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Mental Health Archive 2008

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Margaret L. Stivers, Ph.D.
Clinical Psychologist

Margaret is a clinical and social psychologist trained at the University of Kansas and the University of Miami. She has taught psychology at four major universities and directed mental health, residential, and nonpublic school programs for children and adolescents. Her experience includes 30 years of consultation and collaboration with educational programs throughout the country, including schools in urban and rural areas and on Indian reservation.

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  • How to work with children with selective mutism in a school setting.

Question:

Hi Dr. Stivers,

I work for the West End SELPA in San Bernardino County and am also a PENT Cadre Member. I have been providing services for districts in our area on behavior and recently have had an influx of children with selective mutism. Most are at grade level. Do you have some suggestions on how to work with these students in a school setting?

Jan Van Dyke 
Psychologist/Behavior Specialist


Answer:

Thank you for asking this timely question. Psychologists and teachers from several school districts have reported that they are seeing an increase in selective mutism. At the Diagnostic Center, we receive several referrals each year to assess students with this disorder. Some of these students have already been diagnosed correctly, but many come to us with other labels, such as oppositional-defiant disorder or autism, which are based on misinterpretations of their symptoms.

For those who are not familiar with this diagnosis, I am including some background information to help you understand selective mutism. This is followed by guidelines for supporting these children in school.

About Selective Mutism

Children with selective mutism show a persistent failure to speak in some situations (generally social settings such as school), although they have sufficient language skills and do speak freely in at least one setting (generally at home or in other relaxed, comfortable places with familiar people). Mental health experts are increasingly viewing selective mutism as a childhood anxiety disorder. When children with selective mutism find themselves in settings that provoke anxiety, (e.g. being around unfamiliar people, in large groups, or other situations in which they feel observed or judged by others), their fear constricts their ability to speak, physically as well as psychologically. One boy with selective mutism whispered to us that he cannot speak in these situations, although he wants to, because “my throat closes so tight, I choke on my words.”

Many people, including educators and other professionals, have never been given accurate information about this disorder, so students with selective mutism are often misunderstood and sometimes misdiagnosed. Some adults assume that the absence of speech in social situations is a sure sign of autism. Others perceive a child’s failure to speak in response to adult questions as willful and stubborn behavior. And some well-meaning adults assume that silence on the part of a child must indicate serious trauma or abuse.

As our awareness of selective mutism and our ability to diagnose it accurately are increasing, the prevalence estimates are rising. It was once estimated to occur in 1 out of 1,000 children, but more recent estimates place it just under one percent. If this is correct, then nearly all school districts are likely to serve a student a student with selective mutism at some point in time and most schools and districts are probably serving a few of them now.

Three Important Points About Treatment

  1. Without treatment, there is substantial risk that the symptoms of selective mutism will become more deeply entrenched and resistant to intervention or that the child will develop additional problems. 
  2. Evidence-based treatment strategies have produced very high rates of success in helping children overcome this disorder. While effective treatment is intensive, it is often relatively short-term (a few months to two years), especially when the child is young. 
  3. Successful intervention plans rely on a team approach and often involve repeated interventions in multiple settings. No teacher, counselor, or parent, however dedicated and skillful, can accomplish as much on her own as she can as a member of a team.

Children with selective mutism are as motivated as any other children to succeed in learning and making friends. However, they often dread going to school. On campus, these sensitive and profoundly self-conscious children find themselves continuously surrounded by adults and peers who observe their behavior and may evaluate them academically and socially. Practices that make school a more positive experience not only support longer-term treatment goals, but immediately enhance the quality of these children’s lives.

School Support

Because selective mutism is an anxiety disorder, pressure is counter productive. Initially, all intervention strategies should focus on lowering anxiety, increasing self-confidence, and helping the child associate school with positive experiences. At this stage, adapt environmental demands as much as possible to the comfort level of the student. Once anxiety is lowered, steps can be taken to gradually promote increased communication.

Thorough assessment:

If it has not already been done, a comprehensive evaluation should be conducted to identify possible co-occuring conditions and ensure that all of the student’s needs are addressed. Up to one third of the children with selective mutism may have some degree of language impairment (sometimes subtle). Children with this disorder may also have cognitive processing difficulties, sensory processing issues, and/or co-existing anxiety or mood disorders.

