The following excerpt is taken from Chapter 3 of
Bipolar Disorders: A Guide to Helping Children and Adolescents
by Mitzi Walsh, copyright 2000 