Parenting an Unstable Child with Bipolar Disorder
*First and foremost, understand that this is a chemical imbalance of the brain, a genetic, neurobiological brain disorder that often mimics a behavior issue or parenting issue. Some of the newest research is focusing more on the intracellular level (neuron) more so than what is taking place outside of the neuron between the neurotransmitters (chemicals) as they make their way to the neuron. Because the “target” of your child’s symptoms (disruptive behaviors) is typically you, the parent (a safe-haven who offers unconditional love and support), it can appear to “outsiders” that you are to be blamed or partially to be blamed for your child’s behavior. (For those who feel a lack of “normal”, effective parenting skills, check with your area’s community resources. It’s better to ask for help (prevention/intervention), than to find yourself in a negligent or abusive situation, worsened by the stressors of raising an ill child.) Some communities may offer resources to parents dealing with children with bipolar and other neurobiological brain disorders. For example, in Ohio, NAMI (National Alliance for the Mentally Ill) has developed Hand-to-Hand training to help parents learn about these types of brain disorders and the “systems” in the parents’ communities.
*Start where your child is. Is the child refusing OR unable to cooperate? Look at underlying causes. A child may refuse to do something to “save face” (such as refusing to read because he/she perceives himself/herself as a “poor” reader) because it is beyond his/her ability. As the child develops and begins to recover with the proper treatment for their individual needs, he/she will need to begin to accept that everything does not “revolve” around him/her and that often an activity will need to end without any “heads-up” from you. However, this is very individualized, as some children will have difficulty in transitions no matter what, as well as potentially having adverse reactions to many of the psychotropic medications. Stay flexible, while setting boundaries that are practical for your situation. Consequences should fit the individual child’s ability to understand their actions.
*Understand that children with bipolar often have distorted perceptions of reality. They may actually believe something to be true when it is known by others to be untrue. They may make up stories which are believable to others, or they may know the truth but attempt to make others believe them. When asked, some children will state that they tell “mistruths” out of boredom or because it makes them feel powerful. Other children may be having delusions and/or hallucinations. Speak to your child’s therapist and/or treating doctor about these issues.
*Learn to “pick your battles”. If you haven’t learned already, you’ll be saving yourself from major health problems by evaluating what is and what is not important in raising your ill child. When the child is at his/her most unstable, it is often best to “let go” of what you would consider “normal” parenting, while keeping the child as safe as possible. When deciding on whether to pursue a behavior issue, whether it stems from the child’s illness or not, the parent will need to prioritize the importance of different issues.
*Document (chart/journal) your child’s behaviors, mood swings, sleeping cycles, menstrual cycles if applicable, statements made and anything that may have precipitated a mood shift, such as setting limits (The parent stating “No” can “set-off” a child with bipolar). You can do this on a big, blank calendar or use a mood chart. Because many children with bipolar cycle throughout the day, exhausted parents can simply jot down the most pertinent information, giving examples: [Johnny stated, “I want to die and go to heaven”; Johnny stated, “I can’t control my thoughts….that’s why I broke my favorite toy.”] Remember to jot down these statements and the date and time as soon as you can, since it can be difficult to remember exactly how they were stated. This information can be helpful for the doctor, showing a pattern of the cycling. Praise your child for his/her insightfulness into his/her disorder and continue to encourage him/her to report these feelings to you.
*The adults should be consistent with one another when dealing with children with bipolar. It’s very common for a child or adolescent with bipolar to attempt to “stack” one adult against another adult. Recognize that children with bipolar will often use defense (coping) mechanisms by putting up “barriers” to avoid dealing with a scary/uncomfortable situation. It is common for a child to call a parent or professional inappropriate names or to say one thing to one adult and say the opposite to the other. (ie. To the therapist, a teen may state, “My mom said that you were a stupid jerk and doesn’t know why I have to come here weekly.” And the child may state to the mom on the same day, “The therapist told me that you don’t know how to parent me and need to take parenting classes.” Though it certainly is common for these statements to be made, many times it is the child who is attempting to sabotage the situation) When the adults recognize these coping mechanisms and keep in contact with one another, it can immensely decrease tensions between those adults who are attempting to help the child. This includes significant others, doctors, therapists, teachers, social workers, etc. The bottom-line is that, although the child may want to feel better, he/she may never express this, and may try everything they can to sabotage a situation to avoid having to deal with an issue.
