"Techniques for Dealing with a Bipolar Child " By Julie Ward Mood: Manic  Symptom: Distractibility Signs: Flitting from one activity to another, not able to answer when called, unable to finish a task, unable to sit still or stay in one place for very long Techniques / treatment: Resist the urge to force the child to complete the task at hand Take a 10 minute break from the task Practice concentration in small increments (1 minute or less at a time) on a certain subject or object such as maintaining eye contact. Reward the child for completing small segments of a particular task instead of insisting that the entire task be completed for a reward. Mood: Manic Symptom: Sleep Disturbance, reduced need for sleep Signs: Unable to fall asleep, unable to remain asleep, awaking very early, increased energy despite lack of sleep Techniques / treatment: (Parents) Talk with your psychiatrist about a medication for aiding with sleep such as Trazodone, Benadryl, a benzodiazepine, chloral hydrate, Remeron or an increase in an antipsychotic. (Parents) Have a bedtime ritual in place that includes a set bedtime, warm relaxing bath and spending time with the child reading or rubbing her back. Turn off all lights and play soft music. (Parents) Insist that the child stay in her room. She is not allowed to come out of her room for any reason except to go to the bathroom. (Parents) It may be necessary to lay down with the child in her bed until she falls asleep. (Parents) You may want to consider allowing the child to sleep with you if she absolutely will not fall asleep any other way, or for safety reasons. Do not allow the child to take a nap during the day. This will reinforce the irregular sleep pattern. Mood: Manic  Symptom: Grandiosity or Delusions of grandeur Signs: the child seems to think he is better (bigger, smarter, stronger) than anyone else, he believes they possess supernatural powers, he acts as if he is god or boss and does not listen to authority, the child has exaggerated confidence or self-esteem Techniques / treatment: (Parents) Talk with your psychiatrist about adding or increasing an antipsychotic medication. Do not play into the child's delusion or fantasy, but do not directly contradict him, either. Simply acknowledge his statements and redirect him to reality. (Parents) Talk with your psychiatrist about adding or increasing an antipsychotic medication. Help the child calm down by reducing stressful situations. Reduce stimuli (no TV, video games, no noisy classroom if at school, remove from a visually stimulating classroom) and use calming techniques such as playing soft music and reading aloud to him. Take a picnic in a quiet location. Teach the child meditation. Have him concentrate on one good thought and explore that thought. Have him tell you the story of the thought. Use relaxation / guided imagery tapes. (Search Amazon or google.com for guided imagery for children.) Mood: Manic Symptom: Increased energy / goal-oriented activity Signs: hyperactivity, interest in rearranging furniture, housework, puzzles, homework, or other goal-directed behavior Techniques / treatment: (Parents) Resist the urge to medicate with stimulants. This is not ADHD, most likely. Do not allow caffeine in the diet. Teachers: do not allow sugary treats or chocolate, and no sodas. Allow activities that will burn off energy - get him out of the house (supervised). Swimming, trampolining, running, playing on the playground... are all good exercise for an active child. Put goal-oriented behavior to good use. Channel activities toward completing chores, cooking, puzzles, homework, etc. Mood: Manic Symptom: Rapid speech / pressured speech Signs: stuttering, very fast speech as if the mouth is exploding from the fast thoughts coming from the brain Techniques / treatment: Do not ask the child to slow down. Instead, model the behavior you wish her to emulate. Speak slowly and ask the child to imitate you. Interrupt after she has finished one thought and ask direct questions (You said 'xyz', right?, What did you mean by that?) Be patient with a child with pressured speech. Word recall is often poor. Resist the urge to chime in. Mood: Manic Symptom: Risk taking behavior Signs: jumping out of a moving car, trying to fly, running into traffic, any risky behavior in which the child seems oblivious to the dangers involved Techniques / treatment: (Parents) Talk with your psychiatrist about adding or increasing an antipsychotic medication. Closely supervise the child at all times. Restraint may be necessary. Remove the child from dangerous situations. Try to confine him to his room or another safe place. Avoid using the child's name. This will aggravate the situation. Speak in a low, calm voice. Do not give commands. Try to talk as little as possible. Mood: Manic Symptom: Hypersexuality Signs: inappropriate touching, inappropriate sexually explicit language, masturbation, obsession of the opposite sex Technique / treatment: Supervise the child at all times. Remove the child from potentially harmful situations (keep child away from siblings, other children). (Parents) Allow the child to be by herself in her room, and do not attempt to prohibit masturbation. Insist on arm's length distance between the child & other people. Use a hula-hoop to teach proper boundaries. If the child invades another's space, give her a "boundary maker" by making her wear (carry around her body) the hula-hoop for 15 minutes to remind her of her boundaries. Mood: Mixed Symptom: Aggression / Destruction of Property Technique / treatment: (Parents) Talk to your psychiatrist about the use of a PRN (as needed) medication such as an antipsychotic or benzodiazepine to calm the child. Physical or chemical restraint may be necessary. Remove the child to a safe place such as his room or outdoors (supervised). If at school, have a teacher's aide take him to the library, cafeteria or out doors (to a non-punitive place) to calm down. Teachers: If the child is in "lock-down" mode and cannot safely be removed, evacuate the