--Janice Papolos and Demitri F. Papolos, M.D.
We all experience bouts of boredom
in life, but children and adolescents with bipolar disorder seem particularly
prone to them. It often seems difficult for these children to become engaged
with projects, or to set goals, and though a parent can offer any number of
choices of activities, the children can’t seem to invest in any of them.
They whine and complain constantly of being bored.
Often the children’s response
to this internal state of boredom is to provoke a stimulus from the environment—from
a parent, usually, or from a sibling. They create chaos, despite the fact that
it so often results in family members becoming angry at the provocateur in their
midst. One mother wrote and described her thirteen-year-old daughter this way:
She complains and whines constantly
about being bored. The Internet is the first place she goes to try and find
something to do—either instant messaging or emailing friends. I have
to be very careful that she doesn’t use the Internet in inappropriate
ways. The ability to get online and connect with someone —anyone
really—when they are in that bored state is very dangerous in my mind.
If she can’t find a friend
to instant message online, her next pattern is to get on the phone and to
try to call anyone she knows. She is always trying to set up impossible activities
and asking a friend if she can do these things without my even knowing about
it or approving it.
She went on to say:
When she realizes she has to stay
at home, she starts “playing” with her little brother and sister.
However, this playing is more in the form of torture. She tickles Maddy to
the point of crying. She jumps into Jared’s Nintendo game and makes
him lose. She chases them, annoys them, pretends she is playing with them
and lures them into a false sense of security and then starts bothering them
in any way possible. They cry and she seems happy not to be bored anymore.
Another mother emailed us and described
her son’s boredom and the provocative behavior that often follows this
state:
Oh, yeah. Boredom “R“
Us. Because Jamie seems incapable of turning his thoughts and impulses into
a creative activity, he creates busyness that brings him no real satisfaction.
He begins to "go on the prowl" and he very soon becomes intrusive,
provocative and demanding. I think he’s looking for that missing satisfaction
for all his busyness. As the provocateur, he will seek out his brother’s
attention and then either provoke or fabricate an offense. He’ll go
into his brother’s room while his brother is on the computer, lie on
his bed and make annoying sounds until Sam can’t take it anymore and
starts calling Jamie stupid, fat, or worse. Then, naturally, Jamie will yell
that Sam is torturing him and the situation deteriorates from there.
She continued:
Sometimes Jamie will invite Sam
into his room to play with something he has previously withheld, usually a
computer game, but sometimes a gaming magazine that he knows his brother will
devour. Then when Sam takes him up on the offer, Jamie complains that Sam
is not sharing and is taking over. Chaos ensues and we order them into their
separate rooms.
Why are these children so often
bored, and why do they need to provoke someone close to them and create such
chaos and bad feeling?
The answers are multi-determined
and no doubt a combination of psychological and biological factors.
Some Possible Reasons For This
State of Boredom
Adults suffering with depression
experience low-energy states and often a distinct lack of pleasure in things
they previously enjoyed. This arid state is called anhedonia. In Overcoming
Depression, we quoted a woman who was experiencing the clinical symptom
of anhedonia and she described it this way:
The most awful thing was that
I realized that my days had been composed of little moments of anticipated
pleasure: that first cup of coffee in the very early morning, the inner thoughts
that made me chuckle, a browse through a book store, the satisfaction of a
job or chore completed…Now these moments failed to hold the crest of
pleasure—everything was flat and gray. Life seemed locked away from
me and I was filled with an unspeakable dread.
When the mind is laid barren of
thought, the imagination cannot make the necessary leap into the future, and
the individual experiences himself as out of time and isolated from the ongoing
currents of life. He cannot reconnect.
This slowed-down state where nothing
is enjoyable may—in children—present as boredom. Children with bipolar
disorder are both easily excited and easily disengaged and bored (this dysregulation
would make sense in light of the quicksilver shifts between high and low states,
as well as the mixed states in which they are often trapped).
