Chat With Mary Fristad, Ph.D. (2008)
The Balanced Mind Foundation Live Event Transcript

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 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.
 

Nanci - The Balanced Mind Foundation
Welcome, Dr. Fristad.

Mary Fristad PhD

Thanks, Nanci, and hello everyone!

Nanci - The Balanced Mind Foundation
Are there any opening comments you'd like to make before we start with the questions?

Mary Fristad PhD
Let's get rolling, I think there are lots of folks with questions out there

jerrypb
Dr. Fristad, thanks for being here. I'm wondering if there are three middle schools in the country that you think are tops in handling BP kids. Which are they, and in what order of favorites?

Mary Fristad PhD
Sorry, don't think I can name 3 top middle schools in the country-- that is a tall order, but we could certainly talk about what make middle schools work for kids with BP

jerrypb

Great. What does, in your opinion?

Mary Fristad PhD
Flexible attitudes, willingness to work together and learn about bp for starters

cmd
I am curious about private schools for children w/ EBD & MH that are strong in academics

Mary Fristad PhD
My favorite recommendation for folks looking for therapeutic schools and programs is to start with http://www.natsap.org/ (editor’s note: National Association of Therapeutic Schools and Programs)

Mary Fristad PhD
We have a local psychologist who specializes in linking families with programs-- but I think how that works from community to community may vary widely and these are expensive options, not available to many families. I like to start with local schools to see what can be done there.

jerrypb
I agree. But, as is currently the case, MS schools, even when flexible and caring, can be overwhelmed by the appearance of mania and/or manic aggression in schools. I had hoped you may have heard of schools whose faculty are trained to understand our kids.

Mary Fristad PhD
Yes, it can be overwhelming. Working within your local district, though, keeps the family intact which is a big plus (not always)

gmom
Would you recommend home schooling over a therapeutic school if home schooling alleviated all anxiety?

Mary Fristad PhD
Yes, if the parent and child have the right "chemistry". I have seen that work frequently. There are also many families for whom I would consider that the "kiss of death"-- more time between parent and child when conflict is high and everyone needs a break. And that can happen with great parents and great kids!

kalee
How young can a child be diagnosis?

Mary Fristad PhD
We have diagnosed preschoolers in our setting, but as the Rebecca Riley case illustrates (well, that case illustrates so very MANY points...), one needs to be very cautious. The younger the child, the stronger the family history that's a general rule of thumb pretty well supported by the data; although we don't have great preschool data. I should say extensive data-- what are there are good.

atiredparent
What do you think of the recent 60 minutes show by Katie Couric? What kind of impact will it have?

Mary Fristad PhD
Good and bad. Good-- helps people think through the diagnosis, helps them not just "add another pill" mindlessly. Bad-- the diagnosis can come across as a willy-nilly any acting up child gets called this phenomenon.

donna
Who are the most important 'team' players at school? In other words is it more important to have the teacher on your side or the special ed director? What is the bottom line person that you need to have 'get it'?

Mary Fristad PhD
Everyone.

The principal sets the tone for the building.
The teacher has the most contact time with the student.

The special education director sets the tone within the special ed dept and should have useful strategies or resources.  I have to say, optimistically, I am receiving many more inquiries from schools wanting to learn about bipolar disorder. Very caring staff need help knowing what to do. We are doing research in this area right now, and publishing as many guidelines as we can for school folks.

Nanci - The Balanced Mind Foundation
Do you have any recommended strategies for fostering that team in the schools? We have many families where the schools seem to resist offering support.

Mary Fristad PhD
I like to recommend to families that they print out the handouts from The Balanced Mind Foundation-- a great starting point for school personnel. I ask that the pertinent folks meet together and that the parents, if they are in a position to do so, bring in brief educational handouts to "Educate the Educators".

Mary Fristad PhD
One of the most important points is to set up ahead of time a "cool down" zone-- where the teacher or student can initiate the student going to in order to prevent a melt-down. Adjustable schedules when a child cannot get up in the am to get to school on time.

Nanci - The Balanced Mind Foundation
Good points, I know these accommodations have helped with my daughter. We have a few more school related questions and then we'll shift topics a bit.

texmom
If home schooling, how do I make sure my child has a plan for college?