*Document the child’s biological family history on all four sides, if possible. Who has bipolar, schizophrenia, depression, obsessive-compulsive tendencies, odd behavior, alcohol/drug issues, attempted or completed suicide, etc.? Foster and adoptive parents should make every attempt at getting the biological family history through the agency. Even knowing “bits and pieces”, such as a biological family history of drug/alcohol abuse or receiving information that a family member was in a state hospital, can be very helpful for the doctor. For foster and adoptive parents, check with your area’s laws for privacy issues regarding this.
*Don’t compare your child to another child with bipolar. Each will have individual symptoms and needs. For example, many children with bipolar do not have rages, hyper-sexuality and/or hallucinations.
*Take care of your own basic needs, so that you will be able to take care of your child's needs. If you find it hard to take care of your own needs, think of it as ultimately helping your child.
*Remember to breathe naturally. Parents often are so consumed in finding help for their children, that they do not recognize their own body’s ‘SOS’ symptoms. To relax, find a quiet spot (usually when your child is sleeping), sit up tall (can sit Indian-style), close your eyes, close your mouth, and slowly breathe in through your nostrils slowly (as if you are appreciating a beautiful rose). Hold it for 2 seconds, and then slowly release, parting your lips slightly. Do this 3X.
*Strive to find the right medication or combo of medications for your child's individual needs. Each child differs, and what works for one, won’t necessarily work for the next.
*Stimulants and/or anti-depressants can, and often DO worsen a bipolar condition, at least when the child is not stabilized with his/her moods first. Worsening behaviors may be increased mania, depression, suicide attempts or suicides. Many children can successfully trial stimulants AFTER their moods are more congruent. However, many children will also be unable to tolerate stimulants. There are non-stimulants that might be beneficial in those cases. Discuss your concerns with doctors who want to prescribe a classification of medication that is not geared towards mood stabilization. It may be necessary to find a new doctor who better understands, recognizes and has a successful track record (for the most part) of treating children with bipolar.
*For those professionals, particularly doctors who refuse to acknowledge and/or treat bipolar in children, offer them literature in the Learning Center at www.thebalancedmind.org. For those who feel that children cannot be diagnosed with pediatric bipolar (currently the criteria is not in the Diagnostic Statistical Manual for younger children (The DSM is the book that doctors use to diagnose “mental” illness), refer them to the National Institute of Mental Health Research Roundtable on Prepubertal Bipolar article. This article states that childhood bipolar can now be (since 2000) diagnosed using ‘Bipolar Disorder NOS’ (Not Otherwise Specified). Some diagnosticians will flatly refuse to diagnose bipolar in children, stating that they do not want to “label” the child. The professional needs to understand that, you, neither, want to “label” the child, but rather want the child to be properly diagnosed so that the appropriate treatment that matches the child’s symptoms can begin. It is unethical for a treating doctor, who suspects bipolar in a child, to prescribe medication that is known to potentially induce or worsen bipolar symptoms (such as stimulants or antidepressants) in order to make a diagnosis of bipolar disorder. This is a somewhat common occurrence and can lead to not only worsened symptoms from these other classifications of medications, but also can lead to suicide. Many doctors simply do not understand the potential ramifications of such actions and need to be educated on this issue.
*In general, it is best to seek out a pediatric psychiatrist since they take additional years of schooling to work with children. Due to a lack of pediatric psychiatrists (there are only approx. 6,300 in the U.S., with a need for approx. 30,000), however, this is not always possible. Some parents will seek out an expert in pediatric bipolar, often hours away, to get a thorough evaluation and then have the expert confer with an area doctor for follow-up treatment. Some parents will seek out a research hospital and/or look into research trials. These are often at no or little cost to the family if the criteria is met. (Research trials can be found on www.thebalancedmind.org on left blue bar.) Some doctors prefer to take a “backdoor approach” and first treat the bipolar symptoms to see if there is a decrease in symptoms. If so, they then would make the bipolar diagnosis. The typical first-line treatment would be a mood stabilizing agent. Some of the atypical anti-psychotics are also starting to be used as mood stabilizing agents alone or as an adjunct. In general, any residuals (leftovers) of other symptoms such as ADHD or depression often can be cautiously treated with other classifications of medications after mood stabilization has occurred or mostly occurred. Speak to the doctor about options when there are residual symptoms.