Choice of Classroom:

Depending on the size of the school or district, there may be more than one classroom available to serve the student. Here are some factors to keep in mind when ther is a choice of classrooms:

  • All students, but especially students with selective mutism and other anxiety disorders, benefit from being in a classroom where the social climate feels safe, accepting, and respectful of student differences. A calm atmosphere, high level of organization, and predictable routines can also help lower anxiety.
  • Anxious children generally do best with teachers who interact in a pleasant, low-keyed manner and are patient and non-intrusive. Teaching styles that are high in drama or expressions of excitement may help some students get involved, but often overwhelm students with anxiety and cause them to withdraw further.
  • Flexibility is critical. The teacher must be willing to use creative accommodations to help the student participate as a full member of the class.

Staff Awareness and Attitude:

All staff members who may interact with a student with selective mutism (even in the library or on the playground) should have be given basic information about the disorder. Everyone needs to understand that the child’s lack of speech is caused by an anxiety disorder and not a matter of choice. Keep interactions positive and accepting. Be patient and work as a team; ensure that no one on the staff is determined to be the one to “make this kid talk.”

Accommodations and Strategies:

To help a student participate as fully as possible in school without speaking, be creative in providing a wide variety of opportunities to communicate, interact, and participate without spoken language. The particular methods will vary depending on the individual characteristics of the student, the grade level, and many other factors. The following examples are offered to help stimulate ideas for discussion:

  • Before the student starts attending a new class or school, provide an opportunity for the student to explore the setting with a family member. Choose a time when few people are present (during break or at the end of a school day). Suggest that the family member walk with the student around the classroom or campus and discuss what they see . The student may give spoken answers, helping him/ her realize he/ she CAN speak on the school grounds.
  • Assign roles and responsibilities to the student that promote interaction but do not require speaking, such as marking attendance forms, collecting materials from other students, and delivering written messages to other rooms.
  • Allow the student to point to items, pictures, or icons to respond to questions, convey choices, and request breaks.
  • Provide pre-written cards for the student to use for frequently occurring situations, such as asking for help. Cards may have words or pictures with captions such as, “What does this mean?” or “What page are we on?”
  • Suggest that the student present a report to the class using a poster, computer graphics, and/or video recording.
  • Try to evaluate the student’s knowledge as much as possible using alternative nonverbal and un-timed test formats. Structured tests with strict time limits raise stress levels and often result in inaccurate results with anxious children.
  • Involve the student in small group learning activities, at first with just one or two other students with whom he/ she is relatively comfortable. As the student becomes more comfortable, gradually increase the number of students in the group.
  • During lunch time or recess, consider offering a social-communication group with board games and other activities facilitated by an adult. Alternatively, during lunch or break, pair the student with a volunteer “buddy.”

Increasing Communication:

As the student gains self-confidence and becomes less anxious in the school setting, very gradually introduce opportunities for increased levels of communication.

Plan a slow, but steady, progression, starting with what the student can comfortably do now, and adding by, increments, a series of small, highly specific increases in the level of interaction. For example, start by having the student whisper a message to someone with whom he/ she is comfortable. Once the student can do this successfully for about two weeks, have the partner move to an arm’s length away, so that the student will have to use a louder voice. When comfort with speaking across this distance is well-established, have the student speak softly to the communication partner across a table. From there it is possible, depending on the child’s goals, to continue working toward increased vocal range, to work on delivering longer, more complex spoken messages, or to work toward generalization of speech to new settings, new communication partners, or small groups. Make sure that the student is comfortable at each stage before moving on to a higher level.

Comprehensive Treatment:

Ideally, classroom interventions for the student with selective mutism are part a multifaceted treatment plan. The treatment plan usually includes mental health care, including family support services. There should be provisions for close communication between the mental health professional and the school team. If the child is also placed on medication to reduce anxiety, there should also be some communication between the school team and the prescribing doctor. Coordination among school team members and collaboration with outside care providers and family members can be time-consuming and challenging. It is often useful to agree on a school case manager to coordinate sharing of information.


  • Reactive Attachment Disorder and Aspergers.

