Chat With David Miklowitz, Ph.D.
The Balanced Mind Foundation Live Event Transcript

Did you miss our chat with David Miklowitz, Ph.D? Read the transcript of this exciting and informative chat. The Balanced Mind Foundation will be hosting several more expert chats this Spring. Watch your email for more details. 

Biography

David Miklowitz is the author of Bipolar Disorder: A Family Focused Treatment Approach, The Bipolar Disorder Survival Guide, and The Bipolar Teen: What You Can Do to Help Your Child and Your Family, as well as numerous research articles. Dr. Miklowitz’ research focuses on family environmental factors and family psychoeducational treatments for adult-onset and childhood-onset bipolar disorder.                               
                                              

Nanci-The Balanced Mind Foundation
I am very pleased to welcome today’s guest, David Miklowitz, PhD.. He is the author of “Bipolar Disorder: A Family Focused Treatment Approach”, “The Bipolar Disorder Survival Guide” and “The Bipolar Teen: What You Can Do to Help Your Child and Your Family” as well as numerous research articles. Dr. Miklowitz’ research focuses on family environmental factors and family psychoeducational treatments for adult-onset and childhood-onset bipolar disorder.

Nanci-The Balanced Mind Foundation 
Dr. Miklowitz would you like to make any opening remarks to our group?

David Miklowitz PhD
It's a pleasure to be here. I'm ready whenever you are - just to say I'm a big fan of The Balanced Mind Foundation!

Nanci-The Balanced Mind Foundation
Thank you! Perhaps you could start out by talking a little about your new book “The Bipolar Teen”?

David Miklowitz PhD
Sure - we just published a new book called "The Bipolar Teen." This book is intended for parents of the 12-18 set who are often struggling not only with the disorder but trying to distinguish being a teen from being a bipolar teen. The book focuses on coping strategies, especially those to use when a kid is cycling into mania or depression

David Miklowitz PhD
Any questions from my fellow "goldfish?" (Editor’s note: The default chat icon was a goldfish and we had a chat room filled with ‘fish’!)

Nanci-The Balanced Mind Foundation
Let’s start with a general one from Steph.

Steph
What are the typical signs of bipolar in a child?

David Miklowitz PhD
First look for changes in mood from a baseline state - sudden increases in irritability or giddiness, combined with increases in activity and energy, seeming to need to sleep less (not the same as insomnia), highly reactive moods, sometimes grandiose thinking; sexual preoccupations.

For depression look for lethargy, irritability, withdrawal, not being interested in friends, losing interest in school, negative and pessimistic thinking, hopelessness. Above all look for deteriorations in functioning and changes from a baseline state.

yasa
How do you tell if the issue is BP related, PMS related, or just regular teenage obstinate behavior?

David Miklowitz PhD 
Good question. First, consider the timing of the symptoms in relation to the menstrual cycle - if the irritability just occurs in the 5 - 6 days before the onset of her period and then goes away it's probably PMS related; bipolar tends to cycle throughout the month continuously. Bipolar is not diagnosed just by one behavior like being obstinate - you have to see clusters of symptoms like those above combined with a deterioration in functioning (for example, grades drop)

teddyone
Do you think it is helpful if the parents of a child with bipolar disorder just work on the "big" behaviors of the child instead of focusing on the little things that really don't matter? (Like going to your child when he needs something rather then expecting him to wait and come get you etc)

David Miklowitz PhD
Yes, I do think focusing on the big goals is a better strategy. These kids have significant frontal-cortical deficits, which means they will have trouble shifting from one activity to another or inhibiting their negative emotional reactions. Stick to your guns with rules like when they have to be home, no drugs or alcohol, no opposite-sex overnight guests, etc but let other things go like unwashed dishes, nasty tones of voice, forgetting to feed the dog etc.

Beverly
Hello -- My daughter's "depressive" state looks more like angry/revengeful. She doesn't have the sad/crying behavior that we would think would be classic depression. When she is in this state she becomes destructive and hurtful, especially when there is accountability. My husband and I have made a Parent/Child contract with her, and she was included in all aspects of rules/consequences (hoping that she would feel she had power/choices). However, she places blame for her choices on everyone else, and acts out against consequences (escalating the situation). How do we help her to begin to accept responsibility, and make better choices for herself? It is like "Groundhogs Day" here; we talk and work on the same issues everyday (& in therapy) without any change.

David Miklowitz PhD 
First, it sounds like she tends to have mixed episodes rather than depression only - more like depression combined with irritable mania or agitation. It's very hard to implement behavioral contracts when the kid's mood is cycling but you should forge ahead anyway, just with lowered expectations.

