--Janice Papolos and Demitri F. Papolos, M.D.
This newsletter is a tad late because
we’ve been so busy with the publication of the revised and expanded edition
of The Bipolar Child, and because we’re continuing to develop the
research programs of the Juvenile Bipolar Research Foundation.
A few weeks ago JBRF launched its
new educational forum for parents and educators, and if you haven’t had
a chance to visit yet, there is an extremely comprehensive monograph entitled
“The Educational Issues of Students with Bipolar Disorder” that has
been sighted at IEP meetings in several states already. There is also an interactive
bulletin board where a team of expert educators and advocates will answer questions
pertaining to any part of the education process. It is the JBRF’s intention
to establish and encourage an ongoing national dialogue that will promote a
better understanding of the educational challenges that confront children and
adolescents with bipolar disorder.
So if you have a question about your
child’s IEP, or special ed law, or a Functional Behavior Assessment, or
even home schooling, you’ll get timely answers that will do much to make
your child’s experience at school more comfortable and beneficial. We welcome
your visit at www.bpchildresearch.org (click on “Discussion Forums”).
In this month’s newsletter,
we would like to explore a characteristic of many children with bipolar disorder
that, while not initially as disruptive as rages and hypersexuality, nevertheless
typically concludes in explosions and extremely battered feelings.
Mission Mode
Parents write to us often and mention
that they are assailed all day long by their children’s intense need to
buy something or to do something. The children seem to wake up, decide they have to go to the pet store and purchase a hamster or a puppy, or they
just have to have the expensive sneakers that their friend is wearing,
and no amount of reasoning or discussion can deter them from what parents describe
as “Mission Mode.” Their sheer persistence is all-encompassing and
they become very adept at blocking out any agenda but their own (which they
are feeling very intently and very urgently). Parents, pummeled by this relentless
pursuit of the child’s own need or his or her agenda, describe it thus:
He launched into what I call his
“Mission Mode,” an insatiable state during which every thought that
pops into his head becomes an obsession that must be relentlessly pursued.
It doesn’t matter if it’s a must-have or a must-do. It could be
the urgent need to go out and buy the new cereal he just saw on TV, or the
sudden inspiration to mow the lawn when the neighbors are still sleeping.
It’s as if his orders came down from God on a bolt of lightning.
Another mother from Oregon described
her 11-year-old daughter this way:
Lauren tends to get stuck in this
mode over things like wanting to go to the mall and go shopping. Right then,
right there. Period. Doesn’t matter that it’s 9:00 at night, or
some other impossible, inappropriate time. Trying to reason with her about
why going to the mall right then is a bad idea--it NEVER helps. Reasoning
with a child in this state is a disaster. She often then feels picked on and
“unloved” (her words) because I don’t give in to her demands.
Sometimes “Mission Mode”
can be a sign of impending mania, but not always; Sometimes there is more of
an obsessional, anxiety component to it. The mother whose daughter needed to
go to the mall despite its being closed also told us about her daughter’s
urgent need to have her mother sit with her before dinner every night
and do her homework, and that the child could not get past this worrying need.
Her mother wrote:
It is frustrating when you want
to eat dinner first, then do homework, but she is so anxious about getting
it done and getting good grades that she won’t eat dinner until the homework
is done. And she is not able to do it without me sitting right next to her.
You can imagine how that plays out in the whole family. Lauren insists that
I sit down then and there; Sam (my other child with bipolar disorder) is in
his after-school hyper mode, running around the house needing attention to
keep him calm, so he doesn’t trigger my husband who is also bipolar--and
Cally (my five-year-old, non-bipolar child) is left to go color on her bedspread...and
everyone is hungry and needing dinner.
Why are these children so absolutely
rooted in their agendas? What is really going on here? And how can a parent
deal with these urgent, obsessional needs and help the child become “unstuck”
from these thoughts and demands?
Executive Function Deficits and
the Bipolar Child
Some of the answers may lie in the
fact that many of the children have deficits in the frontal lobe regions that
govern the processes known as executive functions. The frontal lobes coordinate
speech, reasoning, problem solving, strategizing, working memory, attention,
self-control, motor sequencing, and other processes central to higher functioning.
All human beings who approach a problem or a project must recruit executive
functions that include analyzing a problem, anticipating problems, remaining
flexible and reformulating a plan of attack if the assessment shows that the
plan is not working (flexibility of thought and the ability to “shift set”).
