. K., Dell, M. L., Towbin, K., Myers, F. S., Lowe, C. H., Pine, D. W., & et al. (2003).
Clinical correlates of episodicity in juvenile mania. Journal of Child and Adolescent
Psychopharmacology, 1394, 507-514.
Biederman, J. (1998). Mania is mistaken for ADHD in prepubertal children. Journal of
American Academy of Child and Adolescent Psychiatry, 37, 1091-1093.
Biederman, J., Faraone, S., Mick, E., Wozniak, J., Chen, L., Ouellette, C., & et al. (1996).
Attention-deficit hyperactivity disorder and juvenile mania: An overlooked comorbidity?
Journal of the American Academy of Child and Adolescent Psychiatry 35(8), 997-1008.
Biederman, J., Faraone, S. V., Wozniak, J., Mick, E., Kwon, A., Cayton, G. A., & Clark, S. V.
(2005). Clinical correlates of bipolar disorder in a large, referred sample of children and
adolescents. Journal Of Psychiatric Research, 39(6), 611-622.
doi:10.1016/j.jpsychires.2004.08.003
Biederman, J., Faraone, S. V., Wozniak, J., & Monuteaux, M. C. (2000). Parsing the association
between bipolar, conduct, and substance use disorders: A familial risk analysis.
Biological Psychiatry, 48, 1037-1044.
181
Biederman, J., & Garcia, J. (1996). Attention-deficit hyperactivity disorder and juvenile mania:
An overlooked comorbidity? Journal of the American Academy of Child and Adolescent
Psychiatry, 35(8), 997-1008.
Biederman, J., Mick, E., Faraone, S. V., & Wozniak, J. (2004). Pediatric Bipolar Disorder or
Disruptive Behavior Disorder? Primary Psychiatry, 11(9), 36-41.
Bird, H. (1996). Epidemiology of childhood disorders in a cross-cultural context. Journal of
Child Psychology and Psychiatry, 37, 35-49.
Bird, H. (2002). The diagnostic classification, epidemiology, and cross-cultural validity of
ADHD. In P.S. Jensen and J. Cooper (Eds.), Attention deficit hyperactivity disorder:
State of the science; best practices (pp. 12-1 – 12-36). Kingston, NJ: Civic Research
Institute.
Birmaher, B., Axelson, D., Strober, M., Gill, M. K., Valeri, S., Chiappetta, L., & et al. (2006).
Clinical course of children and adolescents with bipolar spectrum disorders. Archives of
General Psychiatry, 63, 175-183.
Blader, J.C., & Carlson, G.A. (2007). Increased rates of bipolar disorder diagnoses among U.S.
child, adolescent, and adult inpatients, 1996–2004. Biological Psychiatry, 62, 107–114.
Blumberg, H. P., Martin, A., Kaufman, J., Leung, H., Skudlarski, Pl, Lacadie, C., & et al. (2003).
Frontostriatal abnormalities in adolescents with bipolar disorder: Preliminary
observations from functional MRI. American Journal of Psychiatry, 160, 1345-1347.
Boardman, A., Arguelles, M. E., Vaughn, S., Hughes, M. T., & Klingner, J. (2005). Special
education teachers’ views of research-based practices. Journal of Special Education, 39,
168–180.
182
Bowden, C. L. (1998). New concepts in mood stabilization: Evidence for the effectivenss of
Valproate and Lamotrigine. Neurpsychopharmacology, 19, 194-199.
Bowden, C. L., & Rhodes, L. J. (1996). Mania in children and adolescents: Recognition and
treatment. Psychiatric Annals, 26, S430-S434.
Bowers, F. E., McGinnis, J. C., Ervin, R. A., & Friman, P. C. (1999). Merging research and
practice: The example of positive peer reporting applied to social rejection. Education
and Treatment of Children, 22, 218–226.
Bowring, M. A., & Kovacs, M. (1992). Difficulties in diagnosing manic disorders among
children and adolescents. Journal of the American Academy of Child and Adolescent
Psychiatry, 31, 611-614.
Brandenburg, N. A., Friedman, R. M., & Silver, S. E. (1990). The epidemiology of childhood
psychiatric disorders: Prevalence findings from recent studies. Journal of the American
Academy of Child and Adolescent Psychiatry, 29, 76-83.
Breen, M. J., & Altepeter, T. S. (1990). Disruptive behavior disorders in children: Treatment
focused assessment. New York: Guilford Press.
Breslau, N. (1987). Inquiring about the bizarre: False positives in Diagnostic Interview Schedule
for Children (DISC) ascertainment of obsessions, compulsions, and psychotic symptoms.
Journal of the American Academy of Child and Adolescent Psychiatry, 26, 639-644.
Brewin, J., Cantwell, R., Dalkin, T., et al. (1997). Incidence of schizophrenia in Nottingham: a
comparison of two cohorts, Environmental risk factors for bipolar disorder 239 1978
1980 and 1992–1994. British Journal of Psychiatry, 171, 140–144.
Brotman, M. A., Schmajuk, M., Rich, B. A., Dickstein, D. P., Guyer, A. E., Costello, E.
J., & et al. (2006). Prevalence, clinical correlates, and longitudinal course of severe
183
mood dysregulation in children. Biological Psychiatry, 60(9), 991-998.
Brown-Chidsey, R., & Steege, M. W. (2005). Response to Intervention: Principles and
Strategies for Effective Practice. Guilford Publications.
Brumback, R. A., & Weinberg, W. A. (1977). Mania in childhood: therapeutic trial of lithium
carbonate and further description of manic-depressive illness in children. American
Journal of Diseases of Children, 131, 1122-1126.
Buchanan, T., & Smith, J. (1999). Using the Internet for psychologcial research: Personality
testing on the World Wide Web. British Journal of Psychology, 90, 125 - 144.
Busse, R. T., & Beaver, B. R. (2000). Informant report: Parent and teacher interviews. In E.
Shapiro & T. R. Kratochwill (Eds.), Conducting school-based assessments of child and
adolescent behavior (pp. 235 – 273). New York: Guilford Press.
Butzlaff, R. L., & Holley, J. M. (1998). Expressed emotion and psychiatric relapse. Archives of
General Psychiatry, 55(6), 547-552.
Cai, X., Kaiser, A. P., & Hancock, T. B. (2004). Parent and Teacher Agreement on Child
Behavior Checklist Items in a Sample of Preschoolers From Low-Income and
Predominantly African American Families. Journal Of Clinical Child & Adolescent
Psychology, 33(2), 303-312.
Canino, G., & Alegria, M. (2008). Psychiatric diagnosis – is it universal or related to culture?
Journal of Child Psychology and Psychiatry, 49(3), 237-250.
Carlson, G. A. (1983). Bipolar affective disorders in childhood and adolescence. In D. P.
Cantwell & G. Carson (Eds.), Affective disorders in childhood & adolescence: An update
(pp. 61-83). New York: Spectrum.
184
Carlson, G. A. (2005a). Diagnosing Bipolar Disorder in children and adolescents. Child and
Adolescent Psychopharmacology News, 10(2), 1-9.
Carlson, G. A. (2005b). Early onset bipolar disorder: Clinical and research considerations.
Journal of Clinical Child and Adolescent Psychology, 34(2), 333-343.
Carlson, G. A., Bromet, E. J., & Sievers, S. (2000). Phenomenology and outcome of subjects
with early- and adult-onset psychotic mania. American Journal of Psychiatry, 157, 213219.
Carlson, G. A.,& Goodwin, F. K. (1973). The stages of mania. A longitudinal analysis of the
manic episode. Archives of General Psychiatry, 28(2), 221-228.
Carlson, G. A., & Kashani, J. H. (1988). Manic symptoms in a non-referred adolescent
population. Journal of Affective Disorders, 15, 219-226.
Carlson, G. A., & Kelley, K. L. (1998). Manic symptoms in psychiatrically hospitalized children:
What do they mean? Journal of Affective Disorders, 51, 123-135.
Carlson, G. A., & Strober, M. (1979). Affective disorders in adolescence. Psychiatric Clinics of
North America, 2, 511-526.
Carlson, J. S., Demaray, M. K., & Hunter-Oehmke, S. (2006). A survey of school psychologists’
knowledge and training in child psychopharmacology. Psychology in the Schools, 43(5),
623-633.
Cartwright, D. W., Thompson, R. J., Poole, M. C., & Kester, D. D. (1999). Assessing distance
learning using a Website survey. (Eric Document Reprodcution Service No. 433 781).
Cassano, G. B., McElry, S. L., Brady, K., Nolen, W. A., & Placidi, G. F. (2000). Current issues
in the identification and management of bipolar spectrum disorders in ‘special
populations.’ Journal of Affective Disorders, 59, S69-S79.
185
Cassidy, F., Murry, E., Forest, K., & Carroll, B. J. (1998). Signs and symptoms of mania in pure
and mixed episodes. Journal of Affective Disorders, 50, 187-201.
Castillo, M., Kwock, L., Courvoise, H., & Hooper, S. R. (2000). Proton MR spectroscopy in
children with bipolar affective disorder: Preliminary observations. American Journal of
Neuroradiology, 21, 832-838.
Cavanagh, J. T. O., van Beck, M., Juir, W., & Blackwood, D. H. R. (2002). Case-control study
of neurocognitive function in euthymic patients with bipolar disorder: An association
with mania. British Journal of Psychiatry, 180, 320-326.
Chafouleas, S. M., Clonan, S. M., & Vanauken, T. L. (2002). A national survey of current
supervision and evaluation practices of school psychologists. Psychology in the Schools,
39(3), 317-325.
Chafouleas, S. M., Riley-Tillman, T., & Eckert, T. L. (2003). A comparison of school
psychologists’ acceptability, training, and use of norm-referenced, curriculum-based, and
brief experimental analsysis methods to assess reading. School Psychology Review, 32,
272-281.
Chang, K., Adleman, N. E., Dienes, K., Simeonova, D. I., Menon, V., & Reiss, A. (2004).
Anomaolous prefrontal-subcortical activation in familial pediatric bipolar disorder.
Archives of General Psychiatry, 61, 781-792.
Chang, K. D., Blasey, C., Ketter, T. A., & Steiner, H. (2001). Family environment of children
and adolescents with bipolar parents. Bipolar Disorders, 3, 73-78.
Chang, K. D. & Ketter, T. A. (2000). Mood stabilizer augmentation with olanzapine in acutely
manic children. Journal of Child and Adolescent Psychopharmacology, 10(1), 45-49.
186
Chang, K., & Steiner, H. (2003). Offspring studies in child and early adolescent bipolar disorder.
In B. Geller & M. P. DelBello (Eds.), Bipolar Disorder in Childhood and Early
Adolescence (pp. 107-129). New York: The Guilford Press.
Chang, K. D., Steiner, H., & Ketter, T. A. (2000). Psychiatric phenomenology of child and
adolescent bipolar offspring. Journal of the American Academy of Child and Adolescent
Psychiatry, 39, 453-460.
Charvat, J. L. (2005). NASP study: How many school psychologists are there? NASP
Communiqué, 33(6).
Chiaroni, P., Hantouche, E. G., Gouvernet, J., Azorin, J. M., & Akiskal, H. S. (2005). They
cyclothymic temperament in healthy controls and familially at risk individuals for mood
disorder: Endophenotype for genetic studies? Journal of Affective Disorders, 85, 135145.
Child and Adolescent Bipolar Foundation (2007). What are the educational needs of a child
with bipolar disorder? Retrieved from
http://www.bpkids.org/site/PageServer?pagename=lrn_about
Clark, L., & Goodwin, G. M. (2004). State- and trait-related deficits in sustained attention in
bipolar disorder. European Archives of Psychiatry and Clinical Neuroscience, 254, 6168.
Clark, L., Iverson, S. D., & Goodwin, G. M. (2002). Sustained attention deficit in bipolar
disorder. British Journal of Psychiatry, 180, 313-319.
Cohen, R., Linker, J. A., & Stutts, L. (2006). Working together: Lessons learned from school,
family, and community collaborations. Psychology in the Schools, 43(4), 419-428.
Coleman, M. C., & Webber, J. (2002). Emotional behavioral disorders: Theory and practice (4th
187
ed.). Boston: Allyn & Bacon.
Collins, R. L., Ellickson, P. L., Hays, R. D., & McCaffrey, D. F. (2000). Effects of incentive size
and timing on response rates to a follow-up of a longitudinal mailed survey. Evaluation
Review, 24(4), 347-363.
Connell, M. C., Carta, J. J., & Baer, D. M. (1993). Programming generalization of in-class
transition skills: Teaching preschoolers with developmental delays to self-assess and
recruit contingent teacher . Journal of Applied Behavior Analysis, 26, 345–368.
Cook, C., Heath, F., & Thompson, R. L. (2000). A meta-analysis of response rates in web- or
internet-based surveys. Educational and Psychological Measurement, 60(6), 821-836.
Cook, B. G., Landrum, T. J., Tankersley, M., & Kauffman, J. M. (2003). Bringing research to
bear on practice: Effecting evidence- based instruction for students with emotional or
behavioral disorders. Education and Treatment of Children, 26, 345–361.
Costello, E. J., Angold, A., Burns, B. J., Erkanli, A., Stangle, D., & Tweed, D. (1996). The
Great Smoky Mountains Study of Youth: Functional impairment and severe emotional
disturbance. Archives of General Psychiatry, 53, 1137-1143.
Costello, E.J., Edelbrock, C., Costello, A.J., Dulcan, M.K., Burns, B.J., & Brent, D. (1988).
Psychopathology in pediatric primary care: The new hidden morbidity. Pediatrics, 82,
415-424.
Costello, E. J., Egger, H., & Angold, A. (2005). 1-year research update review: The
epidemiology of child and adolescent psychiatric disorders: I. Methods and public health
burden. Journal of the American Academy of child and Adolescent Psychiatry, 44, 972986.
Craney, J. L., & Geller, B. (2003). A prepubertal and early adolescent bipolar disorder-I
188
phenotype: Review of phenomenology and longitudinal course. Bipolar Disorders, 5,
243-256.
Crundwell, R. M., & Killu, K. (2007). Understanding and accomodating students with
depression in the classroom. Teaching Exceptional Children, 40(1), 48-54.
Cullinan, D., Epstein, M. H., & Kauffman, J. M. (1984). Teachers’ ratings of students’
behaviors: What constitutes behavior disorder in schools? Behavioral Disorders, 10(1),
9-19.
Cullinan, D., Epstein, M. H., & Sabornie, E. J. (1992). Selected characteristics of a national
sample of seriously emotionally disturbed adolescents. Behavioral Disorders, 17(4), 273
280.
Cullinan, D, & Sabornie, E, (2004). Characteristics of emotional disturbances in middle and high
school students. Journal of Emotional and Behavioral Disorders, 12, 157-167.
Curtin, R., Presser, S., & Singer, E. (2005). Changes in telephone survey nonresponse over the
past quarter century. Public Opinion Quarterly, 69(1), 87-98.
Curtis, M. J., Chesno-Grier, J. E., & Hunley, S. A., (2004). The changing face of school
psychology: Trends in data and projections for the future. School Psychology Review, 33,
49-66.
Curtis, M. J., Grier, J. E. C., Abshier, D. W., Sutton, N. T., & Hunley, S. A. (2002). School
psychology: Turning the corner into the twenty-first century. Communiqué, 30(8), 1–5.
Curtis, M. J., Grier, J. E. C., & Hunley, S. A. (2004). The changing face of school psychology:
Trends in data and projections for the future. School Psychology Review, 33(1), 49-66.
Curtis, M.J., Hunley, S.A., & Chesno-Grier, J.E. (2002). Relationships among the professional
practices and demographic characteristics of school psychologists. School Psychology
189
Review, 31, 30-42.
Curtis, M. J., Hunley, S. A., Walker, K. J., & Baker, A. C. (1999). Demographic characteristics
and professional practices in school psychology. School Psychology Review, 28(1), 104 –
116.
Curtis, M. J., Lopez, A. D., Castillo, J. M., Batsche, G. M., Minch, D. & Smith, J. C. (2008).
The status of school psychology: Demographic characteristics, employment conditions,
professional practices, and continuing professional development. Communiqué, 36, 2729.
Cytryn, L. (2003). Recognition of childhood depression: Personal reminiscences. Journal of
Affective Disorders, 77(1), 1-9.
Daly, I., Webb, M., & Kaliszer, M. (1995). First admission incidence study of mania,1975–1981.
British Journal of Psychiatry, 167, 463–468.
Danielson, C. K., Feeny, N. C., Findling, R. L., & Youngstrom, E. A. (2004). Psychosocial
treatment of bipolar disorders in adolescents: A proposed cognitive-behavioral