Also, the pattern you're describing of not taking responsibility is a teenage thing but it is exaggerated by bipolar disorder. Make sure the rewards and consequences are meaningful to her (use of cell phone, computer, car are the most common) - if the contracts aren't working for her ask her to design her own. Learning to take responsibility is a gradual process so if you see any evidence at all make sure to reinforce her (praise her, reward her in some other way) as well

Nanci-The Balanced Mind Foundation 
This question ties in to some of the previous one, but relates to the sibling and family dynamic. In the interest of keeping the peace in the family, and picking the 'big battles' how much do we compromise the 'rights' of our other children and expect them to concede or acquiesce to their ill sibling?

David Miklowitz PhD
This is a very tough balancing act. First, it's important to educate siblings about the fact that the older or younger sibling has bipolar disorder and what this means for them (e.g. it may mean giving up certain things, being embarrassed by your sibling at others, feeling that your sib gets all the attention

At times you have to compromise the rights of well sibs but make sure you balance it with paying more attention to them at a different time - spend more time with them, ask them how things are going, tell them you understand how hard it is, but make sure they also have insight into how they may be triggering the bipolar sib with certain looks, accusations, etc. We have an education sheet in our Bipolar Teen book which is aimed at siblings and parents which you can use to start a discussion with them about what bipolar is and what it will mean for your family life.

yasa
How do you handle it when your child acts overwhelmed and/or wants to blame behavior and/or thinking on their disorder instead of focusing and dealing with the real issue?

David Miklowitz PhD
I have seen this happen when bipolar becomes like a "blank check" that enables the kid to do and act however he pleases (how many of us have heard "well, what can I say? I'm bipolar you know"). Think of bipolar as worsening a kids’ ordinary teen reactions to things, kind of like an amplifier, but he or she is still responsible for those reactions. So, a good response might be "yes, you're right, you're bipolar and that probably affects how you react. But that doesn't mean you're not responsible for how you treat others."

Also, yasa, when kids are cycling avoid trying to get them to talk about the real issue until they've calmed down.

gene
How should we be speaking to our kids about the potential for hypersexuality?

David Miklowitz PhD
Gene, good question. When they are old enough to contemplate sexuality, or have their first boyfriend/girlfriend, have that first discussion you would have with any teen about sex but combine it with, "you know, bipolar has a way of affecting your judgment...how will you know when it's what you want versus whether it's what your bipolar disorder wants?"

Educate them about sexual risks; also, if they are planning on staying out late try to make sure they have a responsible friend along. If you have a good relationship with this friend you can even talk to him/her about the sexual risks you are afraid your kid will take and how they can be a good influence...but this varies with the situation.

Make sure their freedom to go out in high risk situations like parties is limited when they are clearly cycling, even if it makes you feel like a jailer at times.

jake 
Our 15 year old son rejects any suggestions by us or by therapists, teachers, etc. He maintains that he has to figure out things for himself (unfortunately, he is seldom successful). Therapy is useful to me in parenting, but seems to be a waste of time for him. Any ideas?

David Miklowitz PhD 
Therapists report mixed luck with adolescents, especially boys. Have a talk with the therapist about whether s/he is making any headway, whether your son seems to be opening up. Some kids do better in groups than individually. Tell him that the purpose of therapy is to help him figure things out for himself and figure out who he is and wants to be.

If it just seems to be going nowhere, though, get a second opinion from a different therapist - sometimes you have to therapist-shop before you find the right one.

tangles 
I find it interesting that you work with both adults and teens. The transition from teen to adulthood seems to be particularly difficult for many. What are your recommendations for easing this transition?

David Miklowitz PhD 
Tangles, the period of time from 17-20 is often the toughest on families. Kids are trying to make transitions to adulthood but are still back in grade school in terms of their emotional and social development (bipolar has a way of delaying and derailing ordinary development). The trick is to figure out what the kid is and is not capable of doing individually. If he says he wants his own place, go through with him what that entails - how will he remember to fill his medications? Do his laundry? How will food work out? Can he live with someone responsible? Can your house be adapted so that he has more independence (e.g. a basement apartment)?

When you look closely you often find that the kid is really terrified - beneath the grandiosity and bravado is the fear that he can't take care of himself and will always be dependent on parents (which can make kids hate their parents for reasons they can't admit to themselves) - so conflict arises at this time.

Deah 
Do kids with bipolar disorder have trouble socially and tend to become reclusive, or is that a sign of something else - like Asperger's Syndrome?

David Miklowitz PhD 
No, that is a sign of bipolar disorder, especially the depressive states - most people withdraw and avoid social contact. If the child has always been socially reclusive, had odd mannerisms and social habits (i.e. looking at his shoes whenever he talks, using odd word emphases, speaking ritualistically), and it has always been that way, it may be a form of Aspergers.