*As a last resort in getting a proper diagnosis and treatment (due to the doctor not recognizing/observing the symptoms) a parent may want to cautiously try video-taping the child’s rages and/or other bipolar symptoms. The parent needs to be very careful with this strategy since the child may find the camera and become upset. Ideally, at least two adults should be on hand. The camera ideally should be small enough to fit in a palm of a hand and put somewhere in which the child cannot see it. Any red lights should be covered and batteries should be checked. The camera should be positioned in an area of the home in which the child is known to exhibit behaviors from their illness. The parent should not “egg on” (provoke) a situation, but rather should simply parent the child in what would be considered an accepted manner. Note that extra precautionary measures need to be taken with older children. Use common sense and your parental intuition when weighing the risk factors in video-taping. It’s best to discuss with the doctor before using this as a resort. Foster parents should ask their county workers about the possibility of video-taping prior to doing so.
*Remove all objects that could be considered dangerous to your child and lock these items up or remove them from the home. This includes guns and any sharp objects, sheets and cords that could be used to tie around a neck, etc. Lock up the medications. Ideally, any potential weapons should be removed from the home when your child’s moods are unstable. Those who refuse to remove guns from the home should understand the potential occurrence of suicidal and/or other dangerous situations. Guns should never be loaded and bullets should never be in the same area of the home as the gun. The risk of suicide attempts and suicides are too high in children with bipolar to not take these precautions seriously.
*When your unstable child is cursing or being abusive in other ways, take a deep breath and count to 10. Walk away to compose yourself if necessary (Disengage).
*Know how to potentially redirect a meltdown. (Meltdowns can be considered as something that has the potential to become a rage, but is less intense.) During a meltdown the child is possibly starting to become upset, possibly throwing an object, while with rages the child is possibly throwing multiple objects, being uncontrollable, possibly ripping off posters off the wall, bouncing non-stop on the bed, using physical contact to hurt self, others or objects (ie., banging head on wall continuously). Some ways to redirect a meltdown: More than anything, simply know your child’s “trigger points”: What sets him/her off? Don’t “challenge” your child (very difficult, especially for parents with bipolar themselves). Don’t necessarily avoid the trigger points (if they are difficult to avoid in every-day-life), but instead, find ways to decrease a hostile response. Disengage from your child in a non-threatening manner when he/she is irrational.
*Check to see when your child ate last. Protein is very important for children with bipolar. When their sugar starts fluctuating, a meltdown may start to occur. Ask your child when the last time he/she ate and what it was. If your child is starting to melt down due to limit-setting (such as telling the child, "no"), try offering two choices instead. "John, would you like to go to the video store with me to pick out a video or would you like to stay home instead?" Don't make a "big production" out of it…just simply ask the question in a neutral, inviting manner. It’s also important that the parent does not allow the child to “reel” the parent in. If a parent calls the child down from the bedroom for supper, the parent should not stick around to listen to the child attempting to “sabotage” the situation. (I HATE chicken! You’re stupid!!!”---when the parent knows this is the child’s favorite food) A meltdown can often be quickly redirected by the parent making a simple, matter-of-fact, non-threatening statement during the meltdown such as, “Katie, let me know if you want a chicken sandwich. Dad’s going to drive to our favorite chicken place. I’ll be downstairs doing the laundry if you want anything from there.” And then the parent simply leaves the area. The child will often “come around” within 0-10 minutes. This does two things: allows your child to make his/her own choice without having an “audience” to “attack”, as well as getting your child the necessary protein in his/her system, potentially decreasing or eliminating the meltdown. The bottom-line is that a meltdown can be potentially decreased or eliminated by the parent making simple, non-threatening communications and not allowing (not engaging) the child with the opportunity (by limiting time) to “attack” verbally, emotionally or physically. By engaging your child with something that he/she is highly interested in, a rage can be avoided.