They also must keep a thought in mind while mustering the selected bits of information
stored in memory so that this information can be brought to bear on the task
(“working memory”).
It is now becoming apparent that
children with bipolar disorder have deficits in just these areas. They are inflexible--they
perseverate or can’t move off a topic, they can’t anticipate that
this kind of behavior will bring negative reactions from those under assault
by their perseverative plans, and they have impulse control problems and cannot
wait for something. (They may also be anxious that they will forget what it
is they want; or they may be using this sudden gusto about a project or new
idea to focus their thinking.) The new idea may be a stabilizing force that
supplies an external structure because deep down inside they are afraid they
are disappearing down the rabbit hole. They experience their need as an emergency
situation, and so urgent that it is as if their very survival depends on their
getting whatever it is they think they have to have. Any refusal on the parent’s
part seems to make them feel unprotected and unloved.
Dr. Nancy Austin, a psychologist
in New York City who works with many children who have been diagnosed with bipolar
disorder has written that:
The fundamental motivation of bipolar
children’s behavior may very well be to find a way to regulate a biologically
compromised, dysregulated system. Behaviors can be adaptive, such as “I
need a break before I continue with my schoolwork,” or nonadaptive, such
as this relentless pursuit of needs.
She goes on to say:
As we know, children who have bipolar
disorder have intense responses to any perceived or biological stress. Stress
causes shifting mood states. Shifting moods means shifting cognitive capacities,
and especially vulnerable is memory. Intense moods result in cognitive rigidity
and irrational thoughts. A quick fix may very well be the only option a stressed
child grappling with bipolar disorder can think of to “soothe the wild
beast inside.” If the child has no cognitive flexibility and may have
some irrational assumptions, no amount of parental reasoning will be successful.
We asked Dr. Austin what she would
advise a parent to do when confronted on a school day with the demand that a
hamster be purchased as soon as the school bus deposits the child back to the
home at 3:00 p.m. She said:
It’s true that children with
bipolar disorder can be hyperfocused, but the parent must also be hyperfocused,
and must stay focused on the task at hand. So, for example, if the child is
getting ready for school and the “relentless demand” is getting
a pet hamster, the parent might go through the following:
- Don’t respond immediately,
think: “Stay calm.” Respond neutrally and slowly.
- Decide if this is a demand
that you are willing to accept. If yes, then do so evenhandedly and without
resentment. If not, move on to step #3.
- Refocus on the task at hand.
Speak in short, direct phrases, repeating the same phrase. Make no
promises. For example, if the next task is for the child to put on his or
her pants, say something like: “Right now, it’s time to put on
your pants.” (The child may whine and cry and say that you’re
a terrible parent --or much worse). You ignore these reactions. You repeat
what you said before, more slowly, more quietly, without looking the child
in the eyes (any added stimulation might add to escalation rather than de-escalation).
You do this repeatedly until the child knows that he or she will get no
other response from you except, “Pants on time.”
Dr. Austin cautions the parent to
ignore any verbal responses from the child that don’t pertain to a positive
indication that he or she is putting on pants. “This way,” she says,
“you are not inadvertently negatively reinforcing a noxious behavior. You
are trying to extinguish it.”
If the child hits, or throws objects,
it suggests signs of medical instability and the parent should speak to the
psychiatrist. But it may be that a pattern has been established and that the
child is incapable of disengaging from the obsessive thought.
Dr. Austin then added:
Parents need to continue to be
disengaged from the demand that’s in the child’s head. Remember,
it’s a ‘quick fix” to activate a distressed biological system
and maladaptive. Parents need to come down on the other side--they need to
model by speaking quietly, neutrally, and slowly, asking for the child to
accomplish a simple task that he or she is capable of doing.
Dr. Austin wants to remind parents
that the child must shift mood in order for a more rational solution to be available
to him. Also, that the child may have specific fears (rational or irrational)
about school and that this “quick fix” means that these concerns may
have not been totally addressed (an enormous job in and of itself).
It’s Not About the Sneakers
We next spoke with Dr. Paul Schottland,
a cognitive psychologist in Florham Park, New Jersey, about the bipolar child’s
often relentless pursuit of his or her own needs, and he also spoke about the
children’s lack of flexibility. He too described how they get caught up
in something and can’t let go (they can’t “shift set”).
He said: “They don’t realize their thinking is rigid. They have to
be taught to activate the flexibility of their thinking.”
