Help At Home: For Parents of Bipolar Children

Suggestions for parents of bipolar children in dealing with situations caused by the illness.

At home, as well as at school, providing a sympathetic and low-stress environment and making some adaptations may be helpful to aid a child or adolescent with bipolar disorder.

• Understand the illness. Understanding the nature of bipolar disorder, its unpredictability, and its consequences for the child will help parents sympathize with a child's struggles. Children whose behavioral symptoms make life stressful for the whole family are most likely vulnerable people who wish they could be "normal" like other kids. It is also important to keep in mind that because children with bipolar disorder are frequently quite impulsive, their actions "in the moment" may not reflect behavioral lessons they have already learned.
• Listen to the child's feelings. Daily frustrations and social isolation can foster low self-esteem and depression in these children. The simple experience of being listened to empathically, without receiving advice, may have a powerful and helpful effect. Parents should not let their own worries prevent them from being a strong source of support for their child.
• Distinguish between symptoms, which are frustrating, and the child. "It's the illness talking." Taking a supportive stance in which parents, child and clinicians unite together to fight symptoms is an effective strategy to encourage a child who is doing the best he or she possibly can. Sometimes it is useful to help the child distinguish himself or herself from the illness ("It sounds like your mood is not very happy today, and that must make it extra hard for you to be patient").
• Plan for transitions. Getting to school in the morning or preparing for bed in the evening may be complicated by fears, anxieties, and the child's fluctuating energy and attention level. Anticipating and planning for these transition times may be helpful for family members.
• Adjust expectations until symptoms improve. Helping a child make more attainable goals when symptoms are more severe is important so that the child can have a positive experience of success. This requires reducing stress on the child where possible: taking a break from after-school activities if they become too stressful, allowing a child who is not functioning well to cut back on homework, and supporting the child's decision to stay home from large social or family functions that may feel overwhelming, for example.
• Keep the "small stuff" small. A parent may need to choose which issues are worth having an argument over (such as hitting a sibling) and which issues are not worth an argument (tonight choosing not to brush teeth). These decisions are not easy, and at times everything may appear to be important. Parenting a child with bipolar disorder requires flexibility that will reduce conflicts at home and instill healthy habits in the child. 
• Understand parental limits. Fulfilling a child's extreme wishes related to symptoms (for example, strong and persistent urges to buy things) may be neither possible nor advisable. Such well-intended efforts to support a child may actually delay the development of new coping strategies and reduce the benefits of behavior therapy. Finding the balance between supportive flexibility and appropriate limit setting is frequently challenging for parents and may be aided by the guidance of a trained professional.
• Talk as a family about what to say to people outside of the family. Determine what feels comfortable for the child (for example, "I was sick and got some help, and now I'm better"). Even if the decision is made not to discuss this medical condition with others, having an agreed-on plan will make it easier to handle unexpected questions and minimize family conflicts about this.
• Behavioral plans may be useful to reinforce a child's successful efforts. Children tend to benefit from behavioral plans that reward good behaviors (rather than punish misbehaviors) because they may otherwise feel as though they get feedback only about their mistakes. Please see the table below.

Behavioral Plans

Provide frequent acknowledgments of success. Experts encourage doing this six times per hour at home. This pattern may not be one parents grew up with, but it is an easy and effective means to help a child develop new habits. For example, tell the child, "Great job getting the table cleaned off with no sticky spots at all," rather than, "I've told you twice already to go pick up your clothes once you get the table cleaned off."

Reward the child for making efforts to reduce problem behaviors. Avoiding a tantrum, demonstrating flexibility in a potentially difficult situation, or increasing times without a rageful episode can all improve daily life and warrant reward or acknowledgment.

Develop meaningful incentives with the child. Praise, gold stars on a calendar, or sitting beside a parent in the car can all be effective rewards. Parents will need to determine with their child what the reward is, and will need to be consistent with the plan for it to be effective. Tangible reminders help children learn that they can be responsible for their actions and will be recognized for their good efforts. Parents can look to the school psychologist or guidance counselor or to their child's treatment professionals for help in developing behavioral plans for the home.

A chart system is often effective, in which a certain number of stars per day may be "cashed in" for the reward (an extra story with a parent, a trip for ice cream, etc.). It is essential that these rewards not become the source of additional conflict. If the child doesn't have the required "points" for a reward, rather than saying, "No, you don't get your treat because you didn't pick up all your clothes today like we asked," parents report more success when they say, "You picked up all your clothing for six days so far-just one more day and you'll earn that ice cream we talked about for picking up for a whole week." Parents need to set appropriate limits, such as saying "no" to an extravagant toy as a reward. On the other hand, the reward needs to be something the child enjoys and will be motivated to earn.

Sources:

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Association, 1994
• Dulcan, MK and Martini, DR. Concise Guide to Child and Adolescent Psychiatry, 2nd Edition. Washington, DC: American Psychiatric Association, 1999
• Lewis, Melvin, ed. Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd Edition. Philadelphia: Lippincott Williams and Wilkins, 2002