BIPOLAR CHILDREN PART 2: THE ROLE OF THE FAMILY
From Mood Disorders in Children and Adolescents, presented by the Nemours Alfred I. duPont Hospital for
Children, Wilmington, Delaware
David J. Miklowitz, PhD, Professor of Psychology and Psychiatry, University of Colorado, Boulder, and Health
Sciences Center, Denver
| Introduction: unlike most adults with bipolar disorder, children and adolescents do not have distinct episodes but do
have more switches, so families usually do not ask how to prevent next episode, but how to deal with day-to-day
fluctuations in child’s mood and how to identify triggers in family and school settings; goals of family-focused
therapy (FFT) include helping adolescents and parents to distinguish age-appropriate moodiness from bipolar disorder,
using developmentally appropriate terminology, exploring participants’ discomfort with diagnosis, emphasizing
regularity of sleep-wake cycles and avoiding overstimulation, using self-rated mood charts and educational
videotapes, encouraging patients’ adherence to medication, supporting parents’ efforts at behavior management,
and addressing mood disorders in other family members
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| Is FFT effective for adolescents? in trial, patients in FFT stabilized more in depressive symptoms than those in control
group; those more depressed or more manic at beginning of trial benefitted more than those less depressed or
less manic
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| Key elements of psychoeducation for families with bipolar teens: keeping mood chart—allows patient to see how
mood varies with sleep-wake cycle; promoting good sleep hygiene—includes establishing regular bed and wake
times; avoiding caffeine and other stimulants; avoiding alcohol, street drugs, or stimulating over-the-counter drugs;
exercising early in day, not right before bedtime; avoiding working in bedroom; avoiding highly stimulating activities
before bedtime; anticipating stressors that could destabilize daily routines; developing management plan
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| “The Relapse Drill”: ask each family member what defines bad mood for him or her; what triggers bad mood? what
are palliative measures? including all family members helps bipolar child feel he or she not being singled out; palliative
measures for bipolar child include medication (may be good time to introduce emergency dose of antipsychotic
if child “really escalating”)
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| Relapse-prevention contracting: relapse prevention offers way for bipolar child to maintain control of his or her life,
even when mood starts to change; develop relapse-prevention plan when patient euthymic rather than during crisis;
identify other agents of plan, including relatives and friends; explain that “there is a brief window of opportunity”
during which early intervention may prevent hospitalization
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 | Elements of early response plan for depression: remind adolescent and parents that depression part of bipolar illness,
not personality flaw; implement behavior-activation plans (eg, get depressed adolescent out of bed, have him or
her interact with others, encourage exercise; discourage spending all of his or her time in his or her room); introduce
cognitive restructuring; develop suicide-prevention plan
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| Elements of early response plan for mania: contact physician and get emergency medical appointment; if appropriate,
have small supply of antipsychotic medication available for parents to administer; keep environment structured and
low in stimulation (use “3-volley rule,” ie, when child says something negative, parent responds negatively, and child
follows with something even more negative, time for parent to end conversation to prevent further escalation); familiarize
all family members with 24-hr on-call service or suicide hotline; try to keep adolescent from using alcohol or
street drugs; encourage consistent sleep-wake cycles; if adolescent going out, pair him or her with someone who has
better judgment during manic episode; provide help with managing money; confiscate car keys; discourage adolescent
from making major life decisions (use “2-person rule” [ie, adolescent checks with 2 people he or she trusts; if both
think idea good, adolescent can go ahead and do it] or “48-hr rule” [ie, if idea good now, still good idea in 48 hr])
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| Inquiring about medication compliance: adolescent and family may have trouble accepting diagnosis and its treatment;
if parents have accepted diagnosis, adolescent may seek revenge on them by not taking medications; adolescent asked
if he or she takes all of his or her medications will answer “yes”; better to ask indirect question such as “do you ever
have any problem taking all of your medications?” or “do you ever try to get along on your own without medications?”
or “how many pills did you miss this week?”
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| Encouraging medication compliance: avoid overly direct approach; ask if adolescent thinks medication helps him or
her to attain personal goals; provide information about various medications available for mood episodes and how
they work; discuss side effects and encourage communication with physician to help contain them; encourage adolescent
and family to stay with treatment, even when improvement not immediate or when side effects troubling;
examine role of medications in teen’s family relationships; examine subtle or overt pressure from family members
to discontinue medications; clarify symbolic significance of taking medications; encourage patient to grieve over
lost healthy self
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| Does my child really have bipolar disorder? valid question; diagnosis not always certain; having doubts natural part
of coming to terms with disorder; ask parent to evaluate his or her assumptions; if he or she accepts diagnosis,
what does it mean about future? does parent feel bad about putting child on medications? have parents reflect on
child’s and family’s strengths
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| How can we tell bipolar disorder from “typical adolescence”? difficult to distinguish; developmental psychologists
say most distinctive features of adolescence are mood swings, family conflict, and impulsivity, which also happen
to be key characteristics of bipolar disorder; true bipolar mood swings accompanied by significant functional
impairment; is child having just mood swing or irritable outburst, or is episode accompanied by bipolar symptoms?
would teen stand out among his or her peers? have peers made comments about teen’s behavior? have parents
received reports from school?
