|
 The
IDEA Classification Debate: ED "Emotionally Disturbed" or OHI
"Otherwise Health Impaired"
by Donna Gilcher, Ruth Field and Martha Hellander,
Newsletter of the Child & Adolescent Bipolar Foundation, March
20, 2004
For more articles like this
visit
https://www.bridges4kids.org.
What is the most appropriate classification for students with
bipolar disorder under the Individuals with Disabilities
Education Act (IDEA)? Parents and schools face this question
each time they meet to develop a student’s Individual
Educational Plan (IEP). Although IDEA states that special
education services are not categorically driven but must instead
be driven by student need, parents often are told that
appropriate accommodations for behavioral issues are not
possible without an Emotionally Disturbed classification. This
belief may arise from a misunderstanding of how IDEA defines
these categories.
IDEA defines Emotionally Disturbed (ED) as follows:
“Emotionally Disturbed means 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:
(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 and teachers
(c) Inappropriate types of behavior or feelings under normal
circumstances
(d) A general pervasive mood of unhappiness or depression
(e) A tendency to develop physical symptoms or fears associated
with personal or school problems.
The term includes schizophrenia. The term does not apply to
children who are socially maladjusted, unless it is determined
that they have an emotional disturbance” (IDEA sec. 300.7c4).
IDEA defines Other Health Impaired (OHI) as follows:
“Other Health Impaired means having limited strength, vitality,
or alertness, including a heightened alertness to environmental
stimuli, that results in limited alertness with respect to the
educational environment, that—
(a) is due to chronic or acute health problems such as asthma,
attention deficit disorder or attention deficit hyperactivity
disorder, diabetes, epilepsy, a heart condition, hemophilia,
lead poisoning, leukemia, nephritis, rheumatic fever, and sickle
cell anemia; and
(b) adversely affects a child’s educational performance” (IDEA
sec300.7c9).
Looking at the above guidelines, it is apparent that children
with pediatric bipolar disorder are most appropriately
categorized as OHI. Pediatric bipolar disorder is a medical
condition that can be explained by intellectual, sensory, and
general health factors, in contrast to the definition of ED. All
of the symptoms of ADHD, a condition specifically named under
OHI, are also seen in bipolar disorder.
The biological nature of bipolar illness as a disorder of the
brain like epilepsy or ADHD is manifestly clear from research
published in leading medical journals. Both structural brain
development and the functioning of neural networks are affected.
For example, recent studies have demonstrated regional volume
reductions, enlargements, or other abnormalities in the temporal
lobes, caudate nuclei, amygdala, hippocampus, neocortex, and
other structures of the brain in patients with bipolar disorder
(El-Badri et al, 2000; Cecil et al, 2002). Recent work done by
Husseini K. Manji, M.D., Chief, Laboratory of Molecular
Pathophysiology at the National Institute of Mental Health, and
colleagues has demonstrated that cellular plasticity and
resilience is also abnormal, with accumulating evidence showing
alterations in the mitochondria, reduced brain cell growth
factor, and accelerated brain cell atrophy and death. Some of
these abnormalities appear to be reversible by treatment with
lithium and other medications used to treat the illness in
adults.
Bipolar disorder is clearly a disability, as defined by OHI,
that demonstrates “having limited strength, vitality, or
alertness, including a heightened alertness to environmental
stimuli, that result in limited alertness with respect to the
educational environment.” The physical energy and alertness of a
child with bipolar disorder can fluctuate dramatically by
season, by cycles (which may last from days to months) and even
several times over the course of a single day. Children with
this disorder typically have a disturbed sleep/wake cycle that
includes low arousal and difficulty awakening from sleep in the
morning (much more so than a normal child of the same age), and
may include increasing energy throughout the day with extreme
hyperactivity in the late evening that prevents normal sleep.
During hypomania or mania, the child may move very quickly with
heightened concentration and focus, during which time academic
progress may occur in leaps and bounds. An outpouring of
creativity may occur during mania in some children, with
attention hyper-focused upon topics that engage the child’s
interest. When depressed, the child may move extremely slowly
and experience fatigue, reduced concentration and alertness,
during which time little or no academic progress may occur.
Disturbances in endocrine functioning, which affect body weight,
growth, puberty, and energy, are also common.
Cognitive abilities are also impaired. Attention, shifting
tasks, verbal learning, declarative memory and visuospatial
memory are often found to be impaired on neuropsychological
testing of bipolar students (Dickstein et al, 2004). A lack of
ability to easily recall information or process it correctly
within the classroom, which in some children may be a constant
trait but seen in others only during acute episodes, often leads
students to experience distress and failure on academic testing.
Executive functioning difficulties are common in students with
bipolar disorder, leading to poor organizational skills (Clark,
2001; Chowdhury et al, 2003). Stress exacerbates these cognitive
problems. Such deficits can lead to impulsivity,
distractibility, and poor decision-making, just as they do in
ADHD, which is specifically listed under OHI.