These children often lack anticipatory
thinking: They don’t process that if they get louder and louder they will
not get what they want, and will perhaps be punished. They also can look as
if they lack empathy or connection to the parent when they’re actually
having difficulty picking up cues that would help them moderate their responses.
They can’t think: “What would it be like for Mom to have to drive
to the mall at this hour of the evening?” They cannot move ahead and think
into a future situation, and they lack the concept of compromise. (Again we
go back to the executive function deficits these children seem to have.)
“It is not about the hamster,
or the sneakers,” says Dr. Schottland. “It’s about the inability
to cope with his not getting what he thinks he needs at that moment. His system
is not sophisticated enough to cope, it’s not that he is a bad child. This
unreasonableness is a handicap and it is the handicap that must be addressed.
He continued:
A parent must ask him-or-herself:
“What does my child need that she doesn’t have? How can I build
in a structure that doesn’t exist?” The parents have to see themselves
as more than providers and disciplinarians. The parents must think:”
Part of our job is to teach her to develop the necessary structures that will
help her cope.” This takes you out of the adversarial role and puts you
in the role of teacher and parent.
Installing the Software
We liked Dr. Schottland’s computer
analogy when he instructs the parent to “install the software that isn’t
there on the hard drive.” It doesn’t come up on their screens naturally
the way it does with other children, and it must be manually installed by the
parents. And then it must be trained in by the parents.
Dr. Schottland talked through an
example. Let’s go back to the sneakers. They cost $125.00 and there is
no way the parent can grant the request. Things escalate and the parent becomes
more exasperated and then the child blows. A rage ensues that shakes both the
parent and the child. Let’s pick it up from there. Dr. Schottland says:
Wait until the emotions settle.
Then approach the child and talk about the situation. Say something like:
“This is not a good situation. We have to figure out a better way to
make it better next time because I love you and I don’t want us to be
this way.”
So you establish the fact that
it is a problem that he or she has had for a long time and then explain that
you understand how difficult it is for him or her and how upsetting it is.
Then the parent can say: “Let’s find some tools so you can think
things through differently next time so that the situation doesn’t have
to repeat itself. I don’t like when we’re angry at each other.”
(This is a bonding response, not an adversarial response.)
The parent then continues: “I
love you and I would do that for you if I could.” And then the parent
can ask: “What can you say in your own mind that could help you deal
with something I can’t do at that time? “
Cognitive Mediators
Dr. Schottland gives the child something
called a “cognitive mediator.” It is a thought that can replace the
uncomfortable thought they are thinking. This new thought can get them unstuck
from the rigid place in their thinking, and it can mediate the experience of
the situation and therefore affect the response and outcome. He actually writes
the cognitive mediator out on a card for the child.
“It’s like installing the
executive functions that are not there or are not working correctly,” says
Dr. Schottland. “You have to give them these tools. So, when the child
is calm and you’re quietly discussing what happened, the parent can say:
‘It’s not your fault you get stuck, you push too hard, but we have
to learn how to replace that thought with another.’”
Here’s an example of a cognitive
mediator:
In reality you’re lucky if
you get what you want fifty percent of the time. You should ask for something,
and then ask one more time, but if I say “no”--can you picture yourself
putting it on the shelf? Imagine saying to yourself: “She said no. I’ll
put it on the shelf and come back to it later.” (This shifts the obsessive
thought away from the child and he or she spends time imagining it on the
shelf and chances are that that cognitive shift will help get the child “unstuck.”)
Another cognitive mediator: “I
won’t get it this time but maybe I’ll have a good shot at the next
thing I ask for.“ (You’re helping them adapt to reality).
A parent and a child can generate
cognitive mediators together. Parents need to understand that that the child
has little ability to grasp the whole picture in the moment. Instead, he or
she gets carried away with the emotion and loses the capacity to hold the complete
picture and understand and anticipate that there may just be alternatives that
can work in an interactive situation. Any possibility of that gets shut down
as they perseverate and escalate about the one thing they think they have to
have at that moment.
Parents must remediate this weakness
by not giving in and teaching them to activate their executive functions and
flex their cognitive thinking.
They need to coach the child and act pre-emptively when another hamster or sneaker
mission begins to develop. If they see “Mission Mode” they must alert
the child to start using clues. Use a conversational tone.
