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

Biography

Dr. Fristad is a Professor of Psychiatry and Psychology at the Ohio State University, where she has been on faculty since 1986. Dr. Fristad is the Director of Research and Psychological Services in the OSU Division of Child and Adolescent Psychiatry. Dr. Fristad’s area of specialty is childhood mood disorders. She is has published over 100 articles and book chapters addressing the assessment and treatment of childhood-onset depression, suicidality and bipolar disorder (manic-depression). 

 Dr. Fristad recently edited the Handbook of Serious Emotional Disturbance in Children and Adolescents. She has also written a book for families entitled Raising a Moody Child: How to Cope with Depression and Bipolar Disorder. Dr. Fristad has been the principal or co-principal investigator on over a dozen federal, state and local grants. Recently, she been awarded a 5-year NIMH grant to investigate the efficacy of Multi-Family Psychoeducation Groups in treating childhood mood disorders and a 2-year grant from the Ohio Department of Mental Health to investigate the efficacy of Individual Family Psychoeducation in treating early-onset bipolar disorder. Dr. Fristad is a member of The Balanced Mind Foundation's Professional Advisory Council. 

 Mary Fristad PhD     

Hello everyone!

Nanci - The Balanced Mind Foundation    
Welcome, and we'll start in just a few minutes. During this chat session you can submit questions at any time. They will be held in a queue and put through one at a time for Dr. Fristad to respond.

Mary Fristad PhD    
One update while I'm waiting for a question— our treatment manual (written for therapists) should be available next year with Guilford Press and we will publish accompanying workbooks for multi-family psycho educational psychotherapy (MF-PEP) and individual family PEP (IF-PEP) for families to use in treatment.

Nanci - The Balanced Mind Foundation    
Excellent, thank you for that update.

Nanci - The Balanced Mind Foundation    
Dr. Fristad, thank you for being here, would you like to make any opening remarks?

Mary Fristad PhD    
Hello, everyone! I am glad that we know more about how to support families of children with BPD than we did 5 or 10 years ago!

sherrie    
My son is adopted from Russia. He has fetal alcohol and bipolar. He is a hard to treat bipolar. Can the bipolar be caused by organic brain damage from alcohol?

Mary Fristad PhD    
Children and adults can have "Mood disorder due to a 'general medication condition'"— this can include fetal alcohol syndrome. This does complicate treatment.

sherrie    
Any suggestions?

Mary Fristad PhD    
How old is your son?

sherrie    
9

Mary Fristad PhD    
It is important for him to recognize his symptoms and to really accept the concept that his symptoms do not define him but rather, he needs to understand them in order to control them.

CTD    
Can you comment on any experience about kids diagnosed at an early age (5-ish) and the likelihood that they go on to develop adolescent or adult BP? Furthermore, is that likelihood affected by whether or not they start meds, in your opinion?

Mary Fristad PhD    
If you mean diagnosed at age 5 with bipolar disorder (and the diagnosis is accurate), my best clinical guess is that they will continue to have bipolar disorder. The critical issue is to manage the symptoms as comprehensively as possible so the child passes through critical developmental phases as healthy as possible.

Nanci - The Balanced Mind Foundation    
We have a related questions about whether the prognosis is better if a child is diagnosed and started on treatment at an early age.

Mary Fristad PhD    
It’s better to effectively (and accurately) diagnose and treat than not.

CTD    
How do you judge is a diagnosis is "accurate" really?

Mary Fristad PhD    
It is so very important for parents to become educated about their children's conditions— this is part of why I am such a big fan of The Balanced Mind Foundation! You need to understand why the provider made the diagnosis he/she made and continue to observe your child (and your child, as well) to see how symptoms manifest over time and respond to treatment. Treatment response does NOT dictate diagnosis, though.

Leah    
What do you think of natural supplements such as EmpowerPlus with choline and inositol either alone or in combination with psych meds?

Mary Fristad PhD    
We just recently published a case study in the Journal of Child Adolescent Psychopharmocology on EmpowerPlus ("EMP+"). We also completed an open label N=10 of EMP+ in children with "severe mood dysregulation". The results were positive; we have not yet submitted that paper for publication.

karshan    
What parenting methods do you recommend for my 10 yr. old child who is verbally abusive to his family members, including cursing and some aggression. Should we expect him to be able to control these behaviors?

