Vol. 20 • Issue 23 • Page 6
Autism is probably the most well-known spectrum disorder, but it's not the only condition that has its mild and extreme sides. Bipolar disorder can manifest in children with Asperger's syndrome or any other disorder.
Individuals with bipolar disorder experience periods of hypomania, or manic behavior, and depression. "The individual cycles through these different episodes throughout the course of the year. If there are more than four cycles within a year, it is considered bipolar disorder," said Kimberly Frazier Baker, PhD, CCC-SLP, assistant professor of communication disorders at the University of Arkansas in Fayetteville. While speech-language pathologists are not qualified to diagnose bipolar disorder, they can offer important insights regarding the behavioral observations of each child.
Hypomania gives people a feeling of well-being. Individuals may feel overly productive, creative and confident. Because they get carried away with what they are doing, they may lose sleep. However, there is a breaking point.
"The individual will become obsessed. They will no longer feel creative and start to feel aggravated, anxious and overwhelmed," said Dr. Baker. This letdown will give way to episodes of depression.
Little solid information is available on how bipolar disorder manifests in children. The only option researchers have is to take what they know about the disorder in adults and apply it to children.
Perhaps the biggest obstacle in diagnosing co-morbid conditions accurately is the overlap in symptomatology. Children with Asperger's syndrome have difficulty interpreting social stimuli and obsess over a topic of interest. Typically, with the exception of pragmatics, language areas such as semantics, syntax, phonology and morphology are within normal limits. They have issues with executive function, theory of mind, and central coherence, or understanding context. The symptom most commonly associated with Asperger's-the obsessive interest in a topic-is also a cornerstone of bipolar disorder.
"Individuals can get engrossed in a particular topic. This can be confused with the creativity that sets in during the hypomania phase of the bipolar person," said Dr. Baker. There is a difference, however. "The big difference between Asperger's and bipolar is the manic stage. Individuals with Asperger's will always want to talk about their topic. They may not have that aggravation or anxiety associated with it, whereas someone in the manic stage might."
Individuals with Asperger's want to have a relationship with other people and talk about their topic of interest, while someone who is bipolar doesn't want to be around others when they are depressed.
As further evidence that symptoms of both conditions can mask each other, the anxiety expressed by an individual with Asperger's can match that of someone who is bipolar. "They could have an anxiety disorder. That, coupled with Asperger's, can sometimes look a lot like bipolar. It's hard to determine which is which," she said.
Reliable statistics on how many children with Asperger's are diagnosed with bipolar disorder have yet to materialize, not to mention what the condition specifically looks like in this population. In addition, Asperger's is a relatively new diagnosis on the autism spectrum, and it took time for researchers and clinicians to reach the understanding they have about the condition today.
"We don't really have a good indication of what bipolar is in children," said Dr. Baker. "We know there is a high occurrence of depression and bipolar disorder in families of individuals on the autism spectrum. Both appear to be genetic-we see both of the conditions among families."
When is it apparent that a person with Asperger's could also have bipolar disorder? Clinicians should begin to suspect bipolar if individuals appear to be going through the hypomania-depression cycle. It may be time to act if they become highly distracted, self-injurious, withdraw from others, cry, become irritable or non-compliant, and have pressured speech.
Before jumping to conclusions, though, it's important to rule out other diagnoses. "Anxiety is one of the first things I would try to rule out before I thought, 'Are we looking more at anxiety coupled with Asperger's, or is it mainly just bipolar?' If you are seeing bouts of depression, you might want to start thinking about bipolar," she advised. A good rule of thumb is to wait a year for signs of cycling and to see if bipolar symptoms subside.
The presence of another disorder can have a significant impact on treatment, she said. "If an individual with bipolar is engaging in self-injurious behavior or being aggressive, you have to take care of that pharmacologically before cognitive behavior therapies will be effective."
Dr. Baker cited her current work with a young patient who has a mixed diagnosis of bipolar and Asperger's. "Now that the proper pharmacological interventions have been initiated, my interventions have really increased with him," she said. "To say he's a different child would be an understatement."
Speech-language pathologists, pediatricians, psychologists, psychiatrists, occupational therapists, counselors, and special and regular education teachers are all part of the multidisciplinary team.
An important reminder is that if a clinician suspects a child has both bipolar and Asperger's, one condition should not take precedence over the other.
The prevalence of bipolar disorder in children with Asperger's is unknown, but speech-language pathologists should be trained to spot the symptoms in order to be able to make the proper recommendations and referrals, Dr. Baker said. "We provide so many psychosocial interventions for individuals. Pragmatic language difficulties encompass schizophrenia, bipolar, Asperger's and autism-all these different types of diagnostic categories. We definitely need training in all these areas."
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Jason Mosheim is a Senior Associate Editor at ADVANCE. He can be contacted at jmosheim@advanceweb.com.