intervention. Cognitive and Behavioral Practice, 11, 283-297.
Davanzo, P. A., & McCracken, J. T. (2000). Mood stabilizers in the treatment of juvenile bipolar
disorder: Advances and controversies. Child and Adolescent Psychiatric Clinics of North
America, 9(1), 159-182.
Davis, A. S. (2006). The neuropsychological basis of childhood psychopathology. Psychology in
the Schools, 43(4), 503-512.
Davis, A. S., Kruczek, T., & McIntosh, D. E. (2006). Understanding and treating
psychopathology in schools: Introduction to the special issue. Psychology in the Schools,
43(4), 413-417.
190
Davis, R. E. (1979). Manic-depressive variant syndrome in childhood: A preliminary report.
American Journal of Psychiatry, 136, 702-706.
Davis, S. D., Young, E. L., Hardman, S., & Winters, R. (2011). Screening for emotional and
behavioral disorders. Principal Leadership, 9, 12-17.
Decina, P., Kestenbaum, C. J., Farber, S., Kron, L., Gargan, M., Sackeim, H. A., et al. (1983).
Clincial and psychological assessment of children of bipolar probands. American
Journal of Psychiatry, 140(5), 548-553.
DeJong, S. & Frazier, J. A. (2003). Bipolar disorder in children with pervasive developmental
disorders. In B. Geller & M. P. DelBello (Eds.), Bipolar Disorder in Childhood and
Early Adolescence (pp. 51-). New York: The Guilford Press.
DelBello, M., Schwiers, M., Rosenberg, H., & Strakowski, S. (2002). A double-blind,
randomized, placebo-controlled study of quetiapine as adjunctive treatment for
adolescent mania. Journal of American Academy of Child and Adolescent Psychiatry, 4,
1216-1223.
Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. (1994). California verbal learning test –
children’s version manual. San Antonio: Psychological Corporation.
DeLong, G. R. (1978). Lithium carbonate treatment of select behavior disorders in schildren
suggesting manic-depressive illness. Journal of Pediatrics, 93, 689-694.
DeLong, G. R., & Aldershof, A. (1987). Long-term experience with lithium treatment in
childhood: Correlation with clinical diagnosis. Journal of the American Academy of Child
and Adolescent Psychiatry, 26, 389-394.
De Los Reyes, A., & Kazdin, A. E. (2005). Informant Discrepancies in the Assessment of
Childhood Psychopathology: A Critical Review, Theoretical Framework, and
191
Recommendations for Further Study. Psychological Bulletin, 131(4), 483-509.
Department of Health and Human Services. (1995). NDA 20-320: Depakote. Proceedings of the
44th Psychopharmacologic Drugs Advisory Committee Meeting. Washington (D. C.),
February 6, 1995.
Depue, R. A., Slater, J. F., Wolfsetter-Kausch, H., Klein, D., Goplerud, E., & Farr, D. (1981). A
behavioral paradigm for identifying persons at risk for bipolar depressive disorder: A
conceptual framework and five validation studies. Journal of Abnormal Psychology
Monograph, 90(5), 381-437.
Dey, E. L. (1997). Working with low survey response rates: The efficacy of weighting
adjustments. Research in Higher Education, 38, 215-227.
Dickstein, D. P., Treland, J. E., Snow, J., McClure, E. B., Mehta, M. S., Towbin, K. E., &
et al. (2004). Neuropsychological performance in pediatric bipolar disorder. Biological
Psychiatry, 55(1), 32-40.
Dillman, D. A. (2000). Mail and internet surveys (2nd ed.). New York: John Wiley & Sons, Inc.
Dillman, D. A., Tortora, R. D., & Bowker, D. (1999). Principles for construcing Web surveys.
Retrieved December 11, 2009, from Washington State University, Social & Economic
Sciences Research Center Web site:
http://www.sesrc.wsu.edu/dillman/papers/websurveyppr.pdf
Doyle, A. E., Wilens, T. E., Kwon, A., Seidman, L. J., Faraone, S. V., Fried, R., & et al. (2005).
Neuropsychological functioning in youth with bipolar disorder. Biological Psychiatry,
58, 540-548.
Drabkin, I. E. (1955). Remarks on ancient psychopathology. Isis, 46(3), 223-234.
Drummond, T. (1994). The student risk screening scale (SRSS). Grants Pass, OR: Josephine
County Mental Health Program.
192
Duffy, M. (2000). Web-based research: An innovative method for nursing research. Canadian
Oncology Nursing Journal, 10(2), 45 - 49.
Dujovne, V. F., Barnard, M. U., & Rapoff, M. A. (1995). Pharmacological and cognitive
behavioral approaches in the treatment of childhood depression: A review and critique.
Clincial Psychology Review, 15(7), 589-611.
Dunner DL, Clayton PJ (1987), Drug treatment of bipolar disorder. In: Psychopharmacology:
The Third Generation of Progress. (H.Y. Meltzer, Ed.). New York: Raven Press.
DuPaul, G. J. (2003). Commentary: Bridging the Gap Between Research and Practice. School
Psychology Review, 32(2), 178.
Dykema, J., Jones, N. R., Piche, T, & Stevenson, J. (2013). Surveying clinicians by web:
Current issues in design and administration. Evaluation & the Health Professions,
36(3), 352 – 381.
Edgar, E. (1987). Secondary programs in special education: Are many of them
justifiable? Exceptional Children, 53, 555-561.
Edlebrock, C. S., Costello, a. J., Dulcan, M. K., Kalas, R., & Conover, N. C. (1985). Age
differences in the reliability of the psychiatric interview of the child. Child Development,
56, 265-275.
Egeland, J. A., Hostetter, A. M., Pauls, D. L., & Sussex, J. N. (2000). Prodromoal symptoms
before onset of manic-depressive disorder suggested by first hospital admission histories.
Journal of the American Academy of Child and Adolescent Psychiatry, 39(10), 1245-52.
Egeland, J. A., Shaw, J. A., Endicott, J., Pauls, D. L., Allen, C. R., Hostetter, A. M., & Sussex, J.
N. (2003). Prospective study of prodromal features for bipolarity in well Amish children.
Journal of the American Academy of Child & Adolescent Psychiatry, 42(7), 786-796.
Egger, H. L., & Emde, R. N. (2011). Developmentally sensitive diagnostic criteria for mental
193
health disorders in Early Childhood. American Psychologist, 66(2), 95-106.
Ellis, E., Farmer, T., & Newman, J. (2005). Big ideas about teaching big ideas. Teaching
Exceptional Children, 38(1), 34–40.
Emde, R. N. (1983). The Spitz-Pinneau controversy. In R. N. Emde (Ed.), Rene A. Spitz:
Dialogues from infancy. Selected papers (with commentary). New York, NY:
International Universities Press.
Emslie, G. J., Kennard, B. D., & Kowatch, R. A. (1994). Affective disorders in children:
Diagnosis and management. Journal of Child Neurology, 10, S42-S49.
Epstein, M. H., Kinder, D., & Bursuck, B. (1989). The academic status of adolescents with
behavior disorders. Behavioral Disorders, 14, 157-165.
Erford, B. T., Balcom, L.C., & Moore-Thomas, C. (2007). The screening test for emotional
problems: Studies of reliability and validity. Measurement and Evaluation in Counseling
and Development, 39(4), 209-226.
Ervin, R., Ehrhardt, K., & Poling, A. (2001). Functional assessment: Old wine in new bottles.
School Psychology Review, 30, 173-179.
Faedda, G., Baldessarini, R., Glovinsky, I., & Austin, N. (2004). Pediatric bipolar disorder:
Phenomenology and course of illness. Bipolar Disorder, 6, 305-313.
Faedda, G., Baldessarini, R., Suppes, T., Tondo, L., Becker I., & Lipschitz D. (1995). Pediatriconset bipolar disorder: A neglected clinical and public health problem. Harvard Review
Psychiatry, 3(4), 171-195.
Fagan, T. K. (1994). A critical appraisal of the NASPs first 25 years. School Psychology Review,
23(4), 604-619.
Fagan, T. K., & Wise, P. S. (2000). School psychology: Past, present, and future (2nd Ed.).
194
Bethesda, MD: National Association of School Psychologists.
Fairchild, T. N. & Zins, J. E. (1992). Accountability practices of school psychologists: 1991
national survey. School Psychology Review, 21(4), 617-628.
Fantuzzo, J. W., & Polite, K. (1990). School-based behavioral self-management: A review and
analysis School Psychology Quarterly, 5, 180–198.
Faraone, S. V., Biederman, J., Mennin, D., Wozniak, J., & Spencer, T. (1997). Attention-deficit
hyperactivity disorder with bipolar disorder: A familial subtype? Journal of the American
Academy of Child and Adolescent Psychiatry, 36, 1378-1387.
Faraone, S. V., Biederman, J., Wozniak, J., Mundy, E., Mennin, D., & O’Donnell, D. (1997). Is
comorbidity with ADHD a marker for juvenile-onset mania? Journal of the American
Academy of Child and Adolescent Psychiatry, 36, 1046 – 1055.
Faraone, S. V., Glatt, S. J., & Tsuang, M. T. (2003). The genetics of pediatric-onset bipolar
disorder. Biological Psychiatry, 53, 970-977.
Farone, S. V., Tsuang, M. T., & Tsuang. (1999). Genetics of mental disorders: What
practitioners and students need to know. New York: Guilford Press.
Farling, W. H., & Hoedt, K. C. (1971). National survey of school psychologists Washington,
DC: National Association of School Psychologists.
Farrell, D. T., Smith, S. W., & Brownell, M. T. (1998). Teacher perceptions of level system
effectiveness on the behavior of students with emotional or behavioral disorders. Journal
of Special Education, 32(2), 89–98.
Feeny, N. C., Danielson, C. K., Schwartz, L., Youngstrom, E. A., & Findling, R. L. (2006). CBT
for bipolar disorders in adolescence: A Piolot Study. Bipolar Disorders, 8, 508-515.
Ferrier, I. N., & Thompson, J. M. (2002). Cognitive impairment in bipolar affective disorder:
195
Implications for the bipolar diathesis. British Journal of Psychiatry, 180, 293-295.
Findling, R., Gracious, B., McNamara, N., Youngstrom, E., & Demeter, C. (2001). Rapid
continuous cycling and psychiatric bipolar I disorder. Bipolar Disorder, 3, 202-210.
Findling, R. L., Youngstrom, E. A., Danielson, C., DelPorto-Bedoya, D., Papish-David, R.,
Townsend, L., & et al. (2002). Clincial decision-making using the General Behavior
Inventory in juvenile bipolarity. Bipolar disorders, 4, 34-42.
Fisher, G.L., Jenkins, S.J., & Crumbley, J.D. (1986). A replication of a survey of school
psychologists: Congruence between training, practice, preferred role, and competence.
Psychology in the Schools, 23, 271-279.
Fitzpatrick, M., & Knowlton, E. (2007). No Child Left Behind’s implementation in urban school
settings: Implications for serving students with emotional and behavior disorders.
Washington, DC: American Academy of Special Education Professionals.
Fitzpatrick, M. & Knowlton, E. (2009). Bringing evidence-based self-directed intervention
practices to the trenchs for students with emotional and behavioral disorders. Preventing
School Failure, 53(4), 253-278.
Flor-Henry, P. (1983). Functional hemispheric asymmetry and psychopathology. Integrative
Psychiatry, 1(2), 46–52.
Flor-Henry, P., Yeudall, L. T., Koles, Z. J., & Howarth, B. G. (1979). Neuropsychological and
power spectral EEG investigations of the obsessive–compulsive syndrome. Biological
Psychiatry, 14(1), 119–130.
Forness, S. (1992). Legalism versus professionalism in diagnosing SED in the public schools.
School Psychology Review, 21, 29-34.
196
Forness, S. R., Kim, J., & Walker, H. M. (2012). Prevalence of Students with EBD: Impact on
General Education. Beyond Behavior, 21(2), 3-10.
Forness, S. R., & Knitzer, J. (1992). A new proposed definition and terminaology to replace
‘serious emotional disturbance’ in individuals with disabilities education act. School
Psychology Review, 21, 12 – 21.
Fowler, S. A., Dougherty, S. B., Kirby, K. C., & Kohler, F. W. (1986). Role reversals: An
analysis of therapeutic effects achieved with disruptive boys during their appointments as
peer monitors. Journal of Applied Behavior Analysis, 19, 437–444.
Fowler, E., & Harrison, P. L. (2001). Continuing professional development needs and activities
of school psychologists. Psychology in the Schools, 38, 75-88.
Fox, R. J., Crask, M. R., & Kim, J. (1988). Mail survey response rate: A meta-analysis of
selected techniques for inducing response. Public Opinion Quarterly, 52, 467-491.
Franceschini, L. A. (2000). Navigating electronic survey methods: Three pilot studies. (ERIC
Document Reproduction Service No. 448 183).
Frankel, M., & Siang, S. (1999). Ethical and legal aspects of human subjects research on the
Internet. Retrieved December 14, 2009, from American Association for the Advancement
of Science web site http://www.aaas.org/spp/sfrl/projects/intres/report.pdf
Frazier, J. A., Biederman, J., Tohen, M., Feldman, P. D., Jac obs, T. G., Toma, V., et al. (2001).
A prospective open-label treatment trial of Olanzipine monotherapy in children and
adolescents with Bipolar Disorder. Journal of Child and Adolescent
Psychopharmacology, 11(3), 239-250.
Frazier, J. A., Meyer, M. C., Biederman, J., Wozniak, J., Wilens, T. E., Spencer, T. J., et al.
(1999). Risperidone treatment for juvenile bipolar disorder: A retrospective chart review.
197
Journal of the American Academy of Child and Adolescent Psychiatry, 38(8), 960-965.
Fricerk, R. D., & Schonlau, M. (2002). Advantages and disadvantages of internet research
surveys: Evidence from the literature. Field Methods, 14(4), 347-367.
Friedman, M. (1909). Zur Kenntis der affectiven: Psychosen des Kindesalters, inabesondere der
milderen Formen. Monatsschrift für Psychiatrie und Neurologie, 26, 36-52.
Friedman, R.M., Kutash, K., & Duchnowski, A.J. (1996). The population of concern: Defining
the issues. In B.A. Stroul & R.M. Friedman (Eds.), Children’s mental health: Creating
systems of care in a changing society (pp. 69-96). Baltimore MD: Brookes.
Fristad, M., & Arnold, J. G. (2004). Raising a moody child: How to cope with depression and
bipolar disorder. New York: Guilford Press.
Fristad, M. A., Gavazzi, S. M., & Mackinaw-Koons, B. (2003). Family psychoeducation: An
adjunctive intervention for children with bipolar disorder. Society of Biological
Psychiatry, 53, 1000-1008.
Fristad, M. A., Weller E. B., & Weller, R. A. (1992). The mania rating scale: Can it be used in
children? A preliminary report. Journal of American Academy of Child and Adolescent
Psychiatry, 31, 252-257.
Gable, R. A., & Hendrickson, J. M. (2000). Strategies for maintaining positive behavior change
stemming from functional behavioral assessment in schools [Electronic version].
Education and Treatment of Children, 23, 286–297.
Geller, B., Bolhofner, K., Craney, J. L., Williams, M., DelBello, M. P., & Gundersen, K. (2000).
Psychosocial functioning in a prepubertal and early adolescent bipolar disorder
phenotype. Journal of the American Academy of child and Adolescent Psychiatry, 39,
1543-1548.
198
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: The Guilford
Press.
Geller, B., Craney, J. L., Bolhofner, K., Nickelsburg, M. J., Williams M., & Zimerman, B.
(2002). Two-year prospective follow-up of children with a prepubertal and early
adolescent bipolar disorder phenotype. American Journal of Psychiatry, 159, 927-933.
Geller, B., Fox, L. W., & Clark, K. A. (1994). Rate and predictors of prepubertal bipolarity
during follow-up of 6- to 12-year-old depressed children. Journal of American Academy
of Child and Adolescent Psychiatry, 33, 461-468.
Geller, B., Fox, L. W., & Fletcher, M. (1993). Effect of tricyclic antidepresants on switching to
mania and on the onset of bipolarity in depressed 6- to 12-year-olds. Journal of the
American Academy of Child and Adolescent Psychiatry, 32, 43-50.
Geller, B. & Luby, J. (1997). Child and adolescent bipolar disorder: A review of the past 10
years. Journal of American Academy of Child and Adolescent Psychiatry, 36(9), 11681176.