Mary Fristad PhD    
That is a complicated question. When a child is "too high" or "too low" they do not respond well to feedback. It is important to have problem solving discussions about behavior at a time when all are calm. However, my bottom line is physical harm to self or others is never tolerated.

Leah    
Regarding physical harm to self and others, how exactly do you not tolerate it? Restraint? Consequences? Other ideas?

Mary Fristad PhD    
Depending on how dangerous the situation is—restraint (this is not always feasible— if it doesn't feel safe, don't do it), consequences, calling the police. Regarding the latter, it is very helpful to have a preemptive discussion with your local precinct worker— so they know how they can most effectively intervene, if needed.

Nanci - The Balanced Mind Foundation    
Yes, many police departments use Crisis Intervention Training and asking for a CIT trained officer can help.

Mary Fristad PhD    
That is a fabulous program.

Janice    
Why are some doctors so hesitant to diagnose young children with bipolar disorder and treat them?

Mary Fristad PhD    
Many clinicians were not trained to diagnose BPD. The research really only started in the 1980s, picked up in the 1990s, and really took off in the 2000s. Thus, many clinicians are not well versed in diagnosis or treatment. Additionally, we do not have long-term follow-up data on medications for growing brains, so there is some legitimate hesitancy.

Janice
Can you talk about the role of psychotherapy (counseling) in addition to medicating a young child with BP? And what strategies should a therapist use?

Mary Fristad PhD    
Therapy is critical for the child and parents. I recommend any form of psychoeducational psychotherapy (PEP) — for young children, our PEP program or the RAINBOW program.

Patty    
My son is 16, diagnosed at 11. When I ask what he feels (sad, frustrated, trapped), he just says fine. He knows he has bipolar disorder, but doesn't really SEE his illness. If we correct him, he thinks we are wrong because he didn't do anything. How do you get kids to SEE their illness?

Mary Fristad PhD    
My favorite starting exercise in therapy is the Symptom-Self (or "Naming the Enemy") exercise. We talk about it in Raising a Moody Child. For a 16 year old, it is probably better to have a therapist help mediate this discussion. The key is for your son to recognize his symptoms as external to his core personality, then you and he can team up to manage the symptoms. 

He may also either be resorting to "fine" because he doesn't want to get into a discussion with you OR he really isn't very aware of a broad array of emotional experiences he is having.

Cindy    
I have a 14 year old who is stable on medications, but we still struggle with end of the day exhaustion and homework battles. I think he still needs a lot of support with his homework because I think not doing well academically would cause too much stress. My husband thinks he should be working independently on his homework and suffer the consequences if he doesn't complete it. It's a tough situation because in so many ways he's stable. Can you please talk some about symptoms that may remain even after stability is achieved and how best to support a teenager while still encouraging independence?

Mary Fristad PhD    
Absolutely, and this is such a common problem. Does he have an IEP? If so you might want to consider a reduced homework load, or a supported study hall to help with the work load at school.

Bernie    
My child is currently in a therapeutic home. She has basically given up her family and her amenities. She has gone to the extreme of getting a tattoo, piercings, and has colored her hair purple, pink and blonde. She is only 14. She has stated that she does not want my authority. Is this part of bipolar and or part of being a teenager?

Mary Fristad PhD    
It’s hard to say without knowing more about your daughter and your family situation. Tattoos, piercings and hair dying are not diagnostic of any disorder, but can be a defiant stance against parents or a rebellious statement. It may fit in quite well in her current setting/peer group?

karshan    
My 13 child has horrible anxiety about school. I never know which day he will wake up and refuse to go. Homework is also a major issue and that is when most of our explosions occur. What do you recommend?

Mary Fristad PhD    
It will be really important to work together with your therapist and school to develop a plan, hopefully in the context of an IEP, to manage emotional distress in the school setting. The IEP should also address the amount of homework coming home— a COMMON concern!

JB    
Is there any current or ongoing research on the effects of omega 3s on early-onset BP? Do you have an opinion about using something like OmegaBrite in lieu of or in addition to medication?

Mary Fristad PhD    
Interesting question. We have two omega 3 protocols under review Oct 5th at NIMH! Cross your fingers! I am extremely interested in conducting additional research. Two studies have been done: one in depressed children (double blind), one open label in children with bipolar disorder. Both are promising.