*Understand that, while meltdowns can often be redirected, rages typically need to take their "course", just like a tornado or hurricane...it just has to go through a (sometimes destructive) path before things are calm again. (Rages can last typically from 20 minutes to 2-4 hours and often occur in the home with only one adult available) It's important to keep an eye on your child during raging to ensure that he/she is as safe as possible; however, interfering during a rage can get the parent, other bystanders or child hurt. Once your child starts to calm down, he/she may respond to a parent who talks calmly, quietly, in a neutral tone and does not say anything that could be perceived (to the ill child) as disrespectful or condescending. If the parent feels safe, it is typically best to be physically at the same level as, or lower level than the child. (ie., sit on the bed if the child is sitting or sit while the child stands) This decreases the chances of the child perceiving the adult as someone who is attempting to control/overpower them. Typically, for the younger child, a parent can ask if he/she wants to be held. Often the child does, but cannot verbalize it, while others are "touchy" (possible sensory issues) and may start becoming more agitated. Some younger children (and sometimes, older children) like to be hugged or held. Back rubs or back scratches may also be helpful. Lavender oil is known to have a calming effect and can be used for back rubs or in the bath tub. The bottom-line is to become aware of how your individual child responds to you and what techniques work and which ones do not. This often allows your child to calm down and allows him/her to know that you love and accept him/her unconditionally. Once your child’s moods are stabilized, your child has the potential to “unlearn” negative behaviors that he/she may have developed (coping mechanism) while unstable. Sometimes this will take therapy, but many parents can help the child deal with behaviors once the moods are stabilized.
*Always strive to remain calm, cool and collected when your child is out-of-control. Do NOT raise your level of tone to his/her level. (It may feel good for the moment but it will only exacerbate the situation). Instead, keep a neutral stance and speak with a soft, lowered voice. (ie. don't "feed" off of one another). (Many parents use specific techniques such as ‘Low Expressed Emotion’ [LEE]) If your child is doing something that you consider unacceptable, simply state that it is inappropriate and ask him/her, in a civil manner, not to do it...then walk away and do your other activities, such as washing clothes, making dinner, etc. If your child follows you around the house, but is not being disruptive, allow him/her to do so, while you continue to work around the house. If your child starts to attempt to "egg on" a situation, you should not allow yourself to be negatively influenced by it. Simply repeat in a matter-of-fact tone that, what your child did was inappropriate. Do not focus on your child's behavior at this point. If the situation worsens, you may be successful in having a younger child lie down on the couch, etc. until he/she can calm down. Preadolescent children may need to go into another area of the home to “settle down”. Often they will state to the parent later, “If you just give me some time, I’ll be fine…don’t keep yelling at me!” This personal insight is invaluable and can allow the parent and child to find some common ground about how to deal with meltdowns. Allowing the child to come up with a plan can help build his/her self-esteem and be part of his/her maintenance plan, such as the child stating, “Give me 10-15 minutes of alone time without you yelling and I should be okay by then. When I come out of my room, you’ll know I’ve cooled down.” For older teens it can get quite tricky since they are transitioning into adulthood and may try to undermine the parent’s authority even more than the younger children. (“You can’t do anything, I have rights, you know! I’ll just stay with my friend tonight! If you try to stop me, I’ll call Child Protective Services on you!!!”) Using a balance of boundaries, compromise and respect is critical. Setting basic house rules without sounding like a “drill sergeant” is ideal. For all age groups, learning to work with the child on his/her behaviors may take some adjustment time, while your child is trialing different medications, but it may help him/her understand that some behaviors will be unacceptable, whether he/she is cycling or not.
*If your child is out-of-control in a way that he/she is being harmful or potentially harmful to him/her or other family members, privately talk to the hospital and/or an ambulance service and explain the situation. Don't allow your child to hear the conversation since it may get out-of-control before an ambulance arrives. If your child is young and not overly strong, an ambulance may suffice. If your child is older and is difficult to physically handle, police back-up may be necessary. Ideally, before a situation such as this potentially occurs, try scheduling a trip to the police station with your child, so that, if the police become involved (through you or a neighbor, etc.), they will have a better understanding on how to effectively handle the situation. By offering police officers some effective tips, such as asking them to talk in an even-keel, non-threatening tone, you are helping your child establish a rapport with the police officers, as well as educating the police officers on these types of serious matters.