Mary Fristad PhD
Some high schools can allow for summer school classes to fill the gap if a full load isn't completed in the school year.

Regarding home schooling; have your child read college guides, perhaps focusing in on those programs designed for kids with learning disabilities--- as they are more sensitized to specialized learning needs.  In general, an advantage to home schooling is that you avoid the amazing pressure cooker college selection has become for students!  Our society has many non-mental health inducing tendencies!

Nanci - The Balanced Mind Foundation

It seems our schools focus more on academics and less on social emotional growth. Are you seeing that at all?

Mary Fristad PhD
Some districts have alternative schools-- I have the good fortune of living in such a district-- solidly middle class-- and it has, I am convinced, prevented suicides in mood disordered kids who have attended these programs.  The "no child left untested" movement in this country has not helped. There is more of a focus on passing tests than academics, in my observation.

Nanci - The Balanced Mind Foundation
We have a question about 504's and IEPs,

missmech
Dr Fristad what does more to help a child a 504 plan or an IEP. I am new to public school and these programs. My son was in private school until they couldn't "handle him anymore" He is redoing the 3rd grade.

Mary Fristad PhD
504 plans are very flexible but the ones I have seen are often ignored, in the best of districts with the most diligent of parents. IEP's hold a bit more weight (and bring $$ to the district) but they are pokier to put into place.

Nanci - The Balanced Mind Foundation
Is there anything else you'd like to share about education before we shift gears and tackle the teen years?

Mary Fristad PhD
There is so much to talk about with schools-- but let's hit a few more topics.

Ah yes, teenagers. Nothing like hormones, especially when parents are going through their own set at the same time...ha!

LaraLee
My dd (dear daughter) is 15. How much is normal teen hormones and how much is truly mood disorder? The brain is still developing. Do some kids grow out of this - no longer have the bipolar diagnosis? Can they go off meds as adults?

Mary Fristad PhD
We don't have evidence that kids with an accurate diagnosis outgrow it. Regarding going off meds, I have yet to meet a teenager who hasn't tried going off. My therapeutic stance is to ask them to be honest with me and their prescriber. And to taper responsibly over the summer, when stakes are lower and not when they are making a big environmental shift, like going to their out-of-state parents' for the summer. That way, if they crash and burn, less damage occurs, and a plan can be pre-established to get them back on meds. It is helpful to keep your parent-network lively. All adolescents have their ups and downs, and parents hyper--tuned in to their children's mood states can very easily over interpret behavior.

Scooter
We have a BP 13 year old daughter who refuses to go to counseling. Any suggestions on how to get her to go?

Mary Fristad PhD
Don't make her go.  Forced therapy is probably counter productive in the end. I fear we will develop a generation of young adults with a strong aversion to treatment when they otherwise might benefit from it. In the meantime, go yourself for parent guidance from someone who really "gets" what you're going through and doesn't just think it's all about parenting.

Raising moody children is not easy! As if I need to point that out to this group...

Mary Fristad PhD
Plus, when kids know you are going to a therapist "behind their backs" sometimes they want to set the record straight.  I've had many sessions with kids plugging their ears or turning my business cards into paper airplanes. Can't say it was useful for them.

Nanci - The Balanced Mind Foundation 
That is reassuring to know because many of our families struggle with 'forcing' kids into therapy, but it's hard to let go/give in.

hopeful
How do you distinguish between normal adolescent behavior and bipolar mood driven behavior?

Mary Fristad PhD
Regarding "normal" vs "mood" behavior-- keep your parenting network alive and well. Is your child doing what "everyone" is doing? Is your child further off-base? Volunteer to drive/chaperone/etc, etc. That provides you the opportunity to (cringe) observe your child in his natural habitat and can also provide you with insights to help coach your child during a "teachable" moment. All parents benefit from that, you see it as an "exponentially important" rule for parents of kids with bipolar disorder.

texmom
What is the best way to diagnosis a teen? My child was diagnosed at 11 or 12. When my child asked her doctor if she is sure of the bipolar diagnosis, the doctor said the only way to know for sure would be to take her off all her meds. None of us is willing to do that.