My clinical recommendations based on our limited info are to take 1-2 grams of EPA+DHA daily (NOT just the total grams of FISH OIL— it needs to be EPA + DHA— and preferably in about a 2:1 ratio— although we really don't have a lot of evidence for the best dose or ratio.

Nanci - The Balanced Mind Foundation    
Are you familiar with Lovaza, the prescription version of an Omega 3 supplement? And if so, any feelings on whether Rx quality is better than OTC or not?

Mary Fristad PhD    
Sorry, no— but make sure that there is a USP label on the bottle. GNC has a triple strength capsule so you only have to swallow 1-2 per day.

cello    
I know discipline is essential, yet how does one meet the challenge? The mood takes a dive (therefore, increased aggression) when "justice" is served (a privilege is removed when the responsibility is not fulfilled). Things get much, much worse!

Mary Fristad PhD    
When your child is calm and able to problem-solve, work really hard on what he/she can do when the mood dives OTHER than resorting to increased aggression. I know, sounds easier than it is to do!

jodi    
What is the best way to handle an outburst directed at me? I've been told to leave the situation, but that seems to make it worse. She feels very abandoned and I think is scared...but when I stay she continues to lash out verbally at me.

Mary Fristad PhD    
I may start to sound like a broken record ...but when your daughter is calm, ask her what her experience is like and ask her what you can do to help her regain calmness. Some kids are soothed by your presence, others calm faster in your absence. The key is that SHE is part of the solution— she needs to take some ownership in success.

pam    
My 9 year old son is bipolar. With medication, he is successful at school. However, after school, he can't seem to hold it together to do his homework. Any suggestions for finding respite care, someone to stay with him while I'm driving his siblings around after school?

Mary Fristad PhD    
Such a common theme— those awful after-school hours! If you live near a college, I would try advertising for a student in special education, social work, psychology, etc., who could provide "specialized" childcare for you. This has been an absolute life-saver for families I've worked with.

Editor’ s note: There is a National Respite Locator link listed in the Resources section of our website.

Janice    
Should discipline remain consistent for the same misbehaviors when a child is unstable, compared to how you would discipline them if they were stable? I tend to be more lenient with my son when I know he is unstable, thinking he cannot help it, but is that the right thing to do?

Mary Fristad PhD    
Yes, flexibility is key, but it is also important to have some "rules" about it— so that he (or his sibs) don't think that you are willy-nilly applying rules. One concept to keep in mind is to process AFTER an event (I like to think of it as a "TIME-IN" that follows "TIME-OUT").

mom2one Jackie    
At what point do you feel ECT (electroconvulsive therapy) is a viable option?

Mary Fristad PhD    
When you have had multiple failed medication trials and symptoms are severe.

Nanci - The Balanced Mind Foundation    
Can you comment on the effectiveness of ECT in severe cases of BP?

Mary Fristad PhD    
For kids, there is almost no literature. Anecdotally, I support its use.

amarte522    
What is electroconvulsive therapy? What does that consist of?

Mary Fristad PhD    
ECT is what people often refer to as "shock therapy"—a small "shock" is sent unilaterally into the brain— and it often has an impressive ability to ameliorate treatment-resistant depression.

pam    
My son is at a private school that doesn't know he is bipolar. We are trying to keep his condition under wraps because we live in a small conservative town and I fear that parents may not allow their kids to play with my son if they knew of his condition. Am I doing him a disservice by not sending him to public school where they have IEPs  and other special help? He has a really tight group of friends at his current school, so I’m not sure change would be good.

Mary Fristad PhD    
If it isn't broken, don't fix it. If I am understanding your situation, he is doing relatively well as is?

CTD    
Are there any success stories of raising a BP child WITHOUT meds? Nutritional and behavioral approaches? I am frustrated at the speed at which I'm told to medicate, and do not have the sense that 'no stone has been left unturned' in the area of treating very young (<10 year olds).

Mary Fristad PhD    
You can probably hear anecdotal stories of anything. I have to say, the case study I mentioned earlier is quite impressive. A child I had treated conventionally for 6+ years, bipolar with psychotic features, OCD and accompanying diagnoses, never was 100% well on psychotropics and therapy. He switched to EMP+ and is the healthiest and most symptom-free he's ever been, and it is going on 2 years of recovery for him. We really need a double-blind placebo controlled study. We are resubmitting that this fall to NIMH.

mom2one Jackie    
Would you recommend trialing EMP+ before resorting to ECT?