Question:

Hi, Thank You for doing what you do... I am a parent of 4 autistic boys, I try to help parents with school problems as much as I can, currently I am helping a grandma who has a 9 year old she cares for with Reactive attachment disorder and aspergers, the girl has behaviors such as pushing, slapping, yelling out, the district says as soon as she touches another student they will suspend her, they are not helping this child, I really would love to have any help or opinion you have, how do I get them to see that at 9 she will have moments and they can not just stick her in NPS she has rights, please any help I would so appreciate it. Thank You, Dee


Answer:

First let us express our admiration for you. It is truly remarkable that, with all you have to do, you have the energy and dedication to help others. You are an inspiration!

Understanding and addressing the needs of a child with such a complex and difficult dual diagnosis can be a major challenge. For this reason, two of us are teaming up to respond to your question. Marji Stivers, Ph.D., clinical psychologist, will provide an introduction to the diagnoses and Dru Saren, Ph.D., behavioral specialist, will address your question from a behavior/IEP standpoint.

Understanding the Diagnoses:

A combination of Asperger’s syndrome and reactive attachment disorder is sure to create intense turmoil and distress for both the child with these diagnoses and for those who nurture and work with her. These two distinctly different diagnoses share a core feature; both are characterized by severe disturbances in social relatedness. Though children with either of the disorders engage in behaviors that interfere with building relationships, the behaviors associated with each disorder have different causes, take different forms, and serve different functions. For readers who are not familiar with these diagnoses, a brief summary of each is provided below:

Asperger’s Disorder:

Asperger’s is a developmental disability on the autism spectrum. In comparison with typically-developing children, children with Asperger’s show delays and differences in the course of their social development and engage in restricted, sometimes ritualistic, patterns of thinking and behavior. Although they are often adept in some areas of learning, they have a great deal of trouble understanding social roles and norms, reading social cues, and learning to initiate or respond appropriately to social overtures. As they get older, children with Asperger’s often develop an interest in having friends, but find the spontaneous and unpredictable nature of social interactions to be confusing and overwhelming. Not surprisingly, they are often more comfortable interacting with more predictable objects, such as computers or books.

Another defining characteristic of individuals with Asperger’s is that they show rigid, restricted, and repetitive patterns of behavior. As young children, instead of using toys to act out imaginary scenarios, they may sort or arrange toys by category (e.g. line up toy trucks be color) or develop a fascination with parts of an object (e.g. spinning a wheel). Through life, they may be unusually attached to having fixed routines and become unduly distraught by changes or interruptions. Or they may become fixated on particular topics of interest and only give their full attention and converse with enthusiasm when activities and conversations correspond to their areas of interest.

As a neurodevelopmentally-based syndrome, Asperger’s is considered to be “hard-wired,” or characterized by inborn differences in the ways a child’s nervous system is “programmed” to develop. Although these nervous system differences are present at birth, the behaviors associated with the syndrome may not be apparent until the child is observed to have unusual difficulty adapting to social environments such as day care or school.

Reactive Attachment Disorder:

In contrast with Asperger’s, the disturbances in social relatedness associated with reactive attachment disorder (RAD) are not caused by inborn neurodevelopmental differences, but result from a child’s early experiences and interactions with her environment. Infants whose basic needs are not reliably met by a consistent and responsive caregiver during the first months of life may fail to develop the strong bond needed to form a strong, secure attachment. are at risk of developing RAD. Early a bandonment, neglect, or disruptions in parenting due to family illness, crisis, or trauma can prevent secure attachment even if adults provide adequate food, shelter, and medical care. A secure attachment during infancy enables the child to develop the sense of safety and feelings of trust and lays the foundation for development of qualities, such as empathy and reciprocity, which form the basis of future social relations. A child with disordered attachment lacks the foundation to develop positive, trusting relationships.

Children with attachment problems typically show some of the following characteristics and behaviors:

  • Inability to trust adults in authority.
  • Resistance to nurturing or guidance.
  • Unwillingness to get close to others; resistance to positive overtures.
  • Ambivalent, approach-avoidance behaviors.
  • Words and actions that purposefully disappoint or provoke anger in others.
  • Poor self-control, frequent impulsive behavior.
  • Few or no close, long-term friends.