Some children appear to lose cognitive abilities as the illness
progresses, although some do not, and recovery between episodes
is possible. A study examining school functioning in bipolar
adolescents showed a significant decline in academic abilities
after onset of the illness. Researchers at the Sunnybrook Health
Science Center in Toronto, Canada, concluded that the “onset of
bipolar illness negatively impacts a child’s ability to function
effectively in the school environment and that very specific
program modifications are required in order to optimize the
child’s success at school” (Quackenbush et al, 1996). Medication
to control symptoms of the illness may impair or improve
cognition and have other unavoidable side effects. Difficult
treatment decisions must be made by physicians and parents.
Behavioral symptoms that impair learning are often produced by
the illness. Rages, negative peer relationships, and the
inability to interpret social situations and react
appropriately, are common. Some children with the illness
experience powerful social anxiety that at times prevents them
from attending regular school. Impulsivity can lead to verbal
outbursts that the child may not be able to control. Some
children manage to contain their behavioral symptoms during
school but are unable to do so at home. Some children (more
often boys but some girls) will show more externalizing
behaviors, while others (more often girls but some boys) will
internalize their distress. Children with bipolar disorder tend
to interpret neutral facial expressions as negative, which
affects relationships. Since no two children are alike,
behavioral symptoms vary widely both between students, and in
each child, during different episodes of the illness.
Furthermore, the central nervous system dysfunction appears to
be an underlying factor in both the expression of mood and the
cognitive disturbances noted in the disorder (Chowdhury,
Ferrier, Thompson, 2003). Repeated episodes of the disorder can
produce large deficits in social and vocational functioning.
Thus, the combination of mood, cognitive, energy, and behavioral
effects of this illness negatively impact academic functioning
in affected children. Without appropriate educational
accommodations and modifications designed to decrease this
negative impact, these students are at risk for school failure.
Fortunately, once the illness is properly diagnosed and treated
with appropriate medical interventions, these symptoms tend to
subside.
Why does the IDEA designation matter? It matters for several
reasons. Sometimes the classification leads to an inappropriate
placement. When a child with bipolar disorder is placed in a
program for emotionally disturbed children (in which traditional
behavior modification techniques are utilized), the child will
frequently experience increased instability, negative self
concept, and feelings of worthlessness, helplessness and poor
self-esteem. The stigma that these children are “bad” is a grave
injustice of the ED classification. We must accept that some of
the most explosive and puzzling behaviors are beyond the child’s
control and that those behaviors are symptoms of medical
instability, not purposeful or malicious conduct. Another
injustice of the ED classification is the often-limited
educational opportunity it provides. In the majority of ED
classrooms, addressing behavior is the primary focus, in
contrast to an academically enriching or challenging environment
needed by the often highly creative children with bipolar
disorder.
OHI classification signals educators to provide the student with
compassion and acceptance, and allows for an understanding that
this illness is beyond the student’s control, as are the
symptoms of diabetes, cancer, epilepsy or sickle cell anemia.
Everyone in the child’s life must work cooperatively to manage
pediatric bipolar disorder. Doctors, parents, mental health
providers, educators and the student must collaborate to meet
the child’s individual educational needs and develop creative
modifications to accommodate the child’s fluctuating medical
condition, including periods of relative wellness and academic
progress and periods of relapse and medical crisis. Students
with pediatric bipolar disorder need non-punitive behavioral
interventions for inappropriate behavior. They need instruction
in appropriate behaviors in a variety of educational and social
situations, as well as practical strategies that reduce stress
at school. These considerations will ultimately increase the
attendance and graduation rates among students with bipolar
disorder, and will provide them the opportunity to find joy in
learning.
For more information, see:
Education
Issues of Pediatric Bipolar Disorder
on the Web site of the Child & Adolescent Bipolar Foundation.
References:
Cecil K, DelBello M, Moreya R and Strakowski S. (2002) Frontal
lobe differences in bipolar disorder as determined by proton MR
spectroscopy. Bipolar Disorders 4 (6) 357- 365.
Chowdhury, R., Ferrier, I.N., Thompson, J., (2003.) Cognitive
Dysfunction in Bipolar Disorder. Current Opinion in Psychiatry
16, (1), 7-12.
Clark, L.D.P., Iversen, S.D., Goodwin, G.M. (2001) A
neuropsychological investigation of prefrontal cortex
involvement in acute mania. The American Journal of Psychiatry,
158 (10) 1605-1611.
Dickstein, P., Treland J, Snow J, McClure E, Mehat M., Towbin K,
Pine D and Liebenluft E (2004). Neuropsychological Performance
in Pediatric Bipolar Disorder. Biological Psychiatry, 55: 32-39.
El-Badri, S., Ashton, H., Moore, B., Marsh, R., and Ferrier, I.N.
(2001) Electrophysiological and cognitive function in young
euthymic patients with bipolar affective disorder. Bipolar
Disorders 3, 79-87.
Quackenbush, D., Kutcher, S., Robertson, H., Boulos, C., Chaban,
P. (1996). Premorbid and postmorbid school functioning in
bipolar adolescents: Descriptive and suggested academic
interventions. Canadian Journal of Psychiatry, 41, 16-22.
Donna Gilcher, Ed.D, is K-12 Educational Programs Director; Ruth
Field, M.S.W., is Managing Director; and Martha Hellander, J.D.,
is Executive Director at CABF. This article is a revised and
updated version of an article originally written by Donna
Gilcher.
back to the top ~
back to Breaking News
~ back to
What's New
|