David Miklowitz PhD 
In my opinion, Aspergers is being over diagnosed in bipolar kids - you really have to see a longstanding pattern of social deficits before diagnosing it.

Nanci-The Balanced Mind Foundation 
I wonder if you could expand a little more on your thoughts about Aspergers? We have historically had a lot of families at The Balanced Mind Foundation with kids with the dual diagnosis of bipolar disorder and Aspergers, and have had several questions today submitted about treating these diagnoses through therapy, or making the distinction between the two.

David Miklowitz PhD 
Sure. First, think about the diagnosis of Aspergers - social isolation, lacking social skills, being unable to communicate nonverbally (e.g. no facial expressions), getting obsessively fixated on one interest or activity to the exclusion of all else, engaging in repetitive ritualistic behaviors, and being physically awkward and uncoordinated.

Sometimes kids with bipolar disorder get this way when depressed. The key question is, when they are not depressed, are any of the above features present? Is this an ongoing state of the child, or only when he or she is in a mood disorder episode? Have these symptoms been present since early childhood (Asperger's is believed to have a very early onset) - i.e., did she have good friends as a kid, or have there always been reports that the kid was awkward, shy, didn't acknowledge people with nonverbal gestures, etc.?

Also, think about treatment - what are the implications for treatment if the kid has Aspergers as well as bipolar? Usually this will mean some kind of individual or group social skills training, which may be useful anyway if the kid just has social problems but does not have Aspergers.

One other feature - did the child reach other developmental milestones like crawling or walking late? This is key to the diagnosis of Aspergers.

autumn 
We have a 16 year old boy who has been mentally ill since 9 years old. We are having trouble getting a handle on the anxiety. Can you recommend best meds, coping skills, or hospitalization success?

David Miklowitz PhD 
Anxiety disorders are comorbid with bipolar disorder in 30%-50% of cases. Sometimes the anxiety is a sign of the depression and sometimes it's a separate condition. First, you may have to consider SSRI antidepressants (which as we all know carry risks of additional cycling), which are often used for anxiety. His doctor may also recommend an atypical antipsychotic like Seroquel which is a good anti-anxiety agent.

For psychotherapy, see books like "Mastering your Anxiety and Panic" by Craske and Barlow - this is a self-help workbook. Is there a mindfulness meditation group available? Some colleagues of mine at Oxford University found that mindfulness meditation was effective for anxiety in bipolar disorder.

lbd 
Even on medications, my daughter is irritable, very active, has highly reactive moods. From your experiences working with kids with bipolar disorder, is it safe to get her off meds to get a baseline and then treat again if needed?

David Miklowitz PhD 
Ibd - if you want to do a medication washout, it's best to do it in a hospital setting, especially if your child has a history of suicidality, psychosis, aggressive behavior, etc. If you are going to take her off medicines, do it under a doctor's supervision, usually one medication at a time, going down slowly on the dosage of each and watching for any return of symptoms. Usually, though, we want to see some period of recovery (eg 6 months) before a medication washout is safe.*

autumn 
How do you know when to hospitalize?

David Miklowitz PhD 
Autumn, first it's good to have the criteria laid out before the kid gets severely ill so you'll know it when you see it. Any suicidal behavior (particularly an attempt like swallowing pills, even if not apparently serious), suicidal ideation which is reasonably specific (e.g., I think about swallowing all my pills at once and checking out) and is getting more frequent; excessive drug/alcohol use (e.g. comes home high (eg on Ecstasy) or drunk regularly; out of control behavior (e.g. aggressiveness, breaking into sudden cursing in class, plus the other symptoms of mania); and being unable to take care of himself (stops bathing or eating).

Bren
Is it much worse for teens on the BP spectrum to experiment with drugs and alcohol? If so, how do parents approach that? How do they help their kids to navigate those waters?

David Miklowitz PhD 
Bren, yes it is more dangerous. Drugs and alcohol make the symptoms worse and can even convert a kid with a mild form of BP into a more severe bipolar I form. Also, bipolar makes it more likely that a kid will develop a substance dependence disorder than a healthy teen who uses the same amount.

A good book on this is "Motivational Interviewing" by Miller and Rollick. Jump on the issue earlier rather than later; if the kid has had, say, one instance of using Ecstasy or cocaine, institute home drug testing as a way of preventing future episodes. He'll hate it, of course, and may even try to doctor the samples, but it lets him know you're concerned about this and will be watching. Some parents use the kid's intention to go to a "Rave" or a party with kids who are known to use drugs as a time to use drug testing (eg it's fine to go to the concert but keep in mind we'll be doing a drug test Sunday morning) Talk to your kid about negative peer pressure, show you understand the dynamics of how peers can pressure you into doing things you don't want to do.