Their behavior often fits one of these two patterns:

  • Severely inhibited, guarded behavior.
  • Extreme vigilance; “frozen watchfulness” (the deer-in-the-headlight look).
  • Apathy; limited responsiveness to the environment.

or

  • Ability to be superficially charming and engaging, especially with strangers.
  • Extreme need to control others (which may worsen as a child gets older).
  • Destructive, cruel, argumentative, or hostile behavior.
  • Little or no expression of empathy, remorse, or compassion.
  • Manipulation, including pitting adults against one another.
  • Frequent tantrums and rages, often over trivial issues.
  • Lying or stealing. May sneak things he/she could have by asking.

It is very important to understand that as infants and toddlers, these children learned that they cannot trust adults to keep them safe. The closer they come to trusting someone, the more affection they feel, and the more they become invested in a relationship, the more vulnerable they feel. Their sense of vulnerability leads to intense anxiety or panic and they desperately try to protect themselves from being let down. For instance, they may withdraw abruptly when others show interest or kindness or resort to obnoxious behavior to push others away. They may reject others, often emphatically and dramatically, before others have a chance to reject or abandon them or suddenly turn against those who are getting closest to them. Working with these children requires tremendous patience, persistence, and perspective (ability to step back and not take the children’s reactions personally).

Behavior Plans and IEP Goals

The complexity of this student requires many layered approaches: behavior support, educational accommodations, and mental health services. I expect the district has personnel who are trained in providing the accommodations for autism spectrum disorders, including Asperger’s syndrome.

You are also absolutely right to assert that this student has rights, and they don’t end even when she is older than nine. When a student has an IEP, which this child clearly has, she is entitled to supports and services to address behavior that interferes with her learning or that of other students. A Behavior Support Plan (BSP) is the first piece of this support. A BSP is an action plan, delineating what the steps the team has determined to take in order to replace the target behaviors with more positive responses as well as the procedures to follow when the problem behavior occurs. Well written goals and objectives and a system for keeping accurate data on the success of the interventions are other key elements of an effective BSP. Extensive information on writing BSPs is on the PENT website of the California Department of Education (http://www.pent.ca.gov/beh-bp.htm).

In California, whenever a student's problem behavior is deemed to be "serious," a Behavior Intervention Case Manager needs to be included in the team process to conduct, or supervise the conducting, of a functional analysis assessment. Forms that meet all legal mandates for data collection, plan development and plan review are also available on the PENT website. Seehttp://www.pent.ca.gov/law/checklistofcomp.pdf for an overview of the process, and the forms themselves can be downloaded easily from this page: http://www.pent.ca.gov/forms.htm. The behaviors you describe may or may not be seen as “serious” depending on the intensity and frequency of her hitting her classmates. Calling out is NOT a severe behavior though it is rated as one of the top nuisances by teachers.

Students like this child, who has mental health issues as well as behavior problems, present a major challenge. Behavior support plans are not designed to remediate mental health issues; they specify how students challenged by mental health factors will be supported in an educated environment. This student will also require treatment for mental health problems that underlie behavior problems and function as long-range triggers of problematic behaviors (e.g. the trust issues/ fears of abandonment associated with reactive attachment disorder). School counseling, referral to community agencies, and other interventions may be necessary. Understanding how to address both her long-range issues and the immediate predictors of problem behaviors will require a high level of staff collaboration and accountability. See http://www.pent.ca.gov/beh/mh/coordinationofplansMH.pdf), with a designated case manager coordinating communication.

In addition, this student has to deal with the challenges of an autism spectrum disorder, so her language and educational needs must be addressed as well. The complexity of the interaction of these diagnoses, assuming them both to be accurate, is immense. However, placement is an IEP team decision and the family is an important member of this team. Your friend seems opposed to a placement in a non-public school (NPS). However, she may want to visit the NPSs that the district is willing to fund to see if there is one that might provide better services for her granddaughter’s multiple needs. On the other hand, the behaviors, as you describe them, can be managed in a public school.

Apart from the services she is entitled to, this student is protected from multiple suspensions. Consult http://www.pent.ca.gov/law.htm to see the procedure that must be followed if her suspensions exceed 10 days. It is the wise IEP team that reviews the girl’s BSP long before the 10 th suspension to see what is not working and to try to tweak the BSP to be more successful.

We hope this helps and, again, thank you for your advocacy.

Best,

Dru and Marji


  • What is an attachment disorder?

Question:

I teach second grade and have a boy who was adopted from Russia in my classroom. His parents are very loving and provide him with a good home. At the parent teacher conference I told them I was concerned about some of his behaviors. They told me that he had an attachment disorder. What is this?