*Do NOT attempt to drive your vehicle when alone with a raging child. Many children with bipolar who are unstable have a tendency to attempt to jump out of moving vehicles or to "attack" the driver. If you happen to find yourself in this situation, make an effort to pull over to a safe area off the road before stopping (preferably in a low-traffic area). If it is necessary to drive, try to bring at least another adult (who is physically and successfully able to control the child) in case this occurs.
*Understand that most communities will use the least restrictive services first, exhausting all of the community services before attempting more intense services. For example, your community resources may start off with utilizing a social worker or therapist first. If those professionals feel that a psychiatrist is necessary, they may make those recommendations. If, after working with a psychiatrist, making little progress, the group of professionals may discuss ‘wrap-around’ services, pulling in more services from the community and working on a solution as a team for those children at risk in the community. Prior to discussing RTCs (residential treatment centers) as an option, try to work with a child psychiatrist to figure out the best treatment regimen for your child's needs. Parents need to be able to relate when their ill children are expressing (verbally or otherwise) signs of the child wanting to hurt themselves and/or others. Hospitalization may be the best option at that point.
*Check local areas for respite care. Easter Seals is one place that offers respite services in many areas. It's important to find out the cost of the service. Some respite care providers will allow a sliding fee scale or will offer respite at no-cost to parents who meet the financial criteria. Local colleges also may be willing to offer respite through students majoring in programs which entail working with special needs children. For those lucky enough to find a good “match” with other area families, it can be a great opportunity to share respite with one another.
*Check for local support groups for caregivers of children with bipolar. Your local United Way Info and Referral Agency or county’s Mental Health Board may be able to refer you.
*Don't feel guilty about your feelings of sadness, anger, frustration, disappointment, etc. These are all natural feelings and it's healthy to discuss them with others. For more serious thoughts or actions, parents should contact their medical professional. It's natural to go through the stages of the grieving process, just as if a parent has lost a child physically. The difference often is that parents dealing with children with bipolar may feel that they are going through the grieving process 1000X over, as the child's moods rapidly change. (roller-coaster riding)
*Learn to laugh and have a sense of humor (appropriate, of course!). If you don’t have a sense of humor, learn to acquire one. If you don’t laugh, learn. Take brisk walks. By doing these things you will release endorphins, the chemicals that decrease depression and lift the spirits.
*Some things that have been helpful to families with children with bipolar: soft music, a favorite tape/CD, massages, pure lavender oil in a warm bath or used as a massage. There are also children's books in the www.thebalancedmind.org bookstore that may help the child relate to and accept his/her illness. It’s also helpful to accommodate the child’s ‘inflexible mind’ by giving him/her enough time to end an activity, such as playing video games or watching television by giving them a 10-15 minutes “heads-up”. Setting an egg timer can do wonders.
*Don't give up hope. There are many medications and combos of medications that can be tried, as well as many new medications coming out in the future.
*Understand that all children (and all people) manipulate in order to get something. It’s human nature but has taken on a negative connotation. It’s doubtful that the human race would be able to survive without people manipulating their environment. The difference with many ill children with bipolar, is that they often do not feel in control of anything, especially their brain functioning. If a parent thinks about the lack of control that children with bipolar may feel in all areas of their lives: being told when to go to bed, when to get up, when to go to school, being told to do schoolwork and housework, having peer-activity restrictions placed on them, feeling no control over their behaviors...it's no wonder that that they will manipulate to protect themselves from their environment. Refusing to do something or acting or lashing out, is often a way for children with bipolar to feel in control. Often they feel badly afterwards and may express remorse. It can be very beneficial to relate this to professionals and other adults who will tell the parent that the parent is being manipulated by their child. You don’t need to say, “No he is not!” (That will simply make a parent appear defensive and in denial). Instead, simply state calmly and matter-of-factly something such as, “Yes, you are right, my child manipulates…we all do…but, for the most part, he is likely doing it to protect himself from his environment and to gain some control over his life. Can you imagine feeling out-of-control of every instance of your life, including your emotions stemming from a brain disorder? Hopefully as his moods are not cycling as much, my child can learn how to cope with his illness in a more effective manner.”