For many children the provocative
behavior that seems to follow a period of restlessness and boredom may be a
way of connecting and even showing affection. It can put a child who can’t
connect and is in a slowed down state in control and give him or her this sense
of connecting.
Executive Function Deficits
Sometimes the boredom is a result
of the deficits that many of the children have in the realm of executive functions.
As we wrote in a past newsletter, The Irrepressible Agendas of Bipolar Children: “Many of these children have deficits in the frontal lobes--regions that
govern the processes known as executive functions. The frontal lobes coordinate
many things, including reasoning, problem solving, strategizing, working memory,
attention, self-control, motor sequencing, intention, and flexibility of thought.”
If children have difficulty paying
attention, planning, strategizing, bringing working memory to bear on a problem,
and relinquishing a task when it proves not to accomplish a desired effect,
imagine how difficult it would be for them to sink their teeth into something
and move themselves along toward a feeling of mastery, reward, and accomplishment.
These executive function deficits,
the slow-down of depression and the often accompanying anhedonia, may cause
these children to lapse into periods where they cannot connect and get no charge
from the environment. They may feel they have no choice but to force the issue
and make the environment respond to them. In other words, they feel compelled
to provoke—even if the provocation results in negative responses from
those who are being pulled into their bored orbit to “fix” the problem.
Few people realize that the provocation
may be a child’s desperate attempt to escape what is experienced as an
intolerable lack of stimulation. The goal, however, shouldn’t be to abolish
the behavior, but to understand it and attempt to modify it. Although it is
a maladaptive behavior, it is a coping mechanism. These children are
trying to cope with something that feels very bad inside.
On the surface it may present as
boredom but several questions arise: Is this a mood state? Are they prone to
boredom because they are experiencing a low level of depression and they can’t
engage and feel pleasure and reward? How much of the boredom is a symptom of
the disruption in their object relations? If they have difficulty creating and
sustaining good relationships, does it make it difficult for them to connect
and do they shut down into a desolate, lonely, and scary inner state? What is
happening on a biological level?
A Few Biological Clues
Researchers have long known that
there are “pleasure centers” in different parts of the brain. As
Dr. David E. Commings writes in his book Tourette Syndrome and Human Behavior: “Correlations between the pleasure centers of the brain and the region
rich in specific neurotransmitters helped to place pleasure on a chemical as
well as on an anatomical basis.”
The neurotransmitter, dopamine,
has long been implicated in the brain's system of reward. Since dopamine neurons
pass to the frontal lobes, this important area of the brain is involved in the
reward pathway. In animal studies, an inhibition in dopamine activity in the
nucleus acumbens (one of the primary dopaminergic nuclei in the brain), results
in abnormalities in motivation, reward, and pleasure. It is quite possible that
some form of dysregulation in dopaminergic pathways leads to the experience
of anhedonia--a lack of the ability to experience pleasure--and its converse,
elation.
But How Can These States Be Handled
in Real Life?
Until we understand the biology
of these states (and even then), isolating and labeling, and understanding the
problem would be extremely helpful for the child and the family. We spoke with
Dr. Paul Schottland, a cognitive psychologist in Florham Park, New Jersey. He
first talked about the child’s need to provoke and stimulate others and
thus him-or-herself. He explained:
When the child teases, he or she
begins to laugh. The child gets a charge out of it, and feels in control (the
other person feels unable to stop it). This, in turn, makes the child feel
power, authority, and superiority—feelings these kids rarely feel in
an encounter with others—and this puts the child in a better mood
state. This power and sense of control can be almost narcotic-like to
the child. But typically the person at the other end of the teasing becomes
incensed and when this "narcotic" wears off and the child sobers
up, he or she often feels so badly and such remorse as the realization hits
that things have gone badly once again.
The child doesn’t understand
the need for this behavior—it seems to right the problem—yet people
around seem to feel only anger and exasperation (and who can wonder why?).