Answer:

Thank you for this important question. Certain psychiatric diagnoses given to children are constantly in the news these days, but many people, including teachers, come across very little information about attachment disorders.

Child development professionals used the term “attachment” to describe the close bond that develops between a child and one or more primary caregivers during the first three years of the child’s life. Through touch, gestures, sounds, and eye contact, the child and caregiver learn to “read” and respond to one another’s signals. Through understanding and responding to the child’s signals, the caregiver is able to meet many of the child’s needs most of the time (no one can be perfect!). This enables the child develop the feelings of safety and trust that are the basis of secure attachment. Secure attachment provides the foundation for developing qualities, such as empathy and reciprocity, which form the basis of future relationships.

Children whose basic needs were not reliably met by a consistent and responsive caregiver at the beginning of life often experience attachment problems. This occurs even if the child was given adequate food, shelter, and medical care. The child with disordered attachment lacks the foundation to develop positive, trusting relationships with others.

Many children adopted from eastern Europe began their lives in poorly-funded orphanages with too few caregivers to provide the consistent, personal care they needed. Other children can be at risk of attachment problems due to parental abandonment, neglect, disruptions in parenting due to family illness, crisis, or trauma.

If a student in your classroom has attachment problems, your student may show some of the following characteristics and behaviors:

  • Inability to trust adults in authority.
  • Resistance to nurturing or guidance.
  • Unwillingness to get close to others; resistance to positive overtures.
  • Ambivalent, approach-avoidance behaviors.
  • Words and actions that purposefully disappoint or provoke anger in others.
  • Poor self-control, frequent impulsive behavior.
  • Few or no close, long-term friends.

Children with attachment problems are extremely challenging to parent or teach. When a child’s attachment problems are extremely severe, the child may be diagnosed with Reactive Attachment Disorder (RAD). If your student has difficulties severe enough to qualify for this diagnosis, you might also see some of the following:

  • Severely inhibited, guarded behavior.
  • Extreme vigilance; “frozen watchfulness” (the deer-in-the-headlight look).
  • Apathy; limited responsiveness to the environment.

or

  • Ability to be superficially charming and engaging, especially with strangers.
  • Extreme need to control others (which may worsen as a child gets older).
  • Destructive, cruel, argumentative, or hostile behavior.
  • Little or no expression of empathy, remorse, or compassion.
  • Manipulation, including pitting adults against one another.
  • Frequent tantrums and rages, often over trivial issues.
  • Lying or stealing. May sneak things he/she could have by asking.

It is very important to understand that:

As infants and toddlers, these children learned that they cannot trust adults to keep them safe. The closer they come to trusting someone, the more affection they feel, and the more they become invested in a relationship, the more vulnerable they feel. Their sense of vulnerability leads to severe anxiety or even panic. To keep themselves safe from being let down, they often react by withdrawing or resorting to obnoxious behavior to push others away.

Teachers can help a student with attachment problems by:

  • Remaining consistent and positive with the student, while carrying out consequences consistent with classroom rules.
  • Maintaining a safe, predictable, highly structured classroom environment.
  • Working with other team members to be consistent and united, even if your student tries to play you off against one another.
  • Remembering that as your student begins to trust you or care about the relationship, he/she may feel more vulnerable and respond by behaving in ways that push you away. The student may withdraw abruptly and avoid you or lash out at you.
  • Trying not to take it personally or become overly upset when your student withdraws or lashes out.

  • I had never heard of children having bipolar disorder. What exactly is this? And, what do I do about it?

Question:

When I started teaching fourth grade fifteen years ago, I had never heard of children having bipolar disorder. What exactly is this? And, what do I do about it?


Answer:

Thank you for your very timely question. Below you will find a brief discussion of pediatric bipolar disorder and the controversy surrounding it, a list of symptoms you might observe in your classroom if you have a student with this diagnosis, and a list of things you can do to support your student.

Bipolar disorder, also known as manic depression, is a mood disorder characterized by episodes of depression, episodes of mania, and/or “mixed” episodes (periods of behaviors associated depression and mania). This condition has been recognized in adults for a very long time, but the application of this diagnosis to children is relatively new and remains controversial. Despite the controversy, diagnoses of pediatric bipolar disorder have been increasing dramatically; during the past decade, there has been a forty-fold increase in the diagnosis of children and adolescents with bipolar disorder. Mental health professionals are unsure about the extent to which that increase reflects previous under-diagnosis, a current trend toward over-diagnosis, an actual increase in children with this disorder, or some combination of these factors.