Geller, B., Sun, K., Zimerman, B., Luby, J., Frazier, J., & Williams, M. (1995). Complex and
rapid cycling in bipolar children and adolescents: A preliminary study. Journal of
Affective Disorders, 34, 259-268.
Geller, B., Tillman, R., Craney, J. L., & Bolhofner, K. (2004a). Four-year prospective and
natural history of mania in children with a prepubertal and early adolescent bipolar
disorder phenotype. Archives of General Psychiatry, 63, 1138-1139.
199
Geller, B., Tillman, R., Craney, J. L., & Bohofner, K. (2004b). Four-year prospective outcome
and natural history of mania in children with a prepubertal and early adolescent bipolar
disorder phenotype. Archives of General Psychiatry, 61, 459-467.
Geller B., Warner, K., Williams, M., & Zimerman, B., (1998). Prepubertal and young
adolescent bipolarity versus ADHD: Assessment and validity using the WASH-U
KSADS, CBCL and TRF. Journal of Affective Disorders, 51, 93-100.
Geller, B., Williams, M., Zimerman, B., Frazier, J., Beringer, L., and Warner, K. (1998).
Prepubertal and early adolescent bipolarity differentiate from ADHD by manic
symptoms, grandiose delusions, ultra-rapid or ultradian cycling. Journal of Affective
Disorders, 51, 81-91.
Geller, B., Williams, M., Zimmerman, B., & Frazier, J. (1996). Washington University in St.
Louis Kiddie Schedule for Affective Disorders and Schizophrenia (Wash-U-KSADS).
Washington University, St. Louis.
Geller, B., Zimerman, B., Williams, M., Bolhofner, K., Craney, J. L., DelBello, M. P., et al.
(2000). Diagnositc characteristics of 93 cases of a prepubertal and early adolescent
bipolar disorder phenotype by gender, puberty and comorbid attention deficit
hyperactivity disorder. Journal of Child and Adolescent Psychopharmacology, 10(3),
157-164.
Geller, B., Zimerman, B., Williams, M., Bolhofner, K., & Craney, J. (2001). Bipolar disorder at
prospective follow-up of adults who had prepubertal major depressive disorder. American
Journal of Psychiatry, 158, 125-127.
Geller, B., Zimerman, B., Williams, M., DelBello, M. P., Bolhofner, K., Craney, J. L., et al.
(2002a). DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder
200
phenotype compared to attention-deficit hyperactive and normal controls. Journal of
Child and Adolescent Psychopharmacology, 12, 11-15.
Geller, B., Zimerman, B., Williams, M., DelBello, M.P., Frazier, J., & Beringer, L. (2002b).
Phenomenology of prepubertal and early adolescent bipolar disorder: Examples of elated
mood, grandiose behaviors, decreased need for sleep, racing thoughts and hyper
sexuality. Journal of Child and Adolescent Psychopharmacology, 12, 3-9.
George, N. L., George, M. P., Gersten, R., & Grosenick, J. K. (1995). To leave or to stay? An
exploratory study of teachers of students with emotional and behavioral disorders.
Remedial and Special Education, 16, 227–236.
George, M., Taylor, L., Schmidt, S. C., & Weist, M. D. (2013). A review of school mental health
programs in SAMHSA’s National Registry of Evidence-Based Programs and Practices.
Psychiatric Services, 64(5), 483 – 486.
Ghaemi, S. N. (2001). On defining "mood stabilizer." Bipolar Disorders, 3, 154-158.
Ghaemi, S. N., Hus, D. J., Soldani, F., & Goodwin, F. K. (2003). Antidepressants in bipolar
disorder: The case for caution.
Ghaemi, S. N., Lenox, M. S., & Baldessarini, R. J. (2001). Effectiveness and safety of long-term
antidepressant treatment in bipolar disorder. Journal of Clincial Psychitary, 62, 565-569.
Ghaemi, S. N., Sachs, G. S., Chiou, A., Pandurangi, A. KI., & Goodwin, F. K. (1999). Is bipolar
disorder still underdiagnosed? Are antidepressants overutilized? Journal of Affective
Disorders, 52, 134-144.
Gillberg, C., Gillberg, I. C., Rasmussen, P., Kadesjo, B., Soderstrom, H., Rastam, M., & et al.
(2004). Co-existing disorders in ADHD: Implications for diagnosis and intervention.
European Child and Adolescent Psychiatry, 13(1), 80-92.
201
Glahn, D. C., Bearden, C. E., Caetano, S., Fonseca, M., Najt, P., Hunter, K., & et al. (2005).
Declarative memory impairment in pediatric bipolar disorder. Bipolar Disorders, 7, 546554.
Glovinsky, I. (2002). A brief history of childhood-onset bipolar disorder through 1980. Child
and Adolescent Psychiatric Clinics of North America, 11, 443-460.
Golden, C. J. (1978). Stroop color and word test: A manual for clinical and experimental use.
Chicago: Stoelting.
Goldstein, T. R., Miklowitz, D. J., & Richards, J. A. (2002). Expressed emotion attitudes and
individual psychopathology among the relatives of bipolar patients. Family Process,
41(4), 645-658.
Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of
Child Psychology and Psychiatry, and Allied Disciplines, 38(5), 581–586.
Goodwin, F. K., & Jamison, K. R. (1990). Manic-depressive illness. New York, NY: Oxford
University Press.
Goodwin, F. K., & Jamison, K. R. (2007). Manic-Depressive Illness: Bipolar Disorders and
Recurrent Depression (Vol. 1). New York: Oxford University Press.
Granello, D. H., & Wheaton, J. E. (2004). Online data collection: Strategies for research. Journal
of Counseling & Development, 82, 387 - 393.
Greenbaum, P. E., Dedrick, R. F., Friedman, R. M., Kutash, K., Brown, E. C.,Lardieri, S. P., et
al. (1996). The National Adolescent and Child Treatment Study (NACTS): Outcomes for
youth with emotional and behavioral disabilities. Journal of Emotional and Behavioral
Disorders, 4(3), 130–146.
Greenwood, C. R., & Abbott, M. (2001). The research-to-practice gap in special education.
202
Teacher Education and Special Education, 24, 276–289.
Greenwood, C. R., Delquadri, J., & Hall, R. V. (1984). Opportunity to respond and student
academic achievement. In W. L. Heward, T. E. Heron, D. S. Hill, & J. Trapporter (Eds.),
Focus on behavior analysis in education (pp. 58–88). Columbus, OH: Merrill.
Greenwood, C. R., Kratochwill, T. R., & Clements, M. (2008). Schoolwide prevention models:
Lessons learned in elementary schools. New York, NY US: Guilford Press.
Gresham, F. M. (2005). Response to intervention: An alternative means of identifying students
as emotionally disturbed. Education & Treatment of Children, 28, 328–344.
Gresham, F. M. (2012). Response to intervention and emotional and behavioral disorders: Best
practices in assessment for intervention. Assessment for Effective Intervention, 32, 214222.
Gresham, F. M., & Gansle, K. A. (1992). Misguided assumptions of the DSM-III-R:
Implications for school psychological practice. School Psychology Quarterly, 7, 79-95.
Gresham, F. M., Lane, K. L., MacMillan, D. L., & Bocian, K. M. (1999). Social and academic
profiles of externalizing and internalizing groups: Risk factors for emotional and
behavioral disorders [Electronic version]. Behavioral Disorders, 24, 231–245.
Gresham, F. M., Watson, T., & Skinner, C. H. (2001). Functional Behavioral Assessment:
Principles, Procedures, and Future Directions. School Psychology Review, 30(2), 156.
Gureasko-Moore, D. P., DuPaul, G. J., & Power, T. J. (2005). Stimulant Treatment for Attention
Deficit/Hyperactivity Disorder: Medication Monitoring Practices of School
Psychologists. School Psychology Review, 34(2), 232-245.
Gutkin, T. B. (1995). School psychology and health care: Moving service delivery into the
twenty-first century. School Psychology Quarterly, 10(3), 236-246.
203
Hanson, T. L., Austin, G. A., & Lee-Bayha, J. (2004). Ensuring that no child is left behind: How
are student health risks and resilience related to the academic progress of schools? Los
Alamitos, CA: WestEd.
Harrington & Myatt (2003). Is preadolescent mania the same condition as adult mania? A British
perspective. Biological Psychiatry, 53, 961-969.
Harris, K. R. (1986). Self-monitoring of attentional behavior versus self-monitoring of
productivity: Effects on on-task behavior and academic response rate among learning
disabled children [Electronic version]. Journal of Applied Behavior Analysis, 19, 417423.
Hazell, P. L. Lewin, T. J., & Carr, V. J. (1999). Confirmation that Child Behavior Checklist
clinical scales discriminate juvenile mania from attention deficit hyperactivity disorder.
Journal of Paediatrics, 35, 199-203.
Healy, D. (1997). The antidepressant era. Cambridge: Harvard University Press.
Healy (2006). The lastest mania: Selling bipolar disorder. Public Library of Science Medical
3(5), e236.
Healy, D., & LeNoury, J. (2007). Pediatric bipolar disorder: An object of study in the creation of
an illness. International. Journal of Risk & Safety in Medicine, 19, 209-221.
Heflin, L. J., & Bullock, L. M. (1999). Inclusion of students with wmotional/behavioral
disorders: A survey of teachers in general and special education. Preventing School
Failure, 43(3), 103-112.
Helfer, R., & Kempe, C. (Eds.). (1974). The battered child. Chicago, IL: University of Chicago
Press.
Helgason L. (1977). Psychiatric services and mental illness in Iceland. Incidence study (1966-
204
1967) with 6–7 year follow-up. Acta Psychiatrica Scandinavica , 268(Supp. 1), 1–140.
Hellander, M., Sisson, D.P., & Fristad, M.A. (2003). Internet support for parents of children
with early-onset bipolar disorder. In B. Geller & M. Del Bello (Eds.) Child and Early
Adolescent Bipolar Disorder: Theory, Assessment, and Treatment (pp. 314-329). New
York: Guilford Publications, Inc.
Heward, W. L. (1994). Three “low tech” strategies for increasing the frequency of active student
response during group instruction. In R. Gardner III, D. M. Sainato, J. O. Cooper, T. E.
Heron, W. L. Heward, J. Eshleman, & T. A. Grossi (Eds.), Behavior analysis in
education: Focus on measurably superior instruction (pp. 51–84). Pacific Grove, CA:
Brooks/Cole.
Hirschfeld, R. M., Williams, J. B., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E, Jr., et al.
(2000). Development and validation of a screening instrument for bipolar spectrum
disorder: The Mood Disorder Questionnaire. American Journal of Psychiatry, 157, 1873
1875.
Hoagwood, K., & Erwin, H. (1997). Effectiveness of school-based mental health services for
children: A 10-year research review. Journal of Child and Family Studies, 6, 435–451.
Hoagwood, K. E., Olin, S., Kerker, B. D., Kratochwill, T. R., Crowe, M., & Saka, N. (2007).
Empirically based school interventions targeted at academic and mental health
functioning. Journal of Emotional and Behavioral Disorders, 15(2), 66-92.
Hodges, K., Gordon, Y., & Lennon, M. (1990). Parent-child agreement on symptoms assessed
via clinical research interview for children: The Child Assessment Schedule (CAS).
Journal of Child Psychology and Psychiatry, 31, 427-436.
Hodgins, S., Faucher, B., Zarac, A., & Ellenbogen, M. (2002). Children of parents with bipolar
205
disosrder. A population at high risk for major affective disorders. Child and Adolescent
Psyhiatric Clinics of North America, 11, 533-553.
Hoeksma, J. B., Oosterlaan, J., & Schipper, E. M. (2004). Emotion regulation and the dynamics
of feelings: A conceptual and methodological framework. Child Development, 75(2),
354-360.
Homburger, A. (1926). Vorleungen über Psychopathologie des Kindesalters. Berlin: Springer.
Hosp, J.L., & Reschly, D.J. (2002). Regional differences in school psychology practice. School
Psychology Review, 31, 11-29.
Huang, L., Macbeth, G., Dodge, J., & Jacobstein, D. (2004). Transforming the workforce in
children’s mental health. Administration and Policy in Mental Health, 32(2), 167-187.
Huang, L., Stroul, B., Friedman, R., Mrazek, P., Friesen, B., Pires, S., & et al. (2005).
Transforming mental health care for children and their families. American Psychologist,
60(6), 615-627.
Hubbard, R., & Little, E. L. (1988). Promised congtributions to charity and mail survey
reponses: Relication with extension. Public Opinion Quarterly, 52, 223-230.
Hughes, C. A., Korinek, L., & Gorman, J. (1991). Self-management for students with mental
retardation in public school settings: A research review [Electronic version]. Education
and Training in Mental Retardation, 26, 271–291.
Indiana Mental Health Needs (2012). Helping children with early-onset bipolar to learn: A guide
for teachers and administrators. Retrieved from
http://www.indianamentalhealthneeds.org/files/Dx_BipolarEarlyOnset_HelpingChildren
Learn.PDF
206
Individuals With Disabilities Education Improvement Act of 2004 (IDEA), Pub. L. No 108–446,
118 stat. 2647 (2004). [Amending 20 U.S. C. §§ 1400 et seq.].
Jackson, S. W. (1986). Melancholia and depression: From Hippocratic times to modern times.
New Haven: Yale University Press.
Jacobson, R. (1998). Teachers improving learning using metacognition with self-monitoring
learning strategies . Education, 118, 579–589.
James, A. C. D. & Javaloyes, A. M. (2001). Practitioner review: The treatment of bipolar
disorder in children and adolescents. Journal of Child Psychology & Psychiatry & Allied
Disciplines, 42(4), 439-449.
Janicak, P. G., Davis, J. M., Preskorn, S. H., & Ayd, F. J. (1993). Principles and practice of
psychopharmacology. Baltimore, MD: Williams & Wilkins.
Jastak, J. & Jastak, S. (1993). Wide Range Achievement Test (3rd Ed.). Wilmington, DE: Jastak
Associates.
Jensen, P. S., Bloedau, L., Degroot, J., Usery, T., & Davis, H. (1990). Children at risk: I. Risk
factors and child symptomatology. Journal of the American Academy of Child and
Adolescent Psychiatry, 29, 51-59.
Jolivette, K., Stichter, J. P., & McCormick, K. M. (2002), Making choices—improving
behavior—engaging in. Teaching Exceptional Children, 34(3), 24–29.
Jonsdotter, S., Bouma, A., Sergeant, J. A., & Scherder, E. J. (2006). Relationships between
neuropsychological measures of executive function and behavioral measures of ADHD
symptoms and comorbid behavior. Archives of Clinical Neuropsychology, 21(5), 383394.
Joyce, P. R. (1984). Age of onset in bipolar affective disorder and misdiagnosis as schizophrenia.
207
Psychological Medicine, 14, 145-149.
Juul, K. D. (1986). Epidemiological studies of behavior disorders in children: An international
survey. International Journal of Special Education, 1, 1-20.
Kafantaris, V., Coletti, D. J., Dicker, R., Padula, G., & Kane, J. M. (2001). Adjunctive
antipsychotic treatment of adolescents with bipolar psychosis. Journal of American
Academy of child and Adolescent Psychiatry, 40(12), 1448-1456.
Kahana, S. Y., Youngstrom, E. A., Findling, R. L., & Calabrese, J. R. (2003). Employing parent,
teacher, and youth self-report checklists in identifying pediatric bipolar spectrum
disorders: An examination of diagnostic accuracy and clincial utility. Journal of child
and Adolescent Psychopharmacology, 13(4), 471-488.
Kamphaus, R. W., & Reynolds, C. R. (2007). BASC-2 Behavioral and Emotional Screening
System (BESS) manual. Circle Pines, MN: Pearson.
Kanner, L., (1957). Child Psychiatry, (3rd ed.). Springfield: C. C. Thomas.
Kashani, J. H., Beck, N. C., Hoelper, E. W., Fallahi, C., Corcoran, C. J., McAllister, J. A., & et
al. (1987). Psychiatric disorders in a community sample of adolescents. American
Journal of Psychiatry, 144, 584-589.
Kauffman, J. M. (1997). Characteristics of emotional and behavioral disorders of children and
youth (6th Ed.). Upper Saddle, NJ: Merrill.
Kauffman, J. M. (1999). How we prevent the prevention of emotional and behavioral disorders.
Exceptional Children, 65, 448-468.
Kauffman, J. M. (2001). Characteristics of emotional and behavioral disorders of children and