Dr. Schottland advises:
The first step may be to understand
some of what’s happening inside the youngster and talk about it, or
show the child you are sympathetic. The response from the adult can be more
compassionate and the adult can view the child in a more benign light. This
opens the possibility for teaching the child a more adaptive way of coping
with these very dark and scary feelings. If the adult can help to "head
off" the mood state and modify the behaviors before they become intractable
and ingrained in the personality, relationships can repair and become more
satisfying and warm.
First Things First
Before anything can be accomplished,
the child must be medically stable. Then, a complete neuropsychological evaluation
will help determine if the child has executive function deficits and which ones
they are (see Chapter 11 of The Bipolar Child, Revised for a complete
battery of tests to explore these domains).
Once these bases are covered, cognitive
therapy can be extremely important and helpful. Dr. Schottland talks to his
young patients and addresses the healthy part of them first. He tells the child:
I think you do this for a reason.
There is a very healthy part of you that can control or modify this behavior.
You’re not always in this mode—you’re a nice, sweet, kid.
But sometimes you go into this teasing, provocative mode that can be very
upsetting to the people around you. When does this get activated? When you
have nothing to do or when you are upset and feeling down—bored inside,
and it feels so bad to you. So when you feel this (or there is no fun happening
for you) you start bothering your family and it makes you not feel bored anymore.
Sometimes the teasing is funny for a bit and you may see others laughing,
but when it goes on too long, or when you don’t listen when people ask
you to stop, it gets you in trouble and people think badly of you.
He continues, explaining to the
child:
These behaviors aren’t you.
This part of you is very small. You are so much more than this. Everyone has
a little bully inside of them, and everyone likes to tease, but this can get
activated in you and you find it hard to stop.
Usually children respond to this
description and the conversation gives them a sense that the behavior might
be managed by them.
Dr. Schottland uses imagery with
the very little ones and asks them to picture sending that little bully to its
room. For older children he instructs them to do something more productive with
the feelings. “Put it into words,” he says. “Tell your mother
you’re feeling so bad and so bored and it makes you want to start teasing
or taunting someone. You need to have a catalogue or laundry list of things
that might take you away from that state.”
The child and Dr. Schottland prepare
this list and begin a strategy to stock the house with what’s needed when
they feel themselves going into this mode. He and the child enlist the help
of the parent because these items must be in the house and available for such
moments. A trip to the store is too late to stop the mode from kicking in, and
once it does, the child is off kilter until it burns itself (and the immediate
family) out.
Hobby shops are a godsend says Dr.
Schottland. Rockets, ship models, art work, video games or movies held in reserve
for just such times.
He also warns that the car is the
“hell-on-earth mobile” for parents with bipolar kids. This is where
they get extremely bored and they begin to nudge their siblings (they also may
be hypersensitive to the closeness of bodies and loudness of sounds in the back
seat of a car). The car is a prime breeding-ground for blow-ups.
Dr. Schottland cautions parents never
to get into a car with the kids—no matter how short the ride—without
what he calls a bag of “distractors”: hand-held video games, CD
players with headsets, a movie if the car is outfitted with a DVD or tape machine.
“Use the child’s considerable ability to hyperfocus to the child’s
advantage,” he says. “Parents should understand that these are therapeutic
tools that result in better management of the problem and stop feeling guilt
about appropriate video games and movies to keep things running smoothly.”
More Ideas That May Work
The mother we interviewed with two
children who have bipolar disorder told us the following:
My younger child is easier to
direct out of this mode, but for him, boredom equals hyperactivity. When he
is bored he starts running around and jumping all over the place. He literally
will just run between two points. He needs a physical outlet for this emotional
state. If I can, I go out and jump on the trampoline with him. I offer to
take him rollerblading. The hard part for me is that it requires that I do
something with him. When he is in this mood, he will not play alone or with
his younger sister. If I am not in a position to drop everything and become
a camp counselor, he too will escalate to the point where he starts bothering
his little sister—teasing her and chasing her just to get a reaction.