Parent: “I think this could
develop into something that neither of us would like. It’s starting to
feel to me like last time over the sneakers. Do you feel that? Do you see that?
Child: “Yes, but I really want
(escalation)...”
Parent:“I would love to do that
if I could but this is one of those times that I can’t. Let’s think
about something else.”
Again, the parent needs to start
them reflecting on the whole picture. They can’t access the emotion or
the memory of the past negative sneaker experience and decide to let this one
go because they have such difficulty retrieving emotional response from the
past or thinking forward into the future . This kind of moving back and forth
requires a cognitive flexibility--the very thing they lack.
“This is such a job for a kid,”
says Dr. Schottland. “Show him how you appreciate how hard he’s working
and every once in a while reward him.”
Dr. Schottland also warned that this
is a process that takes a tremendous amount of effort on the parents’ part.
It is not a quick fix, but must be trained into the child over and over again.
He tells the parents, only half-jokingly: “Get back to me after a thousand
trials.”
He closed our conversation by adding:
You have to understand that you
could do this all one hundred percent right, one hundred percent of the time,
and you still might not get what you want. Don’t judge yourself by how
the child responds, but by how you respond. Are you responding neutrally,
empathically, are you giving the child the tools? Are you enhancing the soul
of the child?
Remember that you are always installing
the software of how the child feels. If you install an empathic, caring, problem-solving
part inside them, you’ve done your job.
And under circumstances that would
try the patience of a saint.
Dr. Austin also followed up our conversation
with an email in which she said:
This is, of course, an enormous
amount to ask of parents. But evaluating how much time parents get pulled
into conflict over an irrational or unacceptable demand, perhaps a focused
response, over time, will help extinguish more of this kind of annoying behavior.
If parents are successful at this, they are empowered, no matter how many
times they have to go through the routine. If parents are consistent, the
child will realize the “demandingness” is useless and begin to try
alternative, more adaptive responses (because they now realize there are alternatives).
This allows the child’s cognition to flex, at least a little. Developmentally,
adaptive responses can stem from the creative capabilities of the child. And,
as we all know, children with bipolar disorder often have a great creative
ability that it unavailable to them during a “mood storm.”
And what about Lauren who can’t
do her homework without her mother at her side? According to Dr. Schottland,
she needs to work with the catastrophic thought that generates such anxiety.
She needs a tool with which to work on her own anxiety and replace it with a
thought that helps her to be more flexible. A therapist could help her digest
the toxic thought--metabolize it and prove to herself that she can do it, after
dinner, or without her Mom.
In fact, her mother emailed and told
us:
I will talk to Lauren when she
needs to talk to me. Usually, taking ten minutes to talk to her at an inconvenient
time helps to prevent a night of perseverating and driving us all crazy. So
I guess my advice on coping with this behavior when it is emotional/anxiety-related
is to deal with the pressing issue. She will not get past this stuck thinking
on her own.
Lauren’s mother also noted that
with time and maturity, things improved. “Lauren has learned some of her
own skills,” she wrote. “She has learned to use email and instant-messaging
to communicate with other friends and family members who can support her when
I might not be able to.”
We remember when we were expecting
our first child, there was a seemingly vital debate on whether a MacClaren or
an Aprica stroller was the best you could buy for your new baby. Purchasing
one or the other seemed to say something about what kind of parent you might
turn out to be. Would anyone have guessed that parenthood would hold unstable,
suffering children, multiple medication trials, school problems and IEPs, hospitalizations,
and this kind of working through of every thought and impulse?
For the parents of children with
bipolar disorder, it does; and we are in awe of your sheer stamina and determination
to make things right. We hope this helps you feel better, cope better, and feel
more satisfaction in your role as a parent. We also hope it helps remediate
some of the cognitive weaknesses that are no fault of the child’s, but
that make life for him or her and for the entire family so fraught with negative
feeling and emotion.
As always, we send you our best and
look forward to hearing from you,
Janice Papolos and Demitri Papolos, M.D.
Bibliography:
Papolos, Demitri, and Janice Papolos. The Bipolar Child, Revised and Expanded Edition. New York: Broadway Books,
2002. (To read more about executive functions and the neuropsychological testing
that reveals
weaknesses in the frontal lobes, read Chapter 11.)
The authors wish to express their
gratitude to Cheryll Hart, Jeanne Langer, Cheryl Matalene, and Drs. Nancy Austin
and Paul Schottland.
Copyright 2002