youth (7th ed.) New York: Merrill.
Kauffman, J. M. (2003). Reflections on the field. Behavioral Disorders, 28, 205-208.
208
Kauffman, J. M., Cullinan, D., & Epstein, M. H. (1987). Characteristics of students placed in
special programs for the seriously emotionally disturbed. Behavioral Disorders, 12, 175–
184.
Kauffman, J. M., & Landrum, T. J. (2009). Characteristics of emotional and behavioral disorders
of children and youth (9th Ed.), Upper Saddle River, NJ: Merrill.
Keck, P. E., McElroy, S. L. and Friedman, L. M. (1992). Valproate and carbamazepine in the
treatment of panic and behavioral dyscontrol syndromes. Journal of Clinical
Psychopharmacology, 12, 36S–41S.
Keel, M. C., Dangel, H. L., & Owens, S. H. (1999). Selecting instructional interventions for
students with mild disabilities in inclusive classrooms [Electronic version]. Focus on
Exceptional Children, 31(8), 1–16.
Kelsoe, J. R. (1997). The genetics of bipolar disorder. Psychiatric Annals, 27, 285-292.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and
age-of-onset distributions of DSM-IV disorders in the national comorbidity survey
replication. Archives of General Psychiatry, 62, 593-602.
Kessler, R., Rubinow, D., Holmes, C., Abelson, J., & Zhao, S. (1997). The epidemiology of
DSM-III-R bipolar I disorder in a general population survey. Psychological Medicine,
27(5), 1079-1089.
Kestenbaum, C. J. (1979). Children at risk for manic-depressive illness: Possible predictors.
American Journal of Psychiatry, 136(9), 1206–1208.
King-Sears, M. E. (1997). Best academic practices for inclusive classrooms. Focus on
Exceptional Children, 29, 1–22.
209
Klein, M. (1934). Psychogenesis of manic-depressive states: Contributions of psychoanalysis.
London: Hogarth.
Klein, R. G., Pine, D. S., & Klein, D. F. (1998). Resolved: Mania is mistaken for ADHD in
prepubertal children. Journal of the American Academy of Child and Adolescent
Psychiatry, 37, 1093-1096.
Klingner, J. K., Ahwee, S., Pilonieta, P., & Menendez, R. (2003). Barriers and facilitators in
scaling up research-based practices. Exceptional Children, 69, 411–429.
Kluger, Song, S., Cray, D., Ressner, J., Dequine, J., Sattley, M., & et al. (2002). Young and
bipolar. Time, 160(8), 38-48.
Knoster, T. P., & McCurdy, B. (2002). Best practices in functional behavioraql assessment for
designing individualized student programs. In A. Thomas & J. Grimes (Eds.). Best
practices in school psychology IV, (pp. 1007 – 1028). Washington, DC: National
Assoication of School Psychologists.
Kochman, F. J., Hantouche, E. G., Ferrari, P., Lancrenon, S., Bayart, D., & Akiskal, H. S. (2005).
Cyclothymic temperament as a prospective predictor of bipolarity and suicidality in
children and adolescents with major depressive disorder. Journal of Affective Disorders,
85, 181-189.
Konold, K. E., Miller, S. P., & Konold, K. B. (2004). Using teaching feedback to enhance
student learning. Teaching Exceptional Children, 36(6), 64–69.
Koonce, D. A. (2007). Attention Deficit Hyperactivity Disorder assessment practices by
practicing school psychologists: A national survey. Journal of Psychoeducational
Assessment, 25, 319-333.
210
Kovacs, M., & Pollock, M. (1995), Bipolar disorder and comorbid conduct disorder in childhood
and adolescence. Journal of the American Academy of Child and Adolescent Psychiatry,
34, 715-723.
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 Child and
Adolescent Psychiatry, 44, 213-235.
Kowatch, R. A., Youngstrom, E. A., Danielyan, A., & Findling, R. L. (2005). Review and meta
analysis of the phenomenology and clincial characteristics of mania in children and
adolescents. Bipolar Diosrders, 7, 483-496.
Krabbendam, L., Honig, A., Wiersma, J., Vuurman, E. F. P. M., Hofman, P. A. M., Derix, M. M.
A., et al. (2000). Cognitive dysfunctions and white matter lesions in patients with
bipolar disorder in remission. Acta Psychiatrica Scandinavica, 101, 274-280.
Kraepelin E. (1921), Manic-depressive insanity and paranoia. Edinburgh: Livingstone.
Kratochwill, T. R. (2007). Preparing psychologists for evidence-based school practice: Lessons
learned and challenges ahead. American Psychologist, 62(8), 829-843.
Kratochwill, T. R., & Shernoff, E. (2004). Evidence-based Practice: Promoting evidence-based
interventions in school psychology. School Psychology Review, 33(1), 34-48.
Kyte, Z. A., Carlson, G. A., & Goodyer, I. M. (2006). Clinical and neuropsychological
characteristics of child and adolescent bipolar disorder. Psychological Medicine, 36,
1197-1211.
Lam, D. (2002). A randomized controlled study of cognitive therapy of relapse prevention for
211
bipolar affective disorder: Outcome of the first year. Bipolar Disorders, 4(Suppl.1), 104
118118.
Landrum, T. J. (1992). Teachers as victims: An interactional analysis of the teacher’s role in
educating atypical learners. Behavioral Disorders, 17, 135–144.
Landrum, T. J., Cook, B. G., Tankersley, M., & Fitzgerald, S. (2002). Teacher perceptions of the
trustworthiness, usability, and accessibility of information from different sources.
Remedial and Special Education, 23, 42–48.
Landrum, T. J., Tankersley, M., & Kauffman, J. M. (2003). What is special about special
education for students with emotional or behavioral disorders? Journal of Special
Education, 37, 148–156.
Lange, J. (1928). Die endogenen und reaktiven Gem Üsterkrankungen und die manisch
depressive Konstitution. O. Bunke (Ed.) Handbuch der Geistes krankheiten, 6(2), 1-231.
Lapalme, M., Hodgins, S., & LaRoche, C. (1997). Children of parents with bipolar disorder: A
metaanalysis of risk for mental disorders. Canadian Journal of Psychiatry, 42, 623-631.
LaRoche, C., Cheifetz, P., Lester, E. P., Schibuk, L., DiTommaso, E., & Engelsmann, F. (1985).
Psychopathology in the offspring of parents with bipolar affective disorders. Canadian
Journal of Psychiatry, 30, 337–343.
Larson, P. D., & Poist, R. F. (2004). Improving response rates to mail surveys: A
research note. Transportation Journal, 43, 67-74.
Lavigne, J. V., Gibbons, R. D., Arend, R., Rosenbaum, D., Binns, H. J., & Chrisoffel, K. K.
(1999). Rational service planning in pediatric primary care: Continuity and change in
psychopathology among children enrolled in pediatric practices. Journal of Pediatric
Psychology, 24(5), 393-403.
Lazar, J., & Preece, J. (1999). Designing and implementing Web-based surveys. Journal of
212
Computer Information Systems, 39(4), 63-67.
Lefkowitz, M. M., & Burton, N. (1978). Childhood depression: A critique of the concept.
Psychological Bulletin, 85, 716-726.
Leibenluft, E., Charney, D. S., & Pine, D. S. (2003a). Researching the pathophysiology of
pediatric bipolar disorder. Biological Psychiatry, 53(11), 1009-1021.
Leibunluft E., Charney, D. S., Towbin, K. E., Bhangoo, R. K., & Pine, D. S. (2003b).
Defining clinical phenotypes of juvenile mania. American Journal of Psychiatry, 160, 430437.
Leibenluft, E., Rich, B. A., Vinton, D. T., Nelson, E. E., Fromm, S. J., Berghorst, L. H., & et al.
(2007). Neural circuitry engaged during unsuccessful motor inhibition in pediatric
bipolar disorder. The American Journal of Psychiatry, 164(1), 52-60.
Lester, E. P., & LaRoche, C. (1978). Schizophreniform psychosis of childhood: Therapeutic.
Comprehensive Psychiatry, 19, 153-159.
Levendoski, L. S., & Cartledge, G. (2000). Self-monitoring for elementary school children with
serious emotional disturbances: Classroom applications for increased academic
responding. Behavioral Disorders, 25, 211–224.
Lewinsohn, P. M., Klein, D. N., & Seeley, J. R. (1995). Bipolar disorders in a community sample
of older adolescents: Prevalence, phenomenology, comorbidity, and course. Journal of
American Academy of Child and Adolescent Psychiatry, 34, 454-463.
Lewinsohn, P. M., Klein, D. N., & Seeley, J. (2000). Bipolar disorder during adolescence and
young adulthood in a community sample. Bipolar Diosrders, 2, 281-293.
Lewinsohn, P. M., Seeley, J. R., & Klein, D. N. (2003a). Bipolar disorders during adolescence.
Acta Psychiatrica Scandinavica, 108(S418), 47-50.
213
Lewinsohn, P. M., Seeley, J. R., & Klein, D. N. (2003b). Bipolar disorder in adolescents:
Epidemiology and suicidal behavior. In B. Geller & M. P. DelBello (Eds.), Bipolar
disorder in childhood and early adolescence (pp. 7-24). New York: The Guilford Press.
Lewis, M. F., Truscott, S. D., & Volker, M. A. (2008). Demographics and professional
practices of school psychologists: A comparison of NASP members and nonNASP school psychologists by telephone survey. Psychology in the Schools,
45(6), 467 – 482.
Lish, J. D., Dime-Meenan, S., Whybrow, P. C., & Price, R. (1994). The National Depressive and
Manic-Depressive Association (DMDA) survey of bipolar members. Journal of Affective
Disorders, 31(4), 281-294.
Liu, S. K., Chiu, C., Chang, C., Hwang, T., Hwu, H., & C. W. J. (2002). Deficits in sustained
attention in schizophrenia and affective disorders: Stable versus state-dependent markers.
American Journal of Psychiatry, 159, 975-982.
Lloyd, T., & Jones, P. B. (2000). The epidemiology of bipolar affective disorder: a review of the
literature and introduction to work in progress. Acta Neuropsychiatrica, 12, 99–102.
Lofthouse, N. & Fristad, M. A. (2004). Psychosocial interventions for children with
early-onset bipolar spectrum disorder. Clinical Child and Family Psychology Review,
7(2), 71-88.
Lofthouse, N. & Fristad, M. A. (2006). Bipolar disorders. Retrieved from
http://www.nasponline.org/publications/booksproducts/NAS-CBIII-05-1001-016-R02.pdf
Lofthouse, N., Mackinaw-Koons, B., & Fristad, M. A. (2004). Bipolar spectrum
disorders: Early onset. National Association of School Psychologists, S5, 13-16.
Retrieved from
http://www.nasponline.org/ communications/spawareness/bipolar_ho.pdf
214
Loranger, A. W., & Levine, P. M. (1978). Age at onset of bipolar affective illness. Archives of
General Psychiatry, 35, 1345-1348.
Luby, J., & Mrakotsky, C. (2003). Depressed preschoolers with bipolar family history: A group
at high risk for later switching to mania? Journal of Child and Adolescent
Psychoparmacology, 13, 187-197.
Luna, B., Garver, K. E., Urban, T. A., Lazar, N. A., & Sweeney, J. A. (2004). Maturation of
cognitive processes from late childhood to adulthood. Child Development, 75(5), 13571372.
Maccini, P., & Hughes, C. A. (1997). Mathematics interventions for adolescents with learning
disabilities [Electronic version]. Learning Disabilities Research and Practice, 12, 168176.
Mackinaw-Koons, B. & Fristad, M. A. (2004). Children with bipolar disorder: How to break
down barriers and work effectively together. Professional Psychology: Research and
Practice, 35(5), 481-484.
MacKinnon, D. F., & Pies, R. (2006). Affective instability as rapid cycling: Theoretical and
clinical implications for borderline personality and bipolar spectrum disorders. Bipolar
Disorders, 8, 1-14.
MacQueen, G., & Young, Y. (2003). Cognitive effects of atypical antipsychotics: Focus on
bipolar spectrum disorders. Bipolar Disorders, 5(suppl. 2), 53-61.
Malkoff-Schwartz, S., Frank, E., Anderson, B. P., Hlastala, S. A., Luther, J. F., Sherrill, J. T., &
et al. (2000). Social rhythm disruption and stressful life events in the onset of bipolar and
unipolar episodes. Psychological Medicine, 30, 1005-1016.
Marneros, A. (2001). Origin and development of concepts of bipolar mixed states. Journal of
215
Affective Disorders, 67(1-3), 229-240.
Martinez-Aran, A., Vieta, E., Colom, F., Torrent, C., Sanchez-Moreno, J., Reinares, M., & et al.
(2004a). Cognitive impairment in euthymic bipolar patients: Implications for clinical and
functional outcome. Bipolar Disorders, 6, 224-232.
Martinez-Aran, A., Vieta, E., Reinares, M., colom, F., Torrent, C., Sanchez-Moreno, J., & et al.
(2004b). Cognitive function across manic or hypomanic, depressed, and euthymic states
in bipolar disorder. American Journal of Psychiatry, 161, 262-270.
Masi, G., Perugi G., Toni, C., Millepiedi, S., Mucci, M., Bertinie, N., & et al. (2006). Attentiondeficit/hyperactivity Disorder - bipolar comorbidity in children and adolescents. Bipolar
Disorders, 8(4), 373-381.
Mathew, M. R., Chandrasekaran, R., & Sivakumar, V. A. (1994). Study of life events in mania.
Journal of Affective Disorders, 32, 157–161.
Mattis, S., Papolos, D., Luck, D., Cockerham, M., & Thode Jr., H. C. (2011).
Neuropsychological factors differentiating treated children with pediatric bipolar disorder
from those with attention-deficit/hyperactivity disorder. Journal of Clinical and
Experimental Neuropsychology, 33(1), 74-84.
McClellan (2005). Commentary: Treatment guidelines for child and adolescent bipolar disorder.
Journal of the American Academy of Child & Adolescent Psychiatry, 44 (3), 236-239.
McClellan, J. & Werry, J. (1997). Practice parameters for the assessment and treatment of
children and adolescents with bipolar disorder. Journal of American Academy of Child
and Adolescent Psychiatry, 36(1), 138-157.
McClelland, M. M., Morrison, F. J., & Holmes, D. L. (2000). Children at Risk for Early Academic
Problems: The Role of Learning-Related Social Skills. Early Childhood Research
216
Quarterly, 15(3), 307-29.
McClure, E. B., Kubiszyu, T., & Kaslow, N. J. (2002). Advances in the diagnosis and treatment of
childhood mood disorders. Professional Psychology: Research and Practice, 33(2), 125134.
McClure, E. B., Pope, K., Hoberman, A., Pine, D., & Leibenluft, E. (2003). Facial expression
recognition in adolescents with mood and anxiety disorders. American Journal of
Psychiatry, 160, 1-3.
McClure, E. B., Treland, J. E., Snow, J., Dickstein, D. P., Towbin, K. E., Charney, D. S., &
et al. (2005). Memory and learning in pediatric bipolar disorder. Journal of the American
Academy of Child and Adolescent Psychiatry, 44(5), 461-469.
McConaughy, S. H. (2000a). Self-report: Child clinical interviews. In Shapiro, E. S., &
Kratochwill, T. R. (Eds.), Conducting school-based assessments of child and adolescent
behavior (pp. 170-202). New York: Guilford.
McConaughy, S. H. (2000b). Self-reports: Theory and practice in interviewing children. In E. S.
Shapiro & T. R. Kratochwill (Eds.). Behavioral assessment in schools: Theory, research,
and clinical foundations (pp. 323-352). New York: Guilford.
McConaughy, S. H., & Achenbach, T. M. (1990). Contributions of developmental
psychopathology to school services. In T. B. Gutkin, C. R. Reynolds (Eds.) , The
handbook of school psychology (2nd ed.) (pp. 244-268). Oxford England: John Wiley &
Sons.
McConaughy, S. H., & Ritter, D. R. (2005). Best practices in multidimensional assessment of
emotional or behavioral disorders. In A. Thomas & J. Grimes (Eds.), Best practices in
school psychology IV (pp. 1303-1320). Bethesda, MD: National Association of School
217
Psychologists.
McDonough-Ryan, P., DelBello, M., Shear, P. K., Ris, D. M., Soutullo, C., & Strakowski, S. M.
(2002). Academic and cognitive abilities in children of parents with bipolar disorder: A
test of the nonverbal learning disability model. Journal of Clinical and Experimental
Neuropsychology, 24(3), 280–285.
McDougall, D. (1998). Research on self-management techniques used by students with
disabilities in general education settings: A descriptive review Remedial and Special
Education, 19, 310–320.
McElroy, S. L., & Keck, P. E. (2000). Pharmacologic agents for the treatment of acute bipolar