Mary Fristad PhD
Look back to what led to the diagnosis originally. Other clues are family history. If symptoms of depression and mania were clearly there, you're set. If not, and if the meds are causing problems, you could try a summer taper. But it sounds like meds are helping in your case.

momof1
My daughter doesn't want to talk about her diagnosis. Any suggestions?

Mary Fristad PhD
How are other conversations with her? It may help if there are other commonalities you can share, like walking the dog, knitting, whatever that makes having a conversation seem "secondary" and less threatening. I would offer to have books available to her, see if she has questions for you. Many kids just don't like to open up at this age. It can be a temperamental thing totally separate from bipolar.

Jenny
My son is 7; at what age should I tell him his diagnosis?

Mary Fristad PhD
I believe full informed consent is important-- talk to him about his symptoms and how they aren't the "core" of him. We describe our "symptom-self" exercise in Raising a Moody Child. It is one of my favorites-- an "opener" in our therapy program. Once a family has gone through it and really internalized the messages, it changes how you deal with bipolar disorder. It isn't your rotten kid, it's the rotten symptoms. But you're all on the same team and will problem solve how to deal with them which you can't do if you don't know what they are!

optimistic
My ds (dear son) is 8 and currently rages often. What should I expect as he enters his teen years? Do children generally shift more towards depression during this time in their life?

Mary Fristad PhD
I would keep working with your child on building a "tool kit" (also described in our book)
and a good thing to work on in therapy, as well. Your child can probably gain some more control over the rages, both through meds and therapy. The more you can get things under control now, the easier adolescence will be.

donna
You made the statement " kids with an accurate diagnosis".... how do we get that elusive correct evaluation?

Mary Fristad PhD
If I were to pick one place to really put my money-- it would be on a top-notch evaluation. 
I really feel for families with crummy behavioral health coverage, but spending the $ on a thorough evaluation will help determine a long-term treatment plan. You want to know how many "piles" of problems you have to "sweep up" once the bipolar disorder is stabilized. Recheck the piles to see if they are all still standing. Some anxiety dissipates when the bipolar disorder is in check.  Sometimes it doesn't, and will need specialized treatment and the same is true for behavior disorders.

Nanci - The Balanced Mind Foundation
Let's talk a bit about sibling issues

Jenn- OH

My younger kids act just like their older brother with bipolar disorder... how do I tell if they are just modeling their older brother's behavior or if they have BP too?

Mary Fristad PhD
Ah yes, I was waiting for this {:) could be either. You will want to have a discussion with the little ones about bp, how their older brother doesn't like his problems but has to deal with them and that if they have the same problems, you will get them treatment also. But in the meantime, you are happy to give them attention for who THEY are. Make that a really clear conversation with them, then you can ask them things like "are you really feeling out of control now, or are you wishing I could spend time with you? I’d be curious to know if that helps settle things down for you.

donna
I was told once that a child will not mimic what is not in their behavior pattern anyway.... is that true? In other words if a child rages they would have raged anyway even without an older sibling to watch?

Mary Fristad PhD
But we learn by example, so younger kids will mimic. Older kids have other reactions, like wanting to separate themselves from the family. Making time for them, or finding other important adults to do so, can help a lot and educating them. I have quite a number of undergrads in my lab who are drawn to my research because they have a sibling with bipolar disorder. That's a really positive outcome, I think.

Nanci - The Balanced Mind Foundation
We have a few questions on hospitalizations and RTC’s (residential treatment centers)

mandygirl
I have a six yr old who is well in hospital and well for others he doesn’t know and a nightmare at home....Why?

Mary Fristad PhD
Our kids save the "best" for those they love the most - such a prize of parenting, huh?
If your community has high quality home-based treatment, you might ask for that. It is hard to come by. That would allow for another set of eyes and ears to be in your home  
and just like a functional behavioral analysis at school, might help point out some strategies you could try at home that would be helpful. It can be hard to problem solve if you feel like you're in a huge rut

mandygirl
How do you feel about residential placement for a 6 yr old with bp who is very dangerous as a treatment option?