*Go “straight to the source”. Many adults will be amazed at what they can find out when they discuss the child’s illness and behaviors with him/her. An adult (parent, teacher, police officer, social worker, doctor, therapist, etc.) often can get the best feedback from the child when the child is treated as a partner of the recovery process. Establishing a rapport and respecting the child’s feelings and feedback is critical. Find a quiet area, away from others to discuss issues with the child. Talk in a neutral, respectful, matter-of-fact manner. For school-age children, an adult might say something such as, “Katie, I can’t imagine what you are going through. I wish I knew, but since I don’t know your thoughts (and/or “I don’t have bipolar), it’s hard for me to understand. All I know is that we all have different challenges we have to face, and that, at least in some ways I can relate to you because of my own challenges I have had to overcome. When I was younger, I remember how I felt when I found out my dad left our family. People kept trying to help me and I kept screaming at them to get away from me. I think I was about your age when that happened. I knew they could never fully understand my emotions I was feeling at that time. Even though I know I can never fully understand, I want to learn and appreciate more about what is going on with you. Can you help me understand?” Offer some coping tips in times when the child is unstable or semi-unstable with his/her moods. The best time to discuss ways in which to cope is when the child is in a "normal" period of their illness (Euthymia), which may occur rarely if the child cycles rapidly and continuously, or if the child is on medication that is inappropriate for the primary symptoms. In general, do not “sugar-coat” the illness. Your child has to live with the illness and it helps him/her to understand that, although it will be a struggle, his/her situation can improve with the proper treatment. At the same time, it’s imperative not to inundate the child with too much information that may overwhelm him/her. Use age-appropriate discussions. Form an alliance with your child and discuss coping strategies which may work for his/her individual needs. This may be the foundation that your child needs in order to start feeling in control again.
*Help your child establish a way to document their moods and feelings. (Mood Charts for children can be found on www.thebalancedmind.org...left blue bar in the Community Center. Many psychiatrists and agencies will also have charts) Put each chart in a safe place, possibly using clear plastic shields, in case your child later tries to rip it up.
*Learn to recognize that this illness can be difficult for many people to understand and accept. Because the illness often manifests itself as a behavior or parenting issue, it can be difficult for people to differentiate between the illness and a true behavior issue. While you are learning how to cope with your child's illness and your own needs, try to also educate family members and others who work closely with your child, and who appear to not understand the illness. For those with significant others who refuse to see their child’s behaviors as a bipolar illness, it often is helpful to put some short, easy reading material in the bathroom or other place where there would be undivided attention. Book-marking and highlighting a page from The Bipolar Child book or other reading material and sitting it on a stool beside the toilet can do wonders. This offers your significant other the chance to read material that he/she may otherwise be hesitant to read in front of you. (It’s best, of course, to remove or put out of reach other “more favored” reading material.) They do not need to know that the purpose was for them to read it. It could be just you catching up on some reading. It is their choice as to accept your information or not, and it is up to them to deal with it in their own way. The best that parents can do is to attempt to educate themselves and others while continuing to strive for mood stability in their ill children. Put your "horse-blinders" on and keep your focus on the prize...which is to find the most appropriate treatment for your child. There is little time or value in allowing yourself to be dictated by guilt, whether deriving from yourself or others. Strive to overcome it. Your ill child's life and childhood are much too precious to allow guilt to be a hindrance to his/her recovery.
*Lastly, remember that you are human, often doing a super-human job. There are few others who have an impressive parenting “resume” such as yours. Appreciate all of your parenting accomplishments whichothers who have an impressive parenting “resume” such as yours. Appreciate all of your parenting accomplishments which you have achieved in raising a child with bipolar.
Debby Rohr (Author)-Licensed Social Worker and parent of a child with Bipolar Disorder
As long as my name and this info is listed, those who wish, may make copies of the above tips and pass them out to parents/caregivers, family members, friends, professionals and others who may benefit---for personal or educational purposes. Professionals such as doctors, therapists, social workers or police officers can easily adapt many of these tips/techniques when dealing with unstable children with Bipolar Disorder and other children with disorders, such as Conduct Disorder and Oppositional Defiant Disorder. Those wanting these tips in a Word document can e-mail me at the above e-mail address. Updated June 2004