mania. Biological Psychiatry, 15(48), 538-557.
McElroy, S. L., Keck, P. E., Jr., Pope, H. G., Jr., Hudson, J. I., Faedda G. L., & Swann, A. C.
(1992). Clinical and research iplications of the diagnosis of dysphoric or mixed mania or
hypomania. American Journal of Psychiatry, 149(12), 1633-1644.
McGrath, J., Scheldt, S., Wilhelm, J., & Clair, A. (1997). Performance on tests sensitive to
impaired executive ability in schizophrenia, mania and well controls: Acute and subacute
phases. Schizophrenia Research, 29(26), 127-137.
McGuffin, P., Rijsdijk, F., Andrew, M., sham, P., Katz, R., & Cardno, A. (2003). The
heritability of bipolar affective disorder and the genetic relationship to unipolar
depression. Archives of General Psychiatry, 60, 497-502.
McInerney, M., Kane, M., & Pelavin, S. (1992).Services to children with serious emotional
disturbance. Washington, DC: Pelavin Associates, Inc.
McIntosh, D. E., & Trotter, J. S. (2006). Early onset bipolar spectrum disorder:
Psychopharmacological, psychological, and educational management. Psychology in the
218
Schools, 43(4), 451-460.
McLeod, C. C., Klabunde, C. N., Willis, G. B., & Stark, D. (2013). Health care provider surveys
in the United States, 2000–2010: A review. Evaluation & The Health Professions, 36(1),
106-126.
McMahon, S. R., Iwamoto, M., Massoudi, M. S., Yusuf, H. R., Stevenson, J. M., David,
F., Chu, S. Y., & Pickering, L. K. (2003). Comparison of e-mail, fax, and postal
surveys of pediatricians. Pediatrics, 111, e299–e303.
McMahon, F. J., Stine, O. D., Chase, G. A., Meyers, D. A., Simpson, S. G., & DePaulo, J. R.
(1994). Influence of clinical subtype, sex, and lineality on age at onset of major affective
disorder in a family sample. The American Journal of Psychiatry, 151(2), 210-215.
Meachem, M.L. & Peckham, P.D. (1978). School psychologists at three-quarters century:
Congruence between training, practice, preferred role, and competence. Journal of School
Psychology, 16, 195-206.
Merikangas, K. R., Akiskal, H. S., Angst, J., Greenberg, P. E., Hirschfeld, R. M., Petukhova, M.,
& et al. (2007). Lifetime and 12-month prevalence of bipolar spectrum disorder in the
National Comorbidity Survey replication. Archives of General Psychiatry, 64(5), 543552.
Merrell, K. W., &Walker, H. M. (2004). Deconstructing a definition: Social maladjustment
versus emotional disturbance and moving the EBD field forward. Psychology in the
Schools, 41, 899-910.
Messer, B. L., Edwards, M. L., & Dillman, D. A. (2012). Determinants of item
nonresponse to web and mail respondents in three address-based mixed-mode
surveys of the general public. Survey Practice, 5, 1–9.
Messmer-Wilson, K. (2006). Autism: Current beliefs, diagnostic practices, and treatment
219
approaches within the state of Indiana. (Unpublished doctoral dissertation). Ball State
University, Muncie, Indiana.
Meyer, S. T., Carlson, G. A., Wiggs, E. A., Martinez, P. E., Ronsaville, D. S., Klimes-Dougan,
B., & et al. (2004). A prospective study of the association among impaired executive
functioning, childhood attentional problems, and the development of bipolar disorder.
Development and Psychopathology, 16(2), 461-476.
Mick, E., Biederman, J., Faraone, S. V., Murray, K., & Wozniak, J. (2003). Defining a
developmental subtype of bipolar disorder in a sample of nonreferred adults by age at
onset.
Miklowitz, D. J. (1996). Psychotherapy in combination with drug treatment for bipolar disorder.
Journal of Clinical Psychopharmacology, 16(Supp. 1), 56S-66S.
Miklowitz, D. J. (2007). The role of the family in the course and treatment of bipolar disorder.
Association for Psychological Science, 16(4), 192-196.
Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L., & Suddath, R. L. (2003). A
randomized study of family-focused psychoeducation and pharmacotherapy in the
outpatient management of bipolar disorder. Archives of General Psychiatry, 60, 904-912.
Miklowitz, D. J., Goldstein, M. J., & Nuechterlein, K. H. (1995). Verbal interactions in the
familis of schizophrenic and bipolar affective patients. Journal of Abnormal Psychology,
104(2), 268-276.
Miklowitz, D. J., & Otto, M. W. (2006). New psychosocial interventions for bipolar disorder: A
review of literature and introduction to the Systematic Treatment Enhancement Program.
Journal of Cognitive Psychotherapy: An International Quarterly, 20(2), 215-230.
Miller, C. J., Klugman, J., Berv, D. A., Rosenquist, K. J., & Ghaemi, S. N. (2004). Sensitivity
220
and specificity of the ood Diosrder Questionnaire for detecting bipolar disorder. Journal
of Affective Disorders, 81, 167-171.
Morgan-D’Atrio, C., Northrup, J., LaFleur, L., & Spera, S. (1996). Toward prescriptive
alternatives to suspensions: A preliminary evaluation. Behavioral Disorders, 21, 190200.
Morris, C. D., Miklowitz, D. J., & Waxmonsky, J. A. (2007). Family-focused treatment for
bipolar disorder in adults and youth. Journal of Clinical Psychology, 63(5), 433-445.
Morselli, P.L., & Elgie, R. (2003). GAMIAN-Europe/BEAM survey I - global analysis of a
patient questionnaire circulated to 3450 members of 12 European advocacy groups
operating in the field of mood disorders. Bipolar Disorder, 5, 265-278.
Moynihan, R., & Cassels A. (2005). Selling sickness. New York: Nation Books.
Murphy, F. C., & Sahakian, B. J. (2001). Neuropsychology of bipolar disorder. British Journal
of Psychiatry, 178, 120-127.
Murphy, F. C., Sahakian, B. J., Rubinsztein, J. S., Micahel, A., Rogers, R. D., Robbins, T. W., &
et al. (1999). Emotional bias and inhibitory control processes in mania and depression.
Psychological Medicine, 29, 1307-1321.
Muschkin, C. G., & Malone, P. S. (2007). Multiple Teacher Ratings: An Evaluation of
Measurement Strategies. Educational Research And Evaluation, 13(1), 71-86.
Nastasi, B. K., Varjas, K., Berstein, R., & Pluymert, K. (1998). Mental health programming and
the role of school psychologist. School Psychology Review, 27(2), 217-32.
National Association of School Psychologists (1993). Position statement on students with
emotional/behavioral disorders. Silver Spring, MD: Author.
221
National Association of School Psychologists (2000a). Guidelines for the Provision of School
Psychological Services. Washington, DC: National Association of School Psychologists.
National Association of School Psychologists. (2000b). Professional conduct manual: Principles
for professional ethics and guidelines for the provision of school psychological services.
Bethesda, MD: Author.
National Association of School Psychologists (2005). Position statement on students with
Emotional and behavioral disorders. Washington, DC: National Association of School
Psychologists.
National Association of School Psychologists. (2008). The importance of school mental health
services (Position Statement). Bethesda, MD: Author.
National Association of School Psychologists (2014). Becoming a school psychologist. Bethesda,
MD: Author. Retrieved March23, 2014 from
http://www.nasponline.org/certification/becoming.aspx
National Institute of Mental Health research roundtable on prepubertal bipolar disorder (2001).
Journal of American Academy of Child and Adolescent Psychiatry, 40, 871-878.
National Institute of Mental Health research roundtable on pediatric bipolar NOS (2002). NIMH,
Rockville, MD. Retrieved from http://www.nimh.nih.gov/sciencetific
meetings/pediatric.cfm
National Center for Health Statistics (2010). Digest of education statistics. Atlanta, GA: Centers
for Disease Control and Prevention.
Nelson, J. R., Smith, D. J., Young, R. K., & Dodd, J. (1991). A review of self-management
outcome research conducted with students who exhibit behavioral disorders. Behavioral
Disorders, 16, 169–179.
222
Olvera, R. L., Semrud-Clikeman, M., Pliszka, S. R., & O'Donnell, L. (2005).
Neuropsychological deficits in adolescents with conduct disorder and comorbid bipolar
disorder: A pilot study. Bipolar Disorders, 7, 57-67.
O’Neill, R. E., Horner, R. H., Albin, R. W., Storey, K., & Sprague, J. R. (1997). Functional
analysis of problem behavior: A practical assessment guide (2nd ed.). Pacific Grove, CA:
Brookes/Cole.
Orvaschel, H., & Puig-Antich, J. (1987). Schedule for Affective Disorder and Schizophrenia for
School-Age Children, Epidemiologic, 4th Version. Ft. Lauderdale, FL: Nova University.
Olympia, D., Farley, M., Christiansen, E., Pettersson, H., Jenson, W., & Clark, E. (2004). Social
maladjustment and students with behavioral and emotional disorders: Revising basic
assumptions and assessment issues. Psychology in the Schools, 41(8), 835-847.
Osher, D., Osher, T., & Smith, C. (1994). Toward a national perspective in emotional and
behavioral disorders. Beyond Behavior, 6, 6-17.
Oswald, D.P., & Coutinho, M.J. (1995). Identification and placement of students with serious
emotional disturbance. Part I: Correlates of state child-count data. Journal of Emotional
and Behavioral Disorders, 3(4), 224-229.
Otto, M. W., Reilly-Harrington, N. A., Kogan, J. N., Henin, A., Knauz, R. O., & Sachs, G. S.
(2009). Managing bipolar disorder: A cognitive-behavioral approach. (Workbook). New
York: Oxford University Press.
Papolos, D. E. (2003). Bipolar disorder and comorbid disorder: The case for a dimensional
nosology. In B. Geller & M. P. DelBello (Eds.), Bipolar Disorder in Childhood and
Early Adolescence (pp. 76-106). New York: The Guilford Press.
Papolos, D., & Papolos, J. (2006). The bipolar child: The definitive and reassuring guide to
223
childhood's most misunderstood disorder. New York: Broadway Books.
Patterson, G. R., DeBeryshe, B. D., & Ramsey, E. (1989). A developmental perspective on
antisocial behavior. American Psychologist, 44, 329–335.
Patton, G. C. (2007). Pubertal transitions in health. The Lancet, 369(9567), 1130-1148.
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.
Pavuluri, M. N., Graczyk, P. A., Henry, D. B., Carbray, J. A., Heidenreich, J., & Miklowitz, D. J.
(2004). Child- and family-focused cognitive-behavioral therapy for pediatric bipolar
disorder: Development and preliminary results. Journal of American Academy of Child
and Adolescent Psychiatry, 54, 528-537.
Pavuluri, M. N., Herbener, E. S., & Sweeney, J. A. (2004). Psychotic symptoms in pediatric
bipolar disorder. Journal of Affective Disorders, 80(1), 19-28.
Pavuluri, M. N., Janicak, P. G., & Carbray, J. (2002). Topiramate plus Risperidone for controlling
weight gain and symptoms in preschool mania. Journal of Child and Adolescent
Psychopharmacology, 12(3), 271-273.
Pavuluri, M. N., O-Connor, M. M., Harral, E. M., Moss, M., & Sweeney, J. A. (2006a). Impact of
neurocognitive function on academic difficulties in pediatric bipolar disorder: A clinical
translation. Biological Psychiatry, 60, 951-956.
Pavuluri, M. N., Schenkel, L. S., Aryal, S., Harral, E. M., Hill, S. K., Herbener, E. S., & et al.
(2006b). Neurocognitive function in unmedicated manic and medicated euthymic pediatric
bipolar patients. American Journal of Psychiatry, 163, 286-293.
Pelco, L. E., Jacobsin, L., Ries, R. R., & Melka, S. (2000). Perspectives and practices in family
224
school partnerships: A national survey of school psychologists. School Psychology
Review, 29, 235-250.
Perfect, M. M. & Morris, R. J. (2011). Delivering school-based mental health services by school
psychologists: Education, training, and ethical issues. Psychology in the Schools, 48(10),
2011.
Perry, A., Tarrier, N., Morriss, R., McCarthy, E., & Limb, K. (1999). Randomised controlled trial
of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse
and obtain treatment. British Medical Journal, 319(7177), 149-153.
Perugi, G., Akiskal, H. S., Micheli, C., Musetti, L., Paiano, A., Quilici, C., et al. (1997). Clinical
subtypes of bipolar mixed states: Validating a broader European definition in 143 cases.
Journal of Affective Disorders, 43(3), 169-180.
Perugi, G., Akiskal, H. S., Micheli, C., Toni, C., & Madaro, D. (2001). Clincial characterization
of depressive mixed state in bipolar-I patients: Pisa-San Diego collagoration. Journal of
Affective Disorder, 67(1-3), 105-114.
Placidi, G. F., Maremmani, I., Signoretta, S., Liguori, A., and Akiskal, H. S. (1998). The semi
structured affective temperament interview (TEMPS-I). Reliability and psychometric
properties in 1010 14 – 26-year old students. Journal of Affective Disorders, 51, 199-208.
Pluymert, K. (2005). Best practices in developing exemplary mental health programs in schools. In
A. Thomas & J. Grimes (Eds.), Best Practices in School Psychology IV (pp. 963-975).
Polanczyk, G., Silva de Lima, M., Horta, B. L., Biederman, J., & Rohde, L. A. (2007). The
worldwide prevalence of ADHD: A systematic review and metaregression analysis.
American Journal of Psychiatry, 164, 942-948.
Popper, C. W. (1995). Balancing knowledge and judgment: A clinician looks at new
225
developments in child and adolescent psychopharmacology. Pediatric
Psychopharmacology II, 4, 483-510.
Porter, S. R. (2004). Pros and cons of paper and electronic surveys. New Directions for
Institutional Research, 121, 91-99.
Porter, S. R. (2004). Raising response rates: What works? New Directions for Institutional
Research, 121, 5-23.
Power, T. J., McGoey, K. E., Heathfield, L. T., & Blum, N. J. (1999). Managing and preventing
chronic health problems in children and youth: School Psychology’s expanded mission.
School Psychology Review, 28(2), 251-63.
President’s New Freedom Commission on Mental Health (2003). Retrieved from
http://www.mentalhealthcommission.gov/subcommittee/children_family020703.doc
Prien, R. F., & Rush, A. J. (1996). National Institute of Mental Health workshop report on the
treatment of bipolar disorder. Biological Psychiatry, 1(40), 215-220.
Quinn, C.A., & Fristad, M.A. (2004). Defining and identifying early onset bipolar spectrum
disorder. Current Psychiatry Reports, 6, 101–107.
Rasmussen, J. (2007). Autism: Assessment and intervention practices of school psychologists and
the implications for training in the United States. (Unpublished doctoral dissertation). Ball
State University, Muncie, IN.
Raziano, D. B., Jayadevappa, R., Valenzula, D., Weiner, M., & Lavizzo-Mourey, R.
(2001). E-mail versus conventional postal mail survey of geriatric chiefs. The
Gerontologist, 41, 799–804.
Rea, M. M., Tompson, M. C., Milowitz, D., Goldstein, M. J., Hwant, S., & Mintz, J. (2003).
Family-focused treatment versus individual treatment for bipolar disorder: Results of a
randomized clinical trial. Journal of Consulting and Clinical Psychology, 71(3), 482-492.
226
Reid, R. (1996). Research in self-monitoring with students with learning disabilities: The
present, the prospects, the pitfalls [Electronic version]. Journal of Learning Disabilities,
29, 317–331.
Reinke, W. M., Stormont, M., Herman, K. C., Puri, R., & Goel, N. (2011). Supporting children's
mental health in schools: Teacher perceptions of needs, roles, and barriers. School
Psychology Quarterly, 26(1), 1-13.
Repie, M. S. (2005). A school mental health issues survey from the perspective of regular and
special education teachers, school counselors, and school psychologists. Education and
Treatment of Children, 28(3), 279-298.
Reschly, D. J. (2000). The present and future status of school psychology in the United States.
School Psychology Review, 29(4), 507-522.