Mary Fristad PhD    
It depends. EMP+ is a bit tricky for a child currently on meds— for our study, to keep things clean, we required a 3-week "washout" of all medications. EMP+ appears to potentiate other meds. If your child is so ill that ECT is being considered, I would probably do that, then consider EMP+.

CTD    
How about trying EMPower+ before any other meds are tried? All the case studies I've seen deal with patients already on meds.

Mary Fristad PhD    
CTD: that is the best way to trial EMP+.

karshan    
We live in a small town where psychiatric resources are lacking. My child has tried several med combinations and doctors are not sure what he has BP, Intermittent Explosive Disorder or ADHD. Can you recommend anywhere in the US for a thorough workup (diagnosis and medication)?

Mary Fristad PhD    
The Balanced Mind Foundation has a Find-a-Doctor service, I would use that.

Nanci - The Balanced Mind Foundation    
Also, there is a consultation program offered by Dr. Birmaher and Dr. Axelson through the University of Pittsburgh Medical Center. It's listed in our State Resources section under Medical for each state.

mom2one Jackie    
Is ECT also effective with mania and/or severe mixed moods?

Mary Fristad PhD    
Not in literature with kids but it has been used with adults.

Nanci - The Balanced Mind Foundation    
Dr. Fristad, I have a question from a member who couldn't be here for chat. She wanted to know if you have any suggestions for how to curb the sugar/carb cravings with a teen girl with BP, particularly during PMS.

Mary Fristad PhD
Ouch. That is really hard. Have lots of healthy choices around (e.g., frozen strawberries, raw celery with low-fat dip) and lots of physical exercise followed by drinking PLAIN WATER, and sufficient sleep. Lack of sleep leads to additional sensation of hunger.

teddyone    
Is there a point where you could consider lowering meds after you've seen stabilization for 2 years on the same 2 meds (Trileptal and Seroquel XR)? My child is 13 and is stable because of taking the meds.

Mary Fristad PhD    
We recommend a slow taper during a steady relatively stress-free time (e.g., summer).

Nanci - The Balanced Mind Foundation    
Any thoughts on whether one should wait until the child is through puberty?

Mary Fristad PhD    
That is a question with a multi-part answer! Puberty can cause interesting responses in kids— but for someone stable, especially if experiencing side-effects, and if the child, parents and prescriber have a good relationship and know how to bump back up to the previous dose, if needed, there is an argument to be made for the smallest effective dose to be used.

Nanci - The Balanced Mind Foundation    
We're getting near the end of our hour, and before I put through any more questions I'd like to see if you have any key points you'd like to share or emphasize to our families here?

Mary Fristad PhD    
Make sure you and your child understand the diagnosis and what you can do to work together to manage symptoms. It is critical that the child does not see the diagnosis as defining who they are as a person, rather, the symptoms need to be effectively managed. This puts the child and parent on the same team and they can talk together about the frustrations (and successes!) of doing so.

Lisa J    
My 12 year old son has an extremely hard time understanding that his 10 year old brother with bipolar disorder has a different set of "rules" than he does. We try not to make things this way, but there are times when you simply have to pick your battles. Other than spending special time with our 12 year old and trying to explain things to him (maybe we aren't saying the right things?)  how can we get him to understand the situation and rationalize the difference between the two of them?

Mary Fristad PhD    
Several ideas here— 
1) who said life was "fair"? (Is it fair that the 12 year old doesn't have to struggle with BPD? Is it fair that he has tougher rules? no and no!)
2) your son may benefit from attending a sibling session with your 10 year olds therapist;
3) it is important your 12 year old continues to lead his life as "normally" as possible—  sounds like you are trying hard to make that happen.

Nanci - The Balanced Mind Foundation    
http://www.siblingsupport.org/ is a great resource for siblings.

sunwillshine    
I'm at my wit's end. We've tried so many different medications and nothing seems to be helping my daughter. At what point does it make sense to try and get my daughter into a research study? Is there any reason to hold back from this?

Mary Fristad PhD    
No reason whatsoever!

Nanci - The Balanced Mind Foundation    
I think it's clear from today’s questions that parenting a child with a chronic illness raises more questions than answers. And we are grateful that you shared your time and expertise with us today. Thank you so much for being here, and for the tremendous work you do on behalf of our kids.

Mary Fristad PhD    
You are welcome!