classroom and have at least one adult, but no more than three adults remain with the child. Insist on the arm's length rule (child can get no closer than an arm's length to another person). Use a hula-hoop to teach proper boundaries. If the child invades another's space, give him a boundary maker by making him wear (carry around his body) the hula-hoop for 15 minutes to remind him of his boundaries. Substitute a pillow or other soft object for the child to take out his aggression on. Hang a punching bag (the kind boxers use) in the garage or basement. Mood: Mixed  Symptom: Raging / Cursing Signs: increased whining, grunting or growling may escalate to a rage, a glazed over look may come into the child's eyes, incoherent speech, cursing Technique / treatment: Ignore the cursing! Talk in a low, calm voice. Avoid using the child's name. Avoid talking at all if possible. Mood: Mixed Symptom: Oppositional behavior with high energy Signs: the child refuses to comply with authority's wishes, the child may become passive/aggressive by seeming to comply with wishes then destroying property or other form of sabotaging the situation Technique / treatment: Do not argue with the child. Do not force the child to comply with your wishes. Do not threaten with ultimatums. Calmly tell the child what you expect of her, then walk away. Give her time to process the information. Later, come back and reiterate your wishes. She may have calmed down enough to comply. If not, offer a reward for completing the task. Offer another task in lieu of the original task. Have her choose between the two. Allow her to cool off in her room or another safe place until she can decide to comply If the child cannot compromise, put the issue in basket C (explained at the end of this article) and let it go for now. Do not push the issue unless it has to do with the child's safety. Mood: Depressed Symptom: Anger Signs: irritability, anger, opposition to authority, anger may or may not have a direct cause Technique / treatment: Avoid talking with the child as much as possible. Do not argue back. Allow him to cool off in a safe, non-punitive place. Remove / reduce all stimuli and stressors to avoid escalation to a rage. Mood: Depressed Symptom: Withdrawn / Anti-social behavior Signs: the child prefers to be alone, may be irritable or angry or extremely sensitive, will not play or play well with others Technique / treatment: Encourage the child to talk about her feelings. If the child won't talk, ask her to draw what she is feeling. Do not leave the child unattended if she has exhibited feelings of suicidality. Try to facilitate 1:1 interaction with another child. Games where no talking is required may be best to begin with so the children can warm up to each other. Mood: Depressed Symptom: Suicidal Ideation / Suicidal Talk Signs: the child states that he/she wishes he were never born or that he/she were dead, may involve planning (talk about a method of suicide) Technique / treatment: Do not leave the child unattended! (Parents) Call your psychiatrist immediately and let him/her know exactly what the situation is. (Teachers / others) Call parents immediately and let them know exactly what the situation is so that they can call the psychiatrist. Lock up all knives, weapons, medications and other harmful substances & objects. Keep child away from all objects that can be potentially used as weapons in the classroom (rulers, pencils, desks, staplers, umbrellas, etc.); this may mean removing him to a small room (counselor's office) or a fenced out doors area. (Parents) Ask about possibly adding Lamictal for bipolar depression if the suicidal ideation and depression continues for more than 2 weeks. Mood: Depressed Symptom: Suicide attempt Signs: strangulation with cords, belts or other rope-like objects, running into busy traffic, overdosing on medications, slitting wrists or throat, consuming poisonous or toxic items Technique / treatment: HOSPITALIZATION • Parents call 911 and rush the child to the Emergency Room for medical care, then admit to the psychiatric unit • Teachers / others, call 911 first THEN call the parents. Mood: Any / All Symptom: Psychosis Signs: bizarre behavior, talking to people who are not there, the child may talk about specific hallucinations, confusion Technique / treatment: (Parents) Talk to psychiatrist about increasing or adding an antipsychotic. Encourage the child to fight back against command auditory hallucinations. Tell her to yell "no" to voices that tell the child to harm herself or others. Constantly reassure the child that the hallucinations are not real. If the child is delusional, keep her safe from attempting anything dangerous or bizarre such as attempting to fly or drive. Mood: Any / All Symptom: Separation Anxiety Signs: the child cannot bear to be alone for an extended length of time (often as short as 5 minutes), extremely clingy, becomes very nervous in novel situations, physically attached - lots of hugging, clinging, touching, the child may be afraid that the parent will abandon him Technique / treatment: Encourage the child to spend at least 5 minutes of time alone per hour. Increase this in 5 minute increments each day (or every other day, or even slower depending on the severity of your child). Give him interesting, engaging activities to occupy his time for those 5 minutes. Find another adult to care for the child, giving the mother (or object of attachment) a break. Hire a teenager to play with the child. Encourage other social interaction. Hire a mentor at a local college or university. Try the education or psychology departments. Some students would consider mentoring in exchange for room and board. Enforce the arm's length rule. Use a hula-hoop to teach proper boundaries. If the child invades another's space, give him a boundary maker by making him wear (carry around his body) the hula-hoop for 15 minutes to remind him of his boundaries. Insist that the child ask permission before hugging or touching. Mood: Any / All Symptom: School phobia Signs: the child refuses to go to school, rages or tantrums when entering school, rages or tantrums at school, withdrawn social behavior Technique / treatment: Do not threaten with ultimatums if the child refuses to go to school. State firmly what is expected. Carry on as if the child will attend school. If the child is severely unstable, it may be best to keep him home from school. Consult your psychiatrist on this issue. Many times, a child will be oppositional in the mornings, yet pull it together and be fine at school. But if a rage ensues over getting to school, or if the school calls repeatedly over behavior, you know that your child is too ill to attend school. Sometimes a shortened school day may reduce stress over having to attend school. Hold an IEP meeting to determine what, if any, accommodations may be made to better serve the child at school to make it a more welcoming environment. If the child does not have an IEP, request testing for one in writing as soon as possible. The law states that testing must be done at the parents' request within a certain time frame and that the results must be presented to the parent in a meeting to determine eligibility for services. At school, reduce stressors and stimuli that may trigger rages or behaviors. Do not make undue demands on the child. Teachers may want to delay testing or allow extra time on tests if they are on the schedule. Teachers should make every effort to keep the child in school. However, if the child exhibits signs of severe depression or aggressive behaviors, the parent(s) should be contacted so that a decision about psychiatric intervention can be made. Mood: Any / all Symptom: Generalized Anxiety Signs: child is anxious over seemingly trivial matters, may develop obsessions or compulsions to relieve stress brought on by anxiety, cries a lot, seems super-sensitive, may be sensitive to auditory and tactile stimuli Techniques / treatment: Reduce all stress: Homework Chores Decision making Reduce stimuli: Noisy, visually stimulating classrooms Allow student to leave class early to avoid crowded hallways Allow student to leave class to go to a quiet, safe place Reduce clutter at home and at school (Parents) Talk with your psychiatrist about treatment for anxiety including benzodiazepines, Buspar,     Inderal, Atenolol, Gabitril, Neurontin, Seroquel and Abilify. Avoid SSRI?s like Paxil or Zoloft as they    may cause mania or rapid cycling in bipolar children. Physical exertion may help. Involve the child in exercise, which releases endorphins, elevating the mood    and promoting a feeling of well-being. Guided imagery or relaxation tapes may help. Do an Amazon or google.com search on guided imagery for children.

LEE - Low Expressed Emotion LEE is using little or no emotion when dealing with or reacting to an unstable child in crisis. Avoid raising your voice. Do not give commands. Do not speak in a condescending manner or criticize the child. Offer reassurances that everything will be all right and that the crisis will soon be over. Avoid being over enthusiastic as well since some children cannot handle the over stimulation of too much exuberance. Think before you speak. In fact, avoid speaking at all if you can. LEE links:  http://www.healerwarrior.com/Psychoeducational%20Family%20Support.htm  http://www.schizophrenia.com/family/expressed.htm  http://www.ncbi.nlm.nih.gov/ http://mentalhealthcare.org.uk/schizophrenia/causes/familyrelationships/

Basket System Simplified  (adapted from Ross Greene's book, The Explosive Child) Basket A - Things that the child must do regardless of their reaction. There is no compromising in Basket A. When unstable, Basket A contains only safety issues:   suicidal behaviors   risk taking behaviors   taking medications Very few things go in Basket A, which means that there are very few things that you should put up with a rage for. Everything else should not come head to head with a rage.  Basket C (going out of order here) - is most everything else. The little things that are inconsequential go in Basket C, such as what to fix for dinner, what movie to watch on TV, even when to shower. When severely unstable, even things like bedtimes and whether or not to brush teeth go in Basket C. These are things that you just let go and do not push, thus avoiding a rage. When the child becomes more stable, you can move most of these into Basket B and A. But for now, let them go.  Basket B is in the middle. These are things you can compromise on, but do not have to endure a rage over. My favorite example is homework: if your child doesn't want to do homework and you want him to do it all, compromise on 30 minutes' worth of homework and let the rest go. You can also compromise on other issues: taking a shower in the morning instead of at night; brushing once a day instead of twice; eating 1 thing that he likes instead of choosing the entire menu; choosing between chores. The best way to know when the child is ready for Basket B is giving him choices. If he cannot handle choices, he cannot handle compromise and the issue remains in Basket C. Take issues one at a time. Don't lump everything into Basket B at the same time. Ross Greene's website: http://www.explosivechild.com

For more information about Childhood Onset Bipolar Disorder, please visit these websites: http://www.gcbf.org – The Georgia Childhood Bipolar Foundation http://www.jbrf.org – The Juvenile Bipolar Research Foundation http://www.bpkids.org – The Child and Adolescent Bipolar Foundation About the author: Julie Ward is the mother of one son diagnosed with Childhood Onset Bipolar Disorder and Asperger’s Syndrome. Julie serves as the president of the Georgia Childhood Bipolar Foundation, a parent-led foundation that provides support and education to families with children diagnosed with or at risk for bipolar disorder in the state of Georgia. Julie also has bipolar disorder. She and her son live in McDonough, Georgia. Copyright © 2004. All rights reserved.

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