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| Stages families pass through when learning to cope with bipolar child: stage 1, path-of-least-resistance style—
parents take passive stance and tolerate adolescent’s outbursts, irritability, or aggression, or give in to his or her demands;
in short run, family tension temporarily diminished; adolescent may experience parents as compassionate,
but may also see them as unassertive or as “pushovers”; in long run, adolescent becomes bully, takes over parent’s
role, learns to exert control over others, and becomes irritable due to lack of boundaries; stage 2, passive-explosive
style—parents go along with adolescent’s dysfunctional behavior most of time, then abruptly and unpredictably
punish transgressions; in short run, adolescent stops aversive behavior due to surprise; in long run, adolescent does
not develop clear sense of rules or boundaries, sees parents as being “crazy,” “unfair,” “unstable,” or “bipolar”;
stage 3, overcontrolling style—parents use autocratic means to assure adolescent’s compliance with family rules
or psychiatric treatment; transgressions punished harshly; in short run, adolescent may comply temporarily, but
may show increases in temper outbursts or in acting out; in long run, adolescent becomes aggressive, acts out in
school, and learns to push limits; stage 4, illness-centric style—parents see most of adolescent’s behavior, including
age-appropriate mood swings, as illness-driven; they are understandably confused about when to request medication
adjustments to control fluctuations in adolescent’s day-to-day mood; they encounter frequent frustrations
with mental health system; in short run, adolescent may feel understood or may feel unfairly labeled; in long run,
style may help adolescent to obtain appropriate treatment but may interfere with his or her learning to assume responsibility
for own behavior; stage 5, balanced style—parents combine compassion with appropriate limit setting;
they use communication and problem-solving strategies to collaborate with adolescent in developing
behavioral plans; they adjust their expectations of adolescent to take into account cycling nature of illness; they
learn to take care of themselves and other family members; in short run, more time, effort, and planning required;
parents may feel guilt over imposing limits on symptom-driven behaviors; in long run, illness better managed and
adolescent develops stronger sense of personal responsibility in managing mood states
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| Accepting reality of disorder: advise adolescent and family that bipolar disorder not “a life sentence,” that many creative,
productive people have it; encourage adolescent and family to maintain healthy sense of who they are and
how their strengths can be drawn on in dealing with bipolar disorder; assure parents that way bipolar child feels
now not way he or she will feel in 3 to 6 mo; counsel adolescent that there are things he or she can do in addition to
taking medications to control mood swings
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| How else can family help? recognize that much of bipolar child’s behavior unintentional and results from his or her
illness; help child to be consistent in taking medications and in keeping all psychiatry or psychotherapy appointments;
help child to maintain regular daily routines and sleep-wake cycles; avoid overstimulation, especially at
night; help child to learn to identify and track moods by keeping daily mood chart; learn as much as possible about
bipolar disorder to facilitate recognizing early warning signs of relapse; develop plan as family for controlling escalation
of mood swings; educate adolescent about refusing alcohol or drugs; educate members of extended family
about bipolar disorder; rely as much as possible on extended family or other social-support systems; maintain tolerant,
predictable, low-key home environment; reduce expectations of what adolescent can accomplish during recovery;
try to continue normal family life as much as possible; attend to needs of all family members, especially other
children; get help for family members who have difficult time; use communication and problem-solving skills
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| How to handle irritability, provocations, and oppositionality: do not allow bipolar child’s mood to determine mood
of everyone else in family; introduce collaborative problem-solving early in escalation; employ “basket approach”
in deciding which battles to fight; use self-soothing techniques; use 3-volley rule (page 1); exit confrontations that
are becoming destructive; impose consequences if effective (if necessary, invent “creative” consequences); call police
if child becomes physically threatening
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| Disclosing to others: bipolar disorder carries stigma in American society, so advise family to disclose prudently; what is
purpose of disclosure? what do parents expect to achieve (alleviating their own discomfort better done in support
group)? who should be told? teachers? parents of friends? friends of parents? what do parents want others to do with
information? involve adolescent in this discussion so he or she does not feel that his or her confidentiality violated
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| Who should be in charge of adolescent’s medications? if child is to take responsibility, he or she must accept diagnosis
and treatment plan; child must be cognitively able to handle dosing requirements; consider whether child more