Nanci-The Balanced Mind Foundation 
I know we started a little bit late this morning, do you have time to take a few more questions?

David Miklowitz PhD 
Yes, happy to take more questions.

momx3

There is so much focus these days on medications, and the media hype about overmedicating kids. In your opinion what is a good balance between medications and therapy?

David Miklowitz PhD 
momx3, this is really the $64,000 question (is it $64 million now?) The recent PBS special on "The Medicated Child" made it look like drugs were the only option, which is a shame. The research literature generally favors combining psychotherapy with medications. For example, in the STEP bipolar study of adults we found that weekly psychotherapy in conjunction with mood stabilizers helped speed up recovery from depression, whereas combining mood stabilizers with antidepressants didn't.

Make sure you have your kid in a weekly therapy with a practitioner who knows about bipolar disorder and makes this the centerpiece of the treatment - family therapy is particularly effective, especially if it's oriented around strategies the families can use to prevent mood swings (e.g., identifying early warning signs and calling the physician; strategies to keep the family environment structured and low-key).

A good question to ask your kid's psychiatrist is, if he or she is about to add a third or fourth medication or raise dosages significantly (and you suspect this is a lot of "trial and error" planning), ask him/her to recommend a therapist first who specializes in BP spectrum disorder - maybe try that before going the extra step of adding yet another medication*

tshura
Does your book deal with family therapy?

David Miklowitz PhD 
Yes, it does, we talk about it at some length. We also have a separate book called "Bipolar Disorder: A Family-Focused Treatment Approach" which is primarily for clinicians working with families of BP persons but has a lot of suggestions for parents as well.

Nanci-The Balanced Mind Foundation 
We have had a tremendous response and many more questions than we could possibly cover in an hour. Probably enough material for another book!

David Miklowitz PhD 
Time for one more?

Nanci-The Balanced Mind Foundation
If you have the time, absolutely!

David Miklowitz PhD 
sure

Western Cardinal
I am both a therapist specializing in pediatric bipolar and a parent of 2 bipolar kids, Lately I have been in a situation where I have to dispute the information about pediatric bipolar with other professionals who swear there is no such thing as pediatric bipolar that it is incomplete parenting. I always bring up the medicine issues that if medicine solves many of the problems then it is definitely pediatric bipolar but we all know that medicine is not a panacea. Any idea on how to combat this line of thinking?

David Miklowitz PhD 
Yes, I have run across this as well. I think your colleagues have not read much of the research literature in the past 20 years! Yes, BP may be being over diagnosed now (witness the study that found a 40-fold increase) but that may be a good thing since it was way under diagnosed for so long. All you can do is educate them about why you think it's bipolar and not something else like ADHD (focus on the cycling of mood and the cardinal symptoms of the disorder), point out that there is no evidence that poor parenting causes a syndrome like this...or meet them halfway and suggest that a particular patient get both a mood stabilizer and family treatment to deal with parent/child conflicts. But hang in there and don't budge!

Nanci-The Balanced Mind Foundation 
Dr. Miklowitz, thank you so much for sharing your time and expertise with us. The information and insights you provided have been extremely helpful and informative. Thank you as well for all of your research and work to benefit our kids and our families.

David Miklowitz PhD 
It's my pleasure. I have enjoyed this hour and all of the questions have been great. Good luck!

yasa 
Thank you SO VERY MUCH doctor!!! I REALLY appreciate this daytime chat as evenings are just IMPOSSIBLE for me to get to when both BP teens are home!! :) Thanks a whole lot!!!!

tshura
thank you!

bren 
Thank you!

Deah 
Yes, thank you!

mitzi 
This has been so very helpful!!!! Thank you so much! I, too, appreciate the daytime CHAT!

teddyone 
Thank you so much for your time spent with us!

Steph 
Thank you

Laura 
Thank you for writing a book concentrating on teens - our "bipolar child" is growing up!

Rae 
Thank you

Western Cardinal 
I will be at a National Assoc of Social Worker conference in Albuquerque next week educating school social workers on both the symptomology of Pediatric bipolar versus ADHD but also various methods for helping kids with non-medical ways to deal with it in addition to medical ways I will be using your book as a reference.

David Miklowitz PhD 
My pleasure, and thanks to Nanci and The Balanced Mind Foundation for making this kind of forum possible.

Nanci-The Balanced Mind Foundation 
We're always delighted to have these chats!

tshura
Indeed, thank you Nanci