Symptom Charting What is symptom charting? Symptom charting is nothing more than a daily system of tracking symptoms and behaviors of individuals with a neurobiological brain disorder. It can be as low-tech as simply noting behaviors on a calendar or as advanced as filling out a computerized diary. Charts can be kept by patients, parents, spouses, children, teachers, doctors, therapists or anyone in close contact with the brain disordered person. Professionals use charts to document progression of the illness, predict reactions and behaviors or to keep a solid record of a patient’s history. Parents use them for the same reasons, but in non-clinical settings. Patients use them for these reasons and to develop insight and awareness of the correlation between their symptoms and behaviors. Who should chart? People familiar with bipolar disorder are probably also familiar with the term “mood chart”. It is understood in most bipolar communities that charting mood and other factors leads to a better understanding of one’s particular brand of bipolar disorder and what affects their illness. But other disorders can benefit from symptom charting. ADHD parents are very familiar with sticker charts, behavior charts and point systems which have been shown helpful in reducing unwanted ADHD symptoms and the behaviors that result. Charting frequency of impulsivity, distractibility, lack of attention, energy level and depression can aid parents of ADHD children in making discipline and other parenting decisions. Tracking obsessions and the behaviors that result can help those with OCD become more cognitively aware of the frequency and severity of their symptoms. Charting social difficulties (and successes, too) of children with autism and NVLD can aid parents and teachers in developing strategies to teach the child more appropriate communication skills. In fact, there is probably no chronic brain condition that could not benefit from daily monitoring or charting. What can be learned from charting? Relationship between symptoms and behavior: If, when charting a child with bipolar, you note that every time the child gets less than four hours of sleep per night (a manic symptom) he is very energized the next day and demands that you cook him a four-course meal for breakfast… in bed (a behavior of mania), you have established a direct relationship between a symptom of the illness and a behavior. Some are not quite as obvious as this example, however. Sometimes symptoms lead to behaviors that parents might not easily pick up on as related. If the child is speaking rapidly but seems otherwise fine then suddenly becomes physically aggressive with a sibling, you may miss this manic manifestation unless it was charted. After many weeks of charting, the parent begins to note relationships, and this awareness can help the parent decide whether or not the child with rapid speech should be allowed to play unsupervised with a younger sibling. Relationship between symptoms or behaviors and medication: Keeping track of any medications given while charting behaviors is crucial to determine the effectiveness or any adverse effects of the medication. For instance, careful charting may reveal that after every time a medication is administered, the child becomes anxious and weepy. If medication was not charted alongside the behavior, the correlation may be missed and the anxiety mislabeled as a separate diagnosis, resulting in additional, unnecessary medication.  Relationship between environmental factors and behavior: Environmental factors such as diet, social situations, death or illness in the family, moving to a new home or seasonal change can bring stressors into the child’s life, affecting his disorder its behavioral manifestation. Pubertal and pre-pubertal girls should also track menses, which can affect energy, mood and overall functioning. Making parenting decisions based on charting: Parents who have previously punished or reprimanded a child for aggression may discover that the child’s aggression is directly related to a symptom of their disorder such as misunderstanding facial expressions. The parent may then decide to prepare the child for social situations by teaching the child to recognize and identify facial expressions. They may monitor social interactions more closely to prevent the aggression or misunderstanding. They may even decide to pursue therapy to address the symptom. Parents who do discipline with time-outs, grounding or other means can chart effectiveness of these consequences by noting if the unwanted behavior returns (and if it does, the frequency and severity of the behavior). Making treatment decisions based on charting: Teachers, doctors and therapists may change the course of treatment or the way they address the issues of the child with a brain disorder based on charts – kept either by the professional or the parent. Teachers may not notice antecedents to behaviors unless charting closely, affecting decisions about discipline. Doctors may not get a clear picture of family life and symptomatic behaviors unless a parent-kept chart reveals a wide range of symptoms. Simply asking a parent to describe how things have been is sure to return as insufficient an answer. Developing self-awareness and ability to control symptoms: Even small children can be taught to evaluate how they are feeling. Older children may develop skills to identify specific symptoms and manifestations of those symptoms. Charting allows the child to discover his own “brand” of disorder, and frequently he becomes more open to insightful discussions. He learns more quickly to be aware of his symptoms, which in turn leads to better control of his behaviors. How do I choose a chart? Besides just picking one and trying it out, there are some questions you can ask to determine if a chart is right for you.   