Rey, A. (1941). L’examen psychologique dans les cas d’encephalopathie truamtique. Archive fur
Psychologie.
Rey, J. M. (1993). Oppositional defiant disorder. The American Journal of Psychiatry, 150(12),
1769-1778.
Reynolds, C. R. & Bigler, E. D. (1994). Test of memory and learning examiner’s manual. Austin:
Pro-Ed.
Reynolds, C., & Kamphaus, R. (2006). Behavior Assessment System for Children 2. Circle Pines,
MN: American Guidance Service.
Reynolds, W. M., & Graves, A. (1989). Reliability of children's reports of depressive
symptomatology. Journal Of Abnormal Child Psychology: An Official Publication Of
The International Society For Research In Child And Adolescent Psychopathology, 17(6),
647-655.
227
Rhode, C., Morgan, D. P., & Young, K. R. (1983). Generalization and maintenance of treatment
gains of behaviorally handicapped students from resource room to regular classroom
using self-evaluation procedures. Journal of Applied Behavior Analysis, 16, 171–188.
Rice, J. P., Rochberg, N., Endicott, J., Lavori, P. W., & Miller, C. (1992). Stability of psychiatric
diagnoses. An application to the affective disorders. Archives of General Psychiatry, 49,
824-830.
Rie, H. E. (1966). Depression in childhood: A survey of some pertinent contributions. Journal of
the American Academy of Child Psychiatry, 5, 653-685.
Rihmer, A., & Kiss, K. (2002). Bipolar disorders and suicidal behaviour. Bipolar Disorders,
4(suppl. 1), 21-25.
Ringeisen, H., Henderson, K., & Hoagwood, K. (2003). "Context matters: Schools
and the "Research to practice gap" in children's mental health." School Psychology
Review 32, (2), 153-168.
Ritter, L. A., & Sue, V. M. (2007). Using online surveys in evaluation. Hoboken, N. J.:
Wiley Periodicals, Inc.
Roberts, R. E., Attkisson, C. C., & Rosenblatt, A. (1998). Prevalence of psychopathology among
children and adolescents. American Journal of Psychiatry, 155, 715-725.
Robins, L. N. (1985). Epidemiology: Reflections on testing the validity of diagnostic interviews.
Archives of General Psychiatry, 42, 918-924.
Rochlin, G. (1959). The loss complex: A contribution to the etiology of depression. Journal of
American Psychoanalytic Association, 7, 299-316.
Rubinsztein, J. S., Fletcher, P. C., Rogers, R. D., Ho, L. W., Aigbirhio, F. I., Paykel, E. S., & et al.
(2001). Decision-making in mania: A PET study. Brain, 124, 2550-2563.
228
Rudy, H. L., & Levinson, E. M. (2008). Best practices in the multidisciplinary assessment of
emotional disturbances: A primer for counselors. Journal of Counseling and
Development, 86, 494-504.
Ruffalo, S. L., & Elliott, S. N. (1997). Teachers' and parents' ratings of children's social skills: A
closer look at cross-informant.. School Psychology Review, 26(3), 489.
Ruhl, K. L., & Berlinghoff, D. H. (1992). Research on improving behaviorally disordered
students' academic performance: A review of the literature. Behavioral Disorders, 17,
178-190.
Rumke, H. C. (1928). Über Psychosen bei Kinders. Neurologica et Psychiatrica, 114, 113-151.
Rutter, M. J. (1972). Childhood schizophrenia reconsidered. Journal of Autism and
Childhood Schizophrenia, 2, 315-317.
Ryan, N. D., Bhatara, V. S., & Perel, J. M. (1999). Mood stabilizers in children and adolescents.
Journal of the American Academy of Child and Adolescent Psychiatry, 38(5), 529 – 536.
Sachs, G. S. (1996). Bipolar mood disorder: Practical strategies for acute and maintenance phase
treatment. Journal of Clinical Psychopharmacology, 16, 32s-47s.
Sachs, G. S., Baldassano, C. F., Truman, C. J., & Guille, C. (2000). Comorbidity of Attention
Deficit Hyperactivity Disorder with early- and late-onset bipolar disorder. American
Journal of Psychiatry, 157(3), 466-468.
Sachs, G.S., Guille, C., & McMurrich, S. L. (2002). A clinical monitoring from for mood
disorders. Bipolar Disorders, 4, 323-327.
Sackheim, H. A., Decina, P., Epstein, D., Bruder, G. E., & Malitz, S. (1983). Possible reversed
affective lateralization in a case of bipolar disorder. American Journal of Psychiatry,
140(9),1191–1193.
229
Salant, P., & Dillman, D. (1994). How to conduct your own survey. New York, NY: John Wiley
& Sons.
Salvatore, P., Baldessarini, R. J., Centorrino, F., Egli, S., Albert, M., Gerhard, A., & Maggini, C.
(2002). Weygandt’s on the mixed states of manic-depressive insanity: A translation and
commentary on its significance in the evolution of the concept of bipolar disorder.
Harvard Review of Psychiatry, 10(5), 255-275.
Sanches, M., Roberts, R. L., Sassi, R. B., Axelson, D., Nicoletti, M., Brambilla, P., & et al.
(2005). Developmental abnormalities in striatum in young bipolar patients: A preliminary
study. Bipolar Disorders, 7, 153-158.
Schaefer, D., & Dillman, D. (1998). Development of a standard emailmethodology: Results of an
experiment. Public Opinion Quarterly, 62, 378-397.
Schaughency, E., & Ervin, R. (2006). Building capacity to implement and sustain effective
practices to better serve children. School Psychology Review, 35(2), 155-166.
Schlitz, M. (1988). Professional standards for survey research. Res. Higher Educ. 28, 67–75.
Schmidt, W. C. (1997). World Wide Web survey research: Benefits, potential problems, and
solutions. Behavioral Researchmethods, Instruments, and Computers, 29, 274-279.
Scott, J., & Colom, F. (2005). Psychosocial treatments for bipolar disorders. Psychiatric Clinics
of North America, 28, 371-384.
Senokossoff, G. W., & Stoddard, K. (2008). Swimming in deep water: Childhood bipolar
disorder. Preventing School Failure, 53(2), 89-93.
Serretti, A., & Olgiati, P. (2005). Profiles of “manic” symptoms in bipolar I, bipolar II and major
depressive disorders. Journal of Affective disorders, 84, 159-166.
Severson, H., & Walker, H. M. (2002). Proactive approaches for identifying children at-risk for
230
sociobehavioral problems. In K. Lane, F. M. Gresham, & T. O’Shaughnessy (Eds.),
Interventions for children with or at risk for emotional and behavioral disorders (pp. 33
54). Boston: Allyn & Bacon.
Shaffer, D., Fisher, P., Lucas, C. P., Dulcan, M., & Scwab-Stone, M. E. (2000) NIMH
Diagnostic Interview Schedule for Children, Version IV(NIMHDISC-IV): Description,
differences from previsou versions and reliability of some common diagnoses. Journal of
the American Academy of child and Adolescent Psychiatry, 39, 28-38.
Shannon, D. M. & Bradshaw, C. C. (2002). A comparison of reponse rate, response time, and
costs of mail and electronic surveys. The Journal of Experimental Education, 70(2),
179-192.
Shapiro, E. S., & Cole, C. L. (1994). Self-management interventions for classroom behavior
change. New York: Guilford Press.
Shapiro, E. S., DuPaul, G. J., & Bradley-Klug, K. L. (1998). Selfmanagement as a strategy to
improve the classroom behavior of adolescents with ADHD Journal of Learning
Disabilities, 31, 545–555.
Shores, R. E., Gunter, P. L., & Jack, S. L. (1993). Classroom management strategies: Are they
setting events for coercion? Behavioral Disorders, 18, 92–102.
Short, K. H., Weist, M. D., Manion, I. G., & Evans, S. W. (2012). Tying together research and
practice: Using ROPE for successful partnerships in school mental health. Administration
And Policy In Mental Health And Mental Health Services Research, 39(4), 238 – 247.
Singer, E., van Hoewyk, J., & Maher, M. P. (1998). Does the payment of incentives create
expectation effects? Public Opinion Quarterly, 62(2), 152-164.
231
Skiba, R., Grizzle, K., & Minke, K.M. (1994). Opening the floodgate? The social maladjustment
exclusion and state SED prevalence rates. Journal of School Psychology, 32, 267–282.
Sloper, P. (1998). Models of service support for paretns of disabled children. What do we know?
What do we need to know? Child: Care, Health and Development, 25(2), 85-99.
Smith, A. L. (1999). School psychologists and Attention-Deficit/Hyperactivity Disorder: A
survey of training, knowledge, practice, and attitude. (Unpublished doctoral dissertation).
Ball State University, Muncie, Indiana.
Smith, C.R., Wood, F.H., & Grimes, J. (1988). Issues in the identification and placement of
behaviorally disordered students. In M.C. Wang, M.C. Reynolds, & H.J. Walberg
(Eds.), Handbook of special education: Research and practice: Vol. 2. Mildly
handicapped conditions (pp. 95-123). New York: Pergamon.
Smith, S. W., & Farrell, D. T. (1993). Level system use in special education: Classroom
intervention with prima facie appeal Behavioral Disorders, 18, 251–264.
Snyder, M. C., & Bambara, L. M. (1997). Teaching secondary students with learning disabilities
to self-manage classroom survival skills Journal of Learning Disabilities, 30, 534–543.
Soukhanoff, S., & Gannouchkine, P. (1903). Etude sur la folie circulaire et sur les formes
circulaires des psychoses. Journal of Neurology, 7, 163-172.
Soutullo, C. A., Chang, K. D., Diez-suarez, A., Figueroa-Quintana, AEscamilla-Canales, I.,
Rapado-Castro, M., & et al. (2005). Bipolar disorder in children and adolescents:
International perspective on epidemiology and phenomenology. Bipolar Disorders, 7,
497-506.
Spicer, C. C., Hare, E. H., & Slater, E. (1973). Neurotic and psychotic forms of depressive
illness: evidence from age-incidence in a national sample. British Journal of Psychiatry,
232
123, 535–541.
Spitz, R. A. (1949). The role of ecological factors in emotional development in infancy. Child
Development, 20(3), 145-156.
Spooner, F., & Browder, D. M. (2003). Special exchange series: Perspectives on defining
scientifically based research in education and students with low incidence disabilities.
Research and Practice for Persons With Severe Disabilities, 28(3), 117–160.
Steege, M. W., Mace, F., & Brown-Chidsey, R. (2007). Functional behavioral assessment of
classroom behavior. In S. Goldstein, R. B. Brooks (Eds.) , Understanding and managing
children's classroom behavior: Creating sustainable, resilient classrooms (2nd Ed.) (pp.
43-63). Hoboken, NJ US: John Wiley & Sons Inc.
Steinhausen, H. C., Haslimeier, C., Metzke, C. W. (2007). Psychosocial factors in adolescent and
Young adult self-report5ed depressive symtpoms: Causal or correlational associations?
Journal of Youth and Adolescence, 36, 89-100.
Stormont, M., Reinke, W. M., Herman, K. C., & Lembke, E. S. (2012). Academic and Behavior
Supports for At-Risk Students: Tier 2 Interventions. Practical Intervention in the Schools
Series. Guilford Publications.
Strain, P. S., Kohler, F. W., Storey, K., & Danko, C. D. (1994). Teaching preschoolers with
autism to self-monitor their social interactions: An analysis of results in home and school
settings. Journal of Emotional & Behavioral Disorders, 2, 78–88.
Strakowski, S. M., Adler, C. M., Holland, S. K., Mills, N. P., DelBello, M. P., & Eliassen, J. C.
(2005). Abnormal fMRI brain activation in euthymic bipolar disorder patients during a
counting Stroop interference task. American Journal of Psychiatry, 162, 1697-1705.
Strober, M., Morrell, W., Lampert, C., & Burroughs, J. (1990). Relapse following
233
discontinuation of lithium maintenance therapy in adolescents with bipolar I illness: A
naturalistic study. American Journal of Psychiatry, 147, 457-461.
Studwell, P., & Moxley, R. (1984). Self-recording in kindergarten: A study in naturalistic
evaluation [Electronic version]. Psychology in the School, 21, 450–456.
Sue, V. M., & Ritter, L. (2007). Conducting online surveys. Los Angeles, CA: Sage
Publications.
Sutherland, K. S., & Wehby, J. H. (2001). The effect of self-evaluation on teaching behavior in
classrooms for students with emotional and behavioral disorders [Electronic version].
Journal of Special Education, 35, 161–171.
Swaggart, B. L. (1998). Implementing a cognitive behavior management program. Intervention
in School and Clinic, 33, 235–238.
Swann, A. C., Dougherty, D. M., Pazzaglia, P. J., Pham, J., & Moeller, F. G. (2004). Impulsivity:
A link between bipolar disorder and substance abuse. Bipolar Disorders, 6, 204-212.
Swann, A. C., Pazzaglia, P., Nicholls, A., Dougherty, D. M., & Moeller, F. G. (2003).
Impulsivity and phase of illnessin bipolar disorder. Journal of Affective Disorders, 73(1
2), 105-111.
SzaÅLdoÅL czky E,Papp Z,Vitrai J,Rı ÅLhmer Z,FuÅN redi J. (1998). The prevalence of major
depressive and bipolar disorders in Hungary. Results from a national epidemiologic
survey. Journal of Affective Disorders, 50, 153–162.
Szymanski, M. L., & Zolotor, A. (2001). Attention-deficit/hyperactivity disorder: Management.
American Family Physician, 64, 1355–1362.
Tashman, N. A., Weist, M. D., Acosta, O., Bickham, N. L., Grady, M., Nabors, L., & Waxman,
R. (2000). Toward the integration of prevention research and expanded school mental
234
health programs. Children’s Services: Social Policy, Research, and Practice, 3(2), 97115.
Thomas, A. (1998). Directory of school psychology graduate programs. Bethesda, MD: National
Association of School Psychologists.
Thompson, J. M., Gallagher, P., Hughes, J. H., Watson, S., Gray, J. M., Ferrier, I. N., & et al.
(2005). Neurocognitive impairment in euthymic patients with bipolar affective disorder.
British Journal of Psychiatry, 186, 32-40.
Thompson, J. M., Gray, J. M., Hughes, J. H., Watson, S., Young, A. H., & Ferrier, I. N. (2007).
Impaired working memory monitoring in euthymic bipolar patients. Bipolar Disorders, 9,
478-489.
Thompson, J. M., Hamilton, C. J., Gray, J. M., Quinn, J. G., Mackin, P., Young, A. H., & et al.
(2006). Executive and visuospatial sketchpad resources in euthymic bipolar disorder:
Implications for visuosptial working memory architecture. Memory, 14(4), 437-451.
Thuppal, M., Carlson, G. A., Sprafkin, J., & Gadow, K. (2002). Correspondence between
adolescent report, parent report, and teacher report of manic symptoms. Journal of Child
and Adolescent Psychopharmacology, 12(1), 27-35.
Tolan, P., & Dodge, K. (2005). Children’s mental health as a primary care and concern: A
system for comprehensive support and service. American Psychologist, 60, 601-614.
Trout, A. L., Nordness, P. D., Pierce, C. D., & Epstein, M. H. (2003). Research on the academic
status of children and youth with emotional and behavioral disorders: A review of the
literature from 1961- 2000. Journal of Emotional and Behavioral Disorders, 11, 198210.
Tsuchiya, K. J., Byrne, M., & Mortensen, P. B., (2003). Risk factors in relation to an emergence
235
of bipolar disorder: A systematic review. Bipolar Disorders, 5, 231-242.
Umbach, P. S. (2004). Web surveys: Best practices. New Directions for Institutional Research,
121, 23-40.
U.S. Department of Education. (1980). Second annual report to Congress on the implementation
of Public Law 94-142: The Education for All Handicapped Children Act. Washington,
DC: Author.
U.S. Department of Education. (1994). Sixteenth annual report to Congress on the
implementation of Public Law 94-142. Washington, DC: U.S. GPO.
U.S. Department of Education. (1998). Tlventy-first annual report to Congress on the
implementation of the Individuals with Disabilities Education Act. Washington, DC: U.S.
Department of Education.
U.S. Department of Education. (2001). Twenty-third annual report to Congress on the
implementation of the Indivudals With Disabilities Act. Washington, DC: Author.
U.S. Department of Education (2002a). Office of Special Education Programs Data Analysis
System (DANS), 2002–2003. Available: IDEAdata.org.