Mary Fristad PhD
Check out the program-- if safe with a good reputation, it may be a viable option. A bad placement is worse than no placement, in my mind.

Nanci - The Balanced Mind Foundation
I'd like to put through as broad a cross section of topics as possible in the time remaining

teddyone
Any link between birth trauma and bp?

Mary Fristad PhD
Sure, some people have "organic mood disorders" meaning their brain had an insult of some type. Genetics is our biggest, but not our only link to the diagnosis.

Renee

Do you recommend support groups for teens?

Mary Fristad PhD

They are WONDERFUL in my experience-- but those are clinician led. Our work has been with 8-12 yr olds. It will be trickier if you aren't doing this in a clinical setting as it can take some significant behavioral management to keep the group therapeutic.

We had, on average, 6 kids per group (range was 3--awfully small to 8-- very large) therapists, a lead therapist who managed content and a second therapist who could help manage kids and we were in a secure facility which kept me from being nervous on group night {:)

Bally

Do you think charting moods, or journaling comparisons with adult and child’s views of self are important methods of self awareness?

Mary Fristad PhD
They are GREAT! It is important, when doing this, that the parent doesn't convey, however, that their ratings are "correct" while their child's ratings are "interesting".

vicky
My daughter is 15 and BPII/NOS/OCD/ODD and hypersexual. How to handle that?

Mary Fristad PhD
That is a complicated pile (of diagnoses) and needs both you and your daughter working together to tackle the piles. I would start with mood stabilization but quickly addressing the OCD with ERP (exposure-response prevention) will be important because these two disorders can ignite each other. The hypersexuality is part of the mood, and again, our current TV shows/culture don't help. When fashion for 6 yr olds can be to look like a...

mandygirl
How do you stand on punishing a child for something they did wrong due to their bp?

Mary Fristad PhD
I always hold the line on safety. Rather than taking a "punishing" stance, though, I like to turn it around to "what will help you manage your symptoms better in the future". If they did something really bad when really manic and now regret it that is often punishment enough. If they deny they have a problem, then a consequence is more helpful to make a point. Or, more clearly, pointing out what their manic behavior has "cost" them.

tgim
My 9 year old has few behavior problems at school (starting to have learning problems though) and as soon as he comes home - the rage starts. How can he be so good from 9-3? Can a child with bp really hold it in for that long?

Mary Fristad PhD
It is easier to believe in children with tics who don't tic all day, then tic when they come home but the same thing can happen for kids with bp. It just LOOKS more interpersonal than neurologic. Kids don't want to look bad in front of peers. It’s part of how public education actually works {:)

jerrypb
Many professionals say that our only child (bpd and adhd) is doing everything he can do to cope; that to introduce a new sibling (even an older adopted child, which is what we've discussed) might be more of a problem than we realize. Yet, we imagine that it could, as in any home, go either way, and possibly be a stabilizing force and secure deep bonds of love and family after our death. Thoughts? Any research on bpd kids/adults benefiting from sibs?

Mary Fristad PhD
Older adopted children often (usually?) come with their own bag of issues. I hear your fear, though, of leaving an only child with an illness "untethered" in the future. Are there other family relationships that could be strengthened? Cousins/aunts/uncles?

Nanci - The Balanced Mind Foundation
We have time for one more question and then some closing remarks

CJ
What is the most promising research "frontier" right now in your opinion?

Mary Fristad PhD
All of the work going on-- neuroimagining, pharmacologic trials, psychosocial trials. Oops, neuroimaging; quite the freudian type-slip {:)

Mary Fristad PhD
I wish you all peaceful moments, remember to take care of yourselves otherwise you will never be able to stay in this marathon. All the best to all of you

Nanci - The Balanced Mind Foundation
Dr. Fristad, I would like to thank you very much for taking the time to chat with us and share your experience and insights

Mary Fristad PhD
you're welcome

Nanci - The Balanced Mind Foundation
We very much appreciate your work and efforts for our children.  Thanks to everyone for attending and we'll have transcripts available on line.

Mary Fristad PhD
Thanks and thanks to The Balanced Mind Foundation, what a wonderful organization!

Nanci - The Balanced Mind Foundation
Thank you!