Students with bipolar disorder have unstable moods and tend to shift between symptoms of depression and more elevated, expansive, and/or explosive moods. When these elevated mood symptoms are extensive enough to meet the criteria for mania, a diagnosis of bipolar disorder is given. Your student with a bipolar diagnosis appears to have a “f aulty emotional thermostat” and may bounce rapidly between extreme mood states with only brief interludes of emotional equilibrium.

For signs of depression in students, please refer to the answer posted in this column last month. If a student in your class experiences mania, you will probably observe the student showing some of the following symptoms in your classroom:

  • Extremely high energy and activity level.
  • Elevated, expansive mood – your student may be unusually outgoing and invested in being involved in everything.
  • Inflated self-esteem, sometimes with belief in having special powers.
  • Overexcitement, extreme silliness, or hysterical laughter, sometimes followed by crying spells.
  • Intense agitation and irritability.
  • Increased frustration and sensitivity to criticism.
  • Rages and explosive outbursts – your student responds to small provocations with extreme intensity; is difficult, if not impossible, to console; and takes a long time to recover.
  • Increased risk-taking.
  • Rapid speech with constant shifting from one subject to another.
  • Defiance , feeling that the rules do not apply to him/her.
  • Fluctuations in concentration, alertness, and speed of mental processing.
  • Impaired ability to plan, organize, and follow through.

It is important to keep in mind that:

  • Bipolar disorder is very difficult to distinguish from other disorders in children. Most children who are diagnosed with bipolar disorder have a previous diagnosis of depression or attention-deficit/hyperactivity disorder (ADHD).
  • A diagnosis of bipolar disorder does not preclude other conditions, such as developmental or learning disabilities. Symptoms of all applicable diagnoses should be targets of interventions.
  • Because of radical mood shifts, your student experiences the world completely differently from one moment to the next. The student’s behavior is no more predictable to him/her than it is to you, causing considerable distress to both of you.
  • The treatment of children diagnosed with bipolar disorder nearly always includes medication. The medications used may have uncomfortable side effects and may affect alertness, memory, and speed of processing information.

There are a number of ways that teachers and other school personnel can support students with bipolar disorder and help increase their positive participation in school. Choice of interventions and supports will depend on your student’s individual characteristics and needs at a particular point in time. Here are some general recommendations:

  • Provide a calm, stable, and predictable classroom setting and routine.
  • Designate a case manager who checks in with student at the beginning of the day and whom student can go to when feeling overwhelmed.
  • Adjust expectations – when a student is going through difficult time, set smaller, easily attainable goals until symptoms improve. Give extra time to complete work and allow your student, when necessary, to stop an activity and resume it when calm.
  • Model appropriate verbal responses to replace irritable behavior. For example, gently suggest, “Perhaps you could say, ‘I can’t focus on that right now’ instead of, ‘Why can’t you just leave me alone?’”
  • Recognize and reinforce all of your student’s efforts at self-management, such as managing to avoid or even postpone a tantrum or increasing the period of time between disruptive outbursts.
  • Identify a quiet, comfortable “time away” place where your student can go when feeling overwhelmed.
  • Arrange a subtle, nonverbal signal for your student to use to let you know when he/she needs to leave the room.
  • Provide objective, relevant information on student behavior to physicians and caregivers, especially for those students on medications.
  • Make an effort to understand and accommodate the side effects of medications (e.g. thirst, more frequent need to use the bathroom).
  • If a student is in therapy to develop emotional coping strategies, find out what strategies the student is working on. Prompt the student to use those strategies, when needed, and recognize and reinforce their use.

I hope that you find these suggestions useful. I would love to hear back from anyone who tries these strategies. Please let me know what worked, what did not work, and any other useful strategies you discovered.

Thank you so much and good luck!

References:

Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007 Sep;64(9).

http://www.nimh.nih.gov/science-news/2007/rates-of-bipolar-diagnosis-in-youth-rapidly-climbing-treatment-patterns-similar-to-adults.shtml