U.S. Department of Education. (2002b). Twenty-fourth annual report to Congress on
implementation of the Individuals with Disabilities Education Act. Washington, DC:
Author.
U.S. Department of Education. (2003). Twenty-fifth annual report to Congress on the
implementation of the Indivudals With Disabilities Act. Washington, DC: Author.
U.S. Department of Education, National Center for Education Statistics. (2008). Digest of
education statistics: 2007 (NCES 2008-022). Washington, DC: U.S. Government
Printing Office. Retrieved June 30, 2012, from
236
http://nces.ed.gov/programs/digest/d07/tables/dt07_002.asp?referrer=report
United States Department of Health and Human Services. (1999). Mental health: A report of the
Surgeon General. Rockville, MD: U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration, Center for Mental Health
Services, National Institutes of Health, National Institute of Mental Health.
United States Department of Health and Human Services. (2001). Report of the Surgeon
General’s conference on children’s mental health: A national action agenda.
Washington, D.C.: Author.
United States Department of Health and Human Services. (2005). The national survey of child
health 2003. Rockville, M.D.: United States Department of Health and Human Services.
United States Public Health Service. (2000). Report of the Surgeon General's conference on
Children's Mental Health: A national action agenda. Washington, D.C.: Department of
Health and Human Services.
van Gorp, W. G., Altshuler, L., Theberge, D. C., Wilkins, J., & Dixon, W. (1998). Cognitive
impairment in euthymic bipolar patients with and without prior alcohol dependence.
Archives of General Psychiatry, 55, 41-46.
Van Horn, P. S., Green, K. E., & Martinussen, M. (2009). Survey response rates and survey
administration in counseling and clinical psychology: A meta-analysis. Educational And
Psychological Measurement, 69(3), 389-403.
Vannest, K. J., Temple-Harvey, K. K., & Mason, B. A. (2009). Adequate yearly progress for
students with emotiona and behavioral disorders through research-based practices.
Preventing School Failure, 53(2), 73-82.
Verhulst, F., vanderEnde, J., Ferinand, R., & Kasius, M. (1997). The prevalence of DSM-III-R
237
diagnoses in a national sample of Dutch adolescents. Archives of General Psychiatry, 54,
329-336.
Vieta, E., & Colom, F. (2004). Psychological interventions in bipolar disorder: From wishful
thinking to an evidenced-based approach. Acta Psychiatrica Scandinavica, 110, 34-38.
Vieta, E., Gasto, C., Otero, A., Nieto, E., & Vallejo, J. (1997). Differential features between
bipolar I and bipolar II disorder. Comprehensive Psychiatry, 38(2), 98-101.
Wagner, M, Blackorby, J., Cameto, R., Hebbler, K., & Newman, L. (1993). Influences in post
school outcomes of youth with disabilities. The third comprehensive report from the
National Longitudinal Transition Study of Special Education Students. Menlo Park,
CA: SRI International.
Wagner,M., Kutash, K., Duchnowski,A. J., & Epstein,M. H. (2005). The Special Education
Elementary Longitudinal Study (SEELS) and the National Longitudinal Transition Study
(NLTS2): Study designs and implications for children and youth with emotional
disturbance. Journal of Emotional and Behavioral Disorders, 13(1), 25–41.
Wagner, M., Kutash, K., Duchnowski, A. J., Epstein, M. H., & Sumi, W. C. (2005). The children
and youth we serve: A national picture of the characteristics of students with emotional
disturbances receiving special education. Journal of Emotional and Behavioral
Disorders, 13(2), 79-96.
Walker, E. F. (2002). Adolescent neurodevelopment and psychopathology. Current Directions,
11(1), 24-28.
Walker, H.M., Nishioka, V., Zeller, R., Severson, H., & Feil, E. (2000). Causal factors and
potential solutions for the persistent under-identification of students having emotional or
behavioral disorders in the context of schooling. Assessment for Effective Intervention,
238
26, 29–40.
Walker, H. M., Ramsay, E., & Gresham, F. M. (2004). Antisocial behavior in school: Evidence
based practices (2nd ed.). Belmont, CA: Wadsworth/Thomson Learning.
Walker, H. M., & Severson, H. H. (1992). Systematic screening for behavior disorders
(SSBD) (2nd ed.). Longmont, CO: Sporis West.
Walker, H. M., Severson, H., & Feil, E. (1995). Early screening project: A proven child-find
process. Longmont, CO: Sopris West.
Walsh, J. (1998). Psychopharmacological treatment of bipolar disorder. Research on Social
Work Practice, 8, 406-425.
Wang, P. S, Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005).
Twelve-month use of mental health services in the United States. Archives of General
Psychiatry, 62, 629-640.
Warriner, K., et al. (1996). Charities, no; Lotteries, no; Cash, yes: Main effects and interactions
in a Canadian incentives experiment. Public Opinion Quarterly, 60, 542-562.
Webber, J., Scheuermann, B., McCall, C., & Coleman, M. (1993). Research on self-monitoring
as a behavior management technique in special education classrooms: A descriptive
review [Electronic version]. Remedial and Special Education, 14, 38–56.
Weckerly, J. (2002). Pediatric bipolar mood disorder. Developmental and Behavioral Pediatrics,
23, 42-56.
Wechsler, D. (1991). Manual for the Wechsler Intelligence Scale for Children (3rd Ed.). San
Antonio, TX: Psychological Corporation/Harcourt Brace Jovanovich.
Weeke, A., Bille, M., Videbech, T., Dupont, A., & Juel-Nielsen, N.(1975). Incidence of
depressive syndromes in a Danish county. The Aarhus county investigation. Acta
239
Psychiatrica Scandinavica, 51, 28–41.
Weinberg, W. A., & Brumback, R. A. (1976). Mania in childhood, case studies and literature
revew. American Journal of Diseases of Childhood, 130, 380-385.
Weissberg, R. P., Kumpfer, K. L., & Seligman, M. P. (2003). Prevention that works for children
and youth: An introduction. American Psychologist, 58(6), 425-432.
Weissman, M., & Bland, R. (1996). Cross-national epidemiology of major depression and
bipolar disorder. JAMA: Journal Of The American Medical Association [serial online],
276(4), 293. Available from: Academic Search Premier, Ipswich, MA. Accessed April
11, 2014.
Weissman, M. M., Wolk, S., Wickramaratne, P., Goldstein, R., Adams, P., Greenwald, S., et al.
(1999). Children with prepubertal-onset major depressive disorder and anxiety grown up.
Archives of General psychiatry, 56, 794-801.
Weist, M. D., Rubin, M., Moore, E., Adelsheim, S., & Wrobel, G. (2007). Mental health
screening in schools. Journal of School Health, 77(2), 53 – 58.
Weisz, J. R., Sandler, I. N., Durlak, J. A., & Anton, B. S. (2005). Promoting and protecting youth
mental health through evidence based prevention and treatment. American Psychologist,
60, 628–648.
Weller, E. B., Weller, R. A., & Fristad, M. A. (1995). Bipolar disorder in children: Misdiagnosis,
underdiagnosis, and future directions. Journal of American Academy of Child and
Adolescent Psychiatry, 34, 709-714.
Weller, R. A., Weller, E. B., Tucker, S. G., & Fristad, M. A. (1986), Mania in prepubertal
children: has it been underdiagnosed? Journal of Affective Disorders, 11, 151-154.
Wijndaele, K., Matton, L., Duvigneaud, N., Lefevre, J., Duquet, W., & Thomis, M. (2007).
240
Reliability, equivalence and respondent preference of computerized versus paper-andpencil mental health questionnaires. Computers in Human Behavior, 23, 1958-1970.
Wilczynski, S. M., Mandal, R. L., & Fusilier, I. (2000). Bridges and barriers to behavioral
consultation. Psychology in the Schools, 27, 495-504.
Wilens, T. E., Biederman, J., Forkner, P., Ditterline, J., Morris, M., Hadley, M., et al. (2003).
Patterns of comorbidity and dysfunction in clinically referred preschool and school-age
children with bipolar disorder. Journal of Child and Adolescent Psychopharmacology,
13(4), 495-505.
Willimack, D. K., Schuman, H., Pennell, B., & Lepkowski, J. M. (1995). Effects of a prepaid
nonmonetary incentive on response rates and response quality in a face-to-face survey.
Public Opinion Quarterly, 59(1), 78-92. doi:10.1086/269459
Wodrich, D. L., Pfeiffer, S. I., & Landau, S. (2008). Contemplating the new DSM-V:
Considerations from psychologists who work with school children. Professional
Psychology: Research and Practice, 39(6), 626-632.
World Health Organization (1992). International statistical classification of diseases and
related health problems (10th Ed). New York: World Health Organization.
World Health Organization (2004). Prevention of mental disorders: Effective interventions and
policy options. Summary Report. Geneva: Author.
Wozniak, J., Biederman, J., Kiely, K., Ablon, J., Faraone, S., Mundy, E., & et al. (1995). Manialike symptoms suggestive of childhood-onset bipolar disorder in clinically referred
children. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 867876.
Wozniak, J., Monuteaux, M. C., Richards, J., Lail, K., Faraone, S., & Biederman, J. (2003).
241
Convergence between structured diagnostic interviews and clinical assessment on the
diagnosis of pediatric-onset mania. Biological Psychiatry, 53, 938-944.
Wozniak, J., Spencer, T., Biederman, J., Kwon, A., Monuteaux, M., Rettew, J., and Lail, K.
(2004). The clinical characteristics of unipolar vs. bipolar major depression in ADHD
youth. Journal of Affective Disorders, 82(Suppl. 1), S59-S69.
Yammarino, F. J., Skinner, S. J., & Childers, T. L. (1991). Understanding mail survey response
behavior: A meta-analysis. Public Opinion Quarterly, 55, 613-639.
Yell, M. L., Katsiyannas, A., & Shiner, J. G. (2006). The No Child Left Behind Act, Adequate
Yearly Progress, and Students With Disabilities. Teaching Exceptional
Children, 38(4), 32-39.
Youngerman, J., & Canino, I. A. (1978). Lithium carbonate use in children and adolescents, a
survey of the literature. Archives of General Psychiatry, 35, 216-224.
Youngstrom, E. (2007). Pediatric bipolar disorder. In E. J. Mash & R. A. Barkley (Eds.),
Assessment of Childhood Disorders, (4th Ed.) (pp. 253-304). The Guilford Press:
New York.
Youngstrom, E., & Duax, J. (2005). Evidence-based assessment of pediatric bipolar disorder,
part I: Base rate and family history. Journal of the American Academy of Child and
Adolescent Psychiatry, 44(7), 712-717.
Youngstrom, E. A., Findling, R. L., & Calabrese, J. R. (2003). Who are the comorbid
adolescents? Agreement between psychiatric diagnosis, youth, parent, and teacher report.
Journal of Abnormal child Psycholgoy, 31(3), 231-245.
Youngstrom, E. A., Findling, R. L., Calabrese, J. R., Gracious, B. L., Demeter, C., Bedoya, D.
D., & et al. (2004). Comparing the diagnostic accuracy of six potential screening
242
instruments for bipolar disorder in youths aged 5 to 17 years. Journal of American
Academy of Child and Adolescent Psychiatry, 43(7), 847-858.
Youngstrom, E. A., Joseph, M. F., & Greene, J. (2008). Comparing the psychometric properties
of multiple teacher report instruments as predictors of bipolar disorder in children and
adolescents. Journal of Clinical Psychology, 64(4), 382-401.
Youngstrom, E., Meyers, O., Demeter, C., Youngstrom, J., Morello, L., Piiparinen, R., & et al.
(2005). Comparing diagnostic checklists for pediatric bipolar disorder in academic and
community mental health settings. Bipolar Disorders, 7, 507-517.
Youngstrom, E., & Youngstrom, J. K. (2005). Evidence-based assessment of pediatric bipolar
disorder, part II: Incorporating information from behavior checklists. Journal of the
American Academy of Child and Adolescent Psychiatry, 44(8), 823-828.
Youngstrom, Youngstrom, & Starr. (2005). Bipolar diagnoses in community mental heatlh:
Achenbach CBCL profiles and patterns of comorbidity. Biological Psychiatry, 58, 569575.
Ysseldyke, J., Burns, M., Dawson, P., Kelley, B., Morrison, D., Ortiz, S., et al. (2006). School
psychology: A Blueprint for training and practice III. Bethesda, MD: National
Association of School Psychologists.
Zhang, Y. (1999). Using the internet for survey research: A case study. Journal of the American
Society for Information Science, 51(1), 57-68.
Ziehan, T. (1926). Die Gesteskrankheiten enschlilich des Schwachsinns und die
psychopathischen Konstitutionen im Kindesalter (as translated by Baethge, Glovinsky, &
Baldessarini, 2004) History of Psychiatry, 15(2),213-226.
Zimmerman, M. E., DelBello, M. P., Getz, G. E., Shear, P. K., & Strakowski, S. M. (2006).
243
Anterior cingulate subregion volumes and executive function in bipolar disorder. Bipolar
Disorders, 8, 281-288.
244
Appendix A
Survey
Hello:
In fulfillment of my dissertation, I invite you to participate in the following survey. The survey's
purpose is to investigate the current assessment and intervention practices of school
psychologists in the United States pertaining to Pediatric Bipolar Disorder. Participating in this
survey will require you to answer questions about the aforementioned topic as well as provide
some demographic information.
Please remember, a donation of $2.00 will be made per completed survey not to exceed a total of
$750.00 to National Association of School Psychologists (NASP) Children’s Fund. The
Children’s Fund is a tax-exempt, non-profit, independent charity, which disperses monies for
purposes consistent with the priorities of NASP. Those priorities include advocating for the
welfare of children and adolescence, promoting optimal learning environments, and developing
meaningful academic and social-emotional interventions.
An additional benefit is that upon request respondents may receive a digital summary of the
study's results. These requests will be handled separately from the survey and will require
participants to contact the researcher by email (jstrotter@anderson.edu). This information will
be treated as confidential and immediately destroyed once the request for a summary is fulfilled.
Your survey responses will be anonymous and data from this research will be reported only in
the aggregate. Respondents are and will always remain unidentifiable to the researcher or any
other entity. As a participant you must be an adult (18 years and above) and a full-time licensed
School Psychologist.
Upon completion of my dissertation and subsequent publication of the research, all collected data
will be removed from any and all storage devices and properly destroyed.
If you have questions at any time about the survey or the procedures, you may contact: Office of
Research Integrity, Ball State University, Muncie, IN 47306, 765-285-5070 or irb@bsu.edu. In
addition my dissertation chair, Dr. David McIntosh (demcintosh@bsu.edu; 765-285-5701) and
myself (jstrotter@anderson.edu; 765-641-4401) are available to you at any time.
It will take approximately 7 to 10 minutes to complete the questionnaire. Your participation in
this study is completely voluntary and there are no foreseeable risks associated with this project.
However, if you feel uncomfortable answering any questions, you can withdraw from the survey
at any point without concern or penalty.
245
It is very important for me to learn your opinions. If you agree to the terms of this study please
indicate so by selecting the Terms/Acceptance Check Box below. Thank you very much for your
time and support. Please start the survey by first selecting "I Agree” and then by clicking on the
continue button below