This family is very complicated
because the father also has bipolar disorder and if the mother can’t get
either child out of this mode soon enough, the kids end up picking on the younger
child and using her as a tool to vent their needs. Of course the noise level
rises as they start chasing each other all over the house and screaming and
complaining. “If my husband is home,” she explains, “he yells,
the kids cry, the kids hit each other, chaos ensues and what I call ‘the
bipolar bounce’ is in full swing.”
She spoke about some other coping
mechanisms:
The best way I know to try to
combat this is to keep my kids busy and scheduled. It really helps that Lizzy
is now ice skating every day after school for three hours. The physical exercise
is great, and just removing her from the after school crisis hours at home
helps. The ability to give each of them some one-on-one attention is a good
way to side-run this problem. I can’t do it all the time, but I try
to spend some time doing something physical with my son (and he chooses this
as often as he can).
Weekends are the hardest. Having
unstructured weekend days sounds like heaven to me personally, but they are
a recipe for disaster here.
She then wrote about some action
plans that can be helpful at times:
When I am really at my wits end
and need to get the kids out of the house, I now take them to a nearby mall
that has a sporting goods store with a climbing wall in it. It doesn’t
cost anything and they can each have a turn or two. I promise them a milkshake
before we go in so they focus on that and not some other expensive sports
item they can suddenly seize upon.
This mother admitted that she is
often not in the mood nor does she always have the time to drop everything she
is doing just to prevent her child from getting bored. “Sometimes I let
a child move a T.V. into his or her bedroom to watch his or her own special
movie alone,” she explained. “Sometimes I just call Grandma and
ask her to take one of my kids for the afternoon or for a sleepover (Maddy is
at my mother’s as I write. I sent her over last night to get her away
from Lizzy who was bothering her!)”
Jamie’s mother sent a follow-up
email in which she said:
After reading over my email yesterday,
I realized I’d wandered off track and left out one management technique
that actually is helpful. When I see a block of free-time coming—a “boredom
trouble spot”—I try to come up with an assignment. Jamie loves
pens and markers and doodling, so I’ll ask him to draw something about
a Web site he’s been into, or to make a birthday card for someone (a
child or adult). This actually keeps him busy for a while—when he’s
engageable. If it’s a snow day we’ll let him loose with the
slow blower, which is one of his favorite things. We have begun to have success
with getting him on the elliptical trainer while he watches a movie (we’ll
see how long this lasts). On a single day off from school you need to have
all of the above….and you must be prepared that all your camp counselor
scheduling may be met with: “I hate that; I don’t want to do that,”
and a string of negative and surly responses to each one of your enthusiastic
ideas and suggestions. It all depends on the mood of the child.
It’s good to remember that
these are transient states, and will resolve. (However, we understand that this
is little consolation as the time stretches interminably in front of you and
you watch the child begin to go on “the prowl” and begin to light
on you or a sibling for this much-needed spark of life.) But, as Dr. Schottland
says: “If the parent understands why the child feels he or she needs this
behavior as an antidote to an uncomfortable inner state, the parent can intervene
and remind the child of the typical outcome of such behavior.
Dr. Schottland suggests saying something
like: ‘Daniel, you’re going into bully mode. It’s starting
to take over—can you see that? Can you remember that everyone gets upset
at you when this happens? Let’s see what else we can do to make you feel
less bored.’ Dr. Schottland cautions that a parent will not always be
successful in catching it at the right moment. However, this reminder may increase
the odds that the child can gain some control over time.
How the Siblings and the Bipolar
Child Can Be Helped
It should be underscored that sometimes
the provocation starts out as a sort of game and that the children may have
fun for a while before it deteriorates and becomes taunting and upsetting for
all players. In clinical work with families, one of us (DFP) focuses on the
events that are set in motion as the boredom-provocative behavior dynamic caroms
across the household.