How consistent am I likely to be in charting? – The answer will determine the frequency required in the chart and the length of the chart. If you are not a very consistent person, a chart that requires hourly data collection and has ten areas of data to collect may not be the right choice for you. What data is most important to me? – At the very minimum, you’ll want to chart unwanted behaviors and medication. But if your child is sensitive to sugar or caffeine, charting diet will be important. If your child regularly has sleep difficulties or wets the bed, this would be important to you. Make a list of the most important areas of data to your child. Do I prefer sitting at the computer to chart or do I need a more portable system? Am I likely to get confused or bored if the chart is too long, does not have lines or graphs or lacks eye-pleasing graphics? Do I want to keep the chart or have my child keep the chart (or both)? Even if you choose a chart with these questions in mind, you will undoubtedly find ways to personalize the chart after using it for a while. You might even discover that the issues you thought were important really aren’t. Don’t fret. There are many other charts to choose from, and it is quite easy to alter one or create your own. Where can I find a chart that suits my child’s individual needs? There are many charts available through hospitals, schools and even on the internet. But finding one that suits your child’s individual needs takes some searching or even a little creative altering. Charts developed commercially can be used effectively, but the ones designed by parents often include more appropriate tracking data. If you do not find one that you think is perfect, use a word processing program or spreadsheet/database program to take the best aspects of charts you do like to create your own. Here is a list of resources that offer free charts: http://www.gcbf.org/resources/moodcharts.html http://shelly.mcintosh.net/page2.html http://www.bpkids.org/learning/kimberly-instructions.htm http://www.bpkids.org/learning/6-02.pdf (directions at http://www.bpkids.org/learning/directions.doc)  http://www.dbsalliance.org/PDF/BPcalendar.pdf http://www.manicdepressive.org/moodchart.html http://www.fpnotebook.com/PSY91.htm http://www.healthyplace.com/Communities/Bipolar/jinnah/solutions/page_d_040.html http://www.psychiatry24x7.com/bgdisplay.jhtml?itemname=mooddiary http://www.psycheducation.org/PCP/handouts/Mood_Chart.doc http://www.bipolarworld.net/Diagnosis/Diagnosis/moodchart.html http://www.bipolarworld.net/Diagnosis/Diagnosis/rat.html There are also charts in the following books or websites that can be purchased (or check your library): http://www.moodtree.com http://www.amoodjournal.com/ The Bipolar Child by Demitri Papolos, M.D. and Janice Papolos The Bipolar Disorder Survival Guide by David J. Miklowitz, Ph. D. How do I actually chart? Most of the examples of charts given here focus on mood. High, even and low are the most commonly used descriptors of mood. But it can often be difficult to judge. “High” is associated with mania, “low” with depression. But sometimes a child can be angry and irritable (usually depression) but also be hyper and aggressive (very high energy). In situations where a decision must be made, go with the predominant overall mood (depression) and be sure to mark the energy (some use an “E”) in the same area but in the “high” section.  Another way to chart uncertain moods is to use the acronym “DIGFAST” to label specific manic symptoms that occur in low moods. For instance, putting a “G” next to the check mark for “low” mood, you know in a glance that the child was exhibiting grandiosity while also experiencing a depression. DIGFAST stands for: D Distractibility I Insomnia (reduced need for sleep) G Grandiosity F Flight of ideas (racing thoughts) A Actions: goal-oriented or obsessed S Speech: rapid or pressured T Thoughtlessness, risk-taking behaviors Some charts come with instructions on the symbols that you should use, the frequency for charting symptoms and how to notate difficult data. When in doubt, always do whatever makes sense to you. How do I use the charts to communicate with my child’s doctor, therapist or teacher? Keep your chart(s) in a three-ring binder and take them with you to every doctor appointment, therapy session or IEP meeting.  When you show the charts, remember that you are familiar with their meaning, but others are not. Explain in short, concise sentences what codes mean, or prepare a handout for others that gives them the code as a quick-reference. Be patient and offer answers to questions, but otherwise remain silent and give the other person(s) a chance to assimilate the information. Whenever a treatment option is discussed, ask if it is appropriate based on the data in the charts. When consistent charting reveals patterns or relationships between treatment and symptom manifestation, it is easier for the professional to involve the parent as a treatment team member, and it is easier for the professional to arrive at a better treatment option for the child. 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 divorced 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. Edited by Steve Propst. This article appears in the Spring newsletter of the Atlanta chapter of DBSA (Depression and Bipolar Support Alliance). http://www.atlantamoodsupport.com   For a printer-friendly version of this article, click HERE. (.pdf format) Adobe Acrobat Reader required Click HERE to download a free copy of Adobe Acrobat Reader.