I agree
First, you will be asked to provide some demographic information.
Q1. Please indicate each degree you have earned.





Masters
Specialist
Ed.D.
Ph.D.
Other
Q2. Do you belong to any professional organizations? Please select all that apply.




NASP
APA
State Association
Other
Q3. Are you a National Certified School Psychologist?


Yes
No
Q4. Approximately how many years have you been considered a National Certified School
Psychologist?






1 to 5 years
6 to 10 years
11 to 15 years
16 to 20 years
21to 25 years
26 or more
246
Q5. How many years of experience as a school psychologist do you have?






1 to 5 years
6 to 10 years
11 to 15 years
16 to 20 years
21to 25 years
26 or more
Q6. What is your gender?



Male
Female
Other
Q7. How would you describe the geographical location of your current job?




Urban
Suburban
Rural
Other
Q8. How would you describe your current, weekly work setting and the approximate number of
hours in that setting?
Please mark all that apply.
Public school
Private school sect.
Private school nonsect.
State DOE
Residential institution
Mental health agency
College/University
Private Practice
Other
35 or more
hrs/wk









25 to 35
hrs/wk









247
11 to 25
hrs/wk









10 or less
hrs/wk









Q9. Approximately how many psychoeducational evaluations to you complete during a school
year?
Q10. Approximately, what age ranges do you typically assess? Total should equal 100 percent.
_____
_____
_____
_____
2 – 5 Years (Preschool)
6 – 10 Years (Elementary)
11 – 14 Years (Middle School)
15 – 18 Years (High School)
Q11. Approximately, what percent of time do you spend in Special Education related services
(e.g., testing, scoring of tests, classroom observations, writing reports, attending case
conferences, etc.)






Less than 10%
10 - 25%
26 - 50%
51 - 75%
76 - 90%
More than 90%
For the purposes of this survey, Pediatric Bipolar Disorder (PBD) refers to a pre-pubescent
population, exhibiting a distinct period of euphoric and/or irritable mood with a cluster of cooccurring symptoms that are functionally impairing and enduring long enough to be significantly
different from a child's typical presentation and separate from mood variability often
accompanying normal development.
Please indicate to what degree you agree or disagree with the following statements concerning
Pediatric Bipolar Disorder (PBD).
Q12 – 16. Please indicate to what degree you agree or disagree with the following statements
concerning Pediatric Bipolar Disorder (PBD).
PBD is currently under
diagnosed in the United States.
The diagnosis of PBD should
be based on the DSM adult
symptomology.
Most children exhibiting
Strongly
Agree

Mildly
Agree

Undecided

Mildly
Disagree

Strongly
Disagree











248
symptoms of PBD will develop
into adults with Bipolar
Disorder.
Children should not be
diagnosed with Bipolar
Disorder





Behavioral approaches to
reducing problematic behaviors
due to PBD are relatively
ineffective without the
concurrent use of medications.





Q17 – 20. What is your opinion concerning the following statements:
Strongly
Agree

Mildly
Agree

Undecided

Mildly
Disagree

Strongly
Disagree

The course of mania in
children is typically of short
duration and episodic.





Children diagnosed with PBD
are expected to have a
significantly higher Verbal IQ
than Performance IQ.





The majority of adults
diagnosed with Bipolar
Disorder exhibited
symptoms of mania as
children.





It is appropriate to prescribe
antipsychotic medications to
children exhibiting symptoms
of mania.
You have completed over half of the survey! Taking your time to help me is very much
appreciated.
Please remember, a donation of $2.00 will be made per completed survey not to exceed a total of
$750.00 to the National Association of School Psychologists (NASP) Children’s Fund.
249
Q21. Of the following symptoms, which do you think is most likely to be exhibited by children
with PBD?





Euphoria
Hyperactivity
Irritability
Grandiosity
Flight of Ideas
Q22 – 31. In your opinion, how difficult is it to differentiate PBD from the following disorders.
Autism
Very
Easy

Somewhat
Easy

Somewhat
Difficult

Very
Difficult

Asperger’s Disorder




Attention Deficit/Hyperactivity
Disorder




Conduct Disorder




Oppositional Defiant Disorder




Obsessive Compulsive
Disorder




Childhood Depression




Thought Disorder




Anxiety Disorder




Pervasive Developmental
Disorder NOS




250
Q32 – 38 Children with PBD are often diagnosed with additional disorders. Please use the slider
to estimate the percentage of individuals with PBD who also receive a diagnosis of one or more
of the following disorders:
Autism
Asperger’s Disorder
Attention
Deficit/Hyperactivity
Disorder
Conduct Disorder
Oppositional Defiant
Disorder
Obsessive Compulsive
Disorder
Childhood Depression
Thought Disorder
Q39 - 50. Attention Deficit-Hyperactivity Disorder and PBD share a number of similar
symptoms. Of the following symptoms, indicate which ones you think are more common to and
indicative of PBD:
Irritability

Impulsivity

Grandiosity

Hyperactivity

Distractibility

Elated Mood

Flight of Ideas

Decreased Need for Sleep

251
Talkativeness

High Motor Activity

Inattention

Rapid-cycling

Q51. Due to the disruptive behaviors typically associated with the diagnosis, children with PBD
are often in need of Special Education services.
In your opinion, which of the following is the best Special Education category to provide
services for a child diagnosed with PBD:



Emotional Disturbance
Other Health Impaired
Other
Q52. As it relates to your work as a School Psychologist, what is the approximate percentage of
time you are involved in the following Special Education activities?
Assessment for Special
Education services
Counseling Students
Academic Intervention
Behavior Intervention
Functional Behavior
Analysis
Consultation with
Teachers
Research
The Individuals with Disabilities Education Improvement Act (IDEIA) of 2004 uses the term
“Emotional Disturbance” when referring to students who have an inability to learn due to
possible mood. Although the local school system often uses different terms to designate this
Special Education category (Emotionally Disturbed, Behavior Disordered, etc.) disorders, for the
252
purposes of this survey "Emotional Disturbance" will be used.
Q53. As a School Psychologist, which one statement most accurately reflects your primary role
in the determination and classification of an emotional disturbance.
 I participate as part of a multidisciplinary team to determine the special education
eligibility of students with a possible emotional disorder.
 A separate team conducts evaluations, but I sit on the multidisciplinary team to make
eligibility decisions.
 I am not involved in determining and classifying children with emotional disorders at all.
Q54. Please indicate the frequency with which you administer the following when receiving
referrals for a possible emotional disturbance.
If you work as part of a team, please only rate those methods YOU employ or for which you are
responsible:
Always
Often
Sometimes
Never
Review of school records




Review of medical records




Review of academic work




Classroom observation of student




Home environment observation of
student




Functional Behavioral Analysis




Developmental history




Caregiver interview




Student interview




Teacher interview




253
Q55. Please indicate the frequency with which you administer the following types of measures
when receiving referrals for a possible emotional disturbance.
If you work as part of a team, please only rate those methods YOU employ or for which you are
responsible:
Always
Often
Sometimes
Never
Cognitive ability measure




Academic achievement measure




Neuropsychological based evaluation




Adaptive behavior rating measure




Behavior rating measure




Attention Scale




Anxiety Scale




Depression Inventory




Projective measure




Q56. How would you describe your level of involvement in the following activities before a
student is referred for Special Education services due to a possible Emotional Disturbance?
Always
Often
Sometimes
Never
Research Based Intervention




Functional Behavior Analysis




Consultation with Teacher




Q57. How often do you provide the following interventions/services for children receiving
special education support for an Emotional Disorder and/or due to a diagnosis of a mood
disorder (e.g., Depression, Bipolar)?
254
Always
Often
Sometimes
Never
Monitor effects of prescribed
medication(s)




Consult with student's doctor




Provide social skills training for student




Provide caregiver support




Develop behavior modification plans
for home use




Develop behavior modification plans
for school use




Consult with teacher concerning
ongoing instructional strategies and
academic accommodations




Consult with teacher to implement and
monitor effectiveness of behavior
modification plans.




Provide individual counseling for
student




Provide small group counseling/support
for student




Q58. Please select the types of training you have received for the following areas of concern:
Emotional
Disturbances
PBD
Bipolar
Disorder
Formal course work in training
program.



Internship or residency
experience.



Workshop presentation or
inservice training.



255
Q59. How would you describe your preparedness in adequately providing the following services
for students with an Emotional Disturbance:
Not
Prepared at
All
Minimally
Prepared
Somewhat
Prepared
Very
Prepared
Teacher Consultation




Parent Consultation




Special Education
Assessment




Academic Intervention




Behavior Intervention




Q60. Although mood disorder diagnoses typically are not provided by School Psychologists
within school systems, how would you describe your level of confidence to do the following:
Not At All
Confident
Somewhat
Confident
Confident
Very
Confident
Identify the signs and
symptoms of PBD




Make a differential
diagnosis between PBD
and other disorders




Knowledge of current
medications used to treat
childhood mania




Knowledge of current
medications used to treat
childhood depression




256
Appendix B
Initial Contact
Dear Practitioner,
You have been selected from a group of school psychologists to participate in a national
study on emotional disturbances in general and pediatric bipolar disorder (PBD) in particular.
In order to gather research necessary to encourage the attention due this topic, your
assistance is requested. We are asking for your help in providing information about the state of
progress in the areas of PBD assessment, intervention, and professional training.
Please take a few minutes to visit the survey home page
(http://pedatricbipolardisorder.questionpro.com). You will be taken to the home page of the
survey where you can read more about the data collected and the methods for doing so. Your
response is welcomed and appreciated.
Please note your completion of the survey will result in a donation of $2.00 toward the
goal of raising $750.00 for the National Association of School Psychologists Children’s
Fund (http://www.nasponline.org/about_nasp/childrens-fund.aspx).
If you have any questions about this study, please contact lead investigator Jeff Trotter
at jstrotter@anderson.edu or the faculty advisor David E. McIntosh at demcintosh@bsu.edu.
We sincerely appreciate your assistance.
Jeffrey S. Trotter, Ph.D. Candidate
Lead Investigator, Ball State University
David E. McIntosh, Ph.D.
Faculty Advisor, Ball State University
257
Appendix C
Participation by State and NASP Region
State
Arkansas
n
1
California
3
Connecticut
15
Florida
54
Georgia
12
Illinois
6
Indiana
3
Louisiana
3
Massachusetts
6
Maine
5
Nebraska
6
New Hampshire
New Mexico
1
23
Ohio
23
Oregon
1
Pennsylvania
22
Virginia
14
Washington
18
Wyoming
10
Total
n
38
Northeast
86
Southeast
82
Western
33
Total
15
New York
NASP Region
Central
239
258
239
Appendix D
First Follow Up Contact
Dear Practitioner,
Several days ago you received an email requesting your participation in a national study
of the opinions and practices of school psychologists evaluating children with a possible
Pediatric Bipolar Disorder (PBD) identification.
If you have already completed the survey, please accept our sincere thanks. Your
participation has resulted in a donation to the NASP Children’s Fund.
If you have not yet participated, we are asking for your help in providing information
about the state of progress in the areas of Emotional Disturbances as well as PBD assessment,
intervention, and professional training. Your participation is critical for a representative study.
Please visit the survey home page (http://pedatricbipolardisorder.questionpro.com). On
the home page you can read more about the data collected and the methods for doing so.
Your completion of the survey will result in a donation of $2.00 toward the goal of
raising $750.00 for the NASP Children’s Fund
(http://www.nasponline.org/about_nasp/childrens-fund.aspx).
If you have any questions about this study, please contact lead investigator Jeff Trotter at
jstrotter@anderson.edu or the faculty advisor David E. McIntosh at demcintosh@bsu.edu.
We sincerely appreciate your assistance.
Jeffrey S. Trotter, MA
Lead Investigator, Ball State University
David E. McIntosh, Ph.D.
Faculty Advisor, Ball State University
259
Appendix E
Second Follow Up Contact
Dear School Psychologist,
I want to invite you one last time, to participate in a survey concerning the opinions and
practices of school psychologists evaluating children with a possible Emotional Disturbance. In
particular I am interested in your thoughts about Pediatric Bipolar Disorder.
If you have already completed the survey, please accept my sincere thanks. Please
know you will not receive another email after today unless you requested our study results.
If you have not yet participated, please visit the survey home page where you can learn
more about the data collected and our methods: (http://pedatricbipolardisorder.questionpro.com).
The survey has taken most participants about 15 minutes to complete.
As a way of saying “thank you” for spending your valuable time to help me, I will donate
$2.00 to the NASP Children’s Fund (http://www.nasponline.org/about_nasp/childrens-fund.aspx)
for every survey completed.
If you have any questions about this study, please contact me, the lead investigator, at
jstrotter@anderson.edu or the faculty advisor David E. McIntosh at demcintosh@bsu.edu.
I am very grateful for your help.
Jeffrey S. Trotter, MA
Lead Investigator, Anderson University
David E. McIntosh, Ph.D.
Faculty Advisor, Ball State University
260