In this context, the family members
talk about what fun it all can be initially (the kids actually may all see it
as fun—they don’t know any other way to play). The question is:
how can it be fun without it getting out of control? Here the parent is asked
to estimate how long the teasing and chasing goes on before the situation turns
ugly. If the parent estimates about five minutes, an agreement must be made
by all involved that after four minutes there will be a time out and everyone
will go into his or her room for a ten-minute break (just like in sports).
If you turn it into a game with rules,
it gives the children an external boundary and gives all the children a sense
of having fun but being in control and feeling a sense of mastery. Actions can
start and stop without screaming and bad feeling.
The first attempts at this game
with rules and boundaries should be looked at as trials and the children must
be told that they can fail. But for children who have difficulty sequencing
and anticipating outcomes so that they can alter them beforehand, and who can’t
change set quickly and relinquish what ever they’ve set off doing, this
“game” may help them do all that and make them feel better. It “stretches
the muscles” that aren’t strong in the domains of executive functioning.
In Conclusion
We hope that this newsletter sheds
some light and understanding on yet another set of feelings that the child with
bipolar disorder is attempting to cope with, and that a compassionate approach
may help him or her feel not quite so alone, not quite so scared, and in a better
position to solve this uncomfortable problem of boredom in a more adaptive way.
The children can be helped to tolerate periods of boredom. They need
not always fear that they are falling down the rabbit hole and therefore need
to create chaos in order to get a toehold and pull themselves free.
We also hope this discussion helps
parents feel more in control of the situation and feel less dread of an upcoming
“boredom trouble spot.”
Parents should always try to remember
that though the children are prone to boredom—especially in the younger
years—eventually most of them get engaged with something that they are
good at and like, and boredom presents less of a problem as time goes by.
We know that not one of you signed
up as “Camp Counselor/Referee” when you became parents, but we salute
you for striving so hard to solve these very difficult problems for the children
you love.
With great admiration,
Janice and Demitri Papolos,
M.D.
The authors wish to thank Dr. Paul
Schottland, Cheryll Hart, Cheryl Matalene, Jeanne Langer, and Karen Williams
for all their help in preparing this newsletter.
Bibliography
Commings, D. Tourette Syndrome
and Human Behavior. Duarte, California: Hope Press, 1990.
Papolos, D. and J. The Bipolar
Child, Revised. New York: Broadway Books, 2002.
Papolos, D. and J. Overcoming
Depression, Third Edition. New York: HarperCollins, 1997.
Papolos, J. and D. “The Irrepressible
Agendas of Children With Bipolar Disorder.” The
Bipolar Child Newsletter, October, 2002, Vol. 12.
Salamone, JD, Cousins, MS, and Snyder,
BJ. “Behavioral functions of nucleus acumbens dopamine: empirical and
conceptual problems with the anhedonia hypothesis.” Neurosci Biobehav
Rev , May (21): 341-359.
Schottland, Paul. Telephone interview
of January 22, 2004.
ADDITIONAL NEWS:
The Juvenile Bipolar Research Foundation
(JBRF) has been seeking families throughout the nation who have two or more
children diagnosed with early-onset bipolar disorder for an affected sib pair
genetic study. Since August of 2003, over 300 such sibling pairs have been identified
and the researchers are very grateful to all the parents who have responded.
If you are a new subscriber to this newsletter and would like to know more about
this study, please contact Janice Papolos at jpapolos@jbrf.org for more information.
JBRF’s Third Annual Dream Catcher
Evening (Bringing Lives into Harmony) is set for April 16th at the Sheraton
New York in New York City. This exciting event includes cocktails, dinner, a
live and silent auction, and a special performance by Livingston Taylor. To
find out more about this evening, please email info@jbrf.org.
To see how warm and unforgettable last year’s Dream Catcher Evening was, click
here: http://www.jbrf.org/news/events/index.html.
www.bipolarchild.com