or less likely to take medications if parents take directive role; older children more likely able to take responsibility
than younger ones; do not allow medications to become battleground in which autonomy issues are fought
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| What to do if child does not agree to treatment: ultimately, parents make decision; address concerns individually
with child; what does he or she fear will happen? see if child willing to try single session of psychotherapy, with no
obligation to commit to more; if child still unwilling, refer parents to mental health provider or support group that
can provide them with stress-management techniques; give child educational materials via Web; revisit issue with
child from time to time
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| Implementing empirically supported psychosocial interventions: make available brief efficient clinical training materials;
implement particular techniques from larger treatment manuals; implement detachable self-standing treatment
modules; after brief treatment, offer follow-up maintenance sessions; encourage patients and parents to use
self-help manuals with guided exercises; consider educationally oriented support groups for patients or relatives
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| Question and answer: how does one prepare child and family for discontinuing medication? speaker does not recommend
stopping medication; standard of care is that child stays on medication long enough to show that there will be
long period of stability before discontinuing medications; bipolar disorder generally conceptualized as long-term
disorder that requires long-term treatment; if child taking several medications, may be possible to discontinue one
in future; otherwise, speaker does not talk to patient or parents about stopping medications
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Educational Objectives
| The goal of this program is to educate the listener about the role of the family in the course and treatment of bipolar
disorder in children and adolescents. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Determine if family-focused therapy (FFT) is effective in treating children and adolescents with bipolar disorder.
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| 2. Provide psychoeducation to patients and families about bipolar disorder in children and adolescents.
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| 3. Help patients and families to identify mood triggers in home and school settings.
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| 4. Educate patients and families about distinguishing age-appropriate moodiness from bipolar disorder.
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| 5. Answer parents’ questions about and address their discomfort with the diagnosis of bipolar disorder in their
child.
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Suggested Reading
Birmaher B: New Hope for Children and Teens with Bipolar Disorder: Your Friendly, Authoritative Guide to the
Latest in Traditional and Complementary Solutions. New York: Three Rivers Press, 2004; Fawcett J et al: New Hope
for People with Bipolar Disorder: Your Friendly, Authoritative Guide to the Latest in Traditional and Complementary
Solutions, Including. New York: Three Rivers Press, 2000; Frank E, Swartz HA, Kupfer DJ: Interpersonal and
social-rhythm therapy: managing the chaos of bipolar disorder. Biol Psychiatry 48:593, 2000; Fristad MA, Goldberg-
Arnold, JS: Raising a Moody Child: How to Cope with Depression and Bipolar Disorder. New York: The Guilford
Press, 2003; Greene RW: The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated,
Chronically Inflexible Children. New York: Harper Paperbacks, 2005; In Our Own Words: Teens with Bipolar
Disorder. (video) Northfield, IL: The Josselyn Center. www.josselyn.org/Store.htm; accessed March 17, 2006;
Jamison KR: An Unquiet Mind: A Memoir of Moods and Madness. New York: Knopf, 1995; Jamison KR: Touched
with Fire: Manic-Depressive Illness and the Artistic Temperament. Tampa, FL: Free Press, 1996; Miklowitz DJ,
Goldstein MJ: Bipolar Disorder: A Family-Focused Treatment Approach. New York: The Guilford Press, 1997;
Miklowitz DJ: The Bipolar Disorder Survival Guide. New York: The Guilford Press, 2002; Miller WR, Rollnick S:
Motivational Interviewing, Second Edition: Preparing People for Change. New York: The Guilford Press, 2002;
Mufson LH et al: Effectiveness research: transporting interpersonal psychotherapy for depressed adolescents (IPT-A)
from the lab to school-based health clinics. Clin Child Fam Psychol Rev 7:2512004; Papolos D, Paoplos J: The Bipolar
Child: The Definitive and Reassuring Guide to Childhood’s Most Misunderstood Disorder. New York: Broadway,
2006; Simeonova DI et al: Creativity in familial bipolar disorder. J Psychiatr Res 39:623, 2005; Wilens TE:
Straight Talk About Psychiatric Medications for Kids, Revised Edition. New York: The Guilford Press, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
Dr. Miklowitz reported nothing to disclose.
Dr. Miklowitz was recorded at Mood Disorders in Children and Adolescents, presented November 15, 2005, in
Wilmington, Delaware, and sponsored by the Nemours Alfred I. duPont Hospital for Children. The Audio-Digest
Foundation thanks Dr. Miklowitz and the Nemours Alfred I. duPont Hospital for Children for their cooperation in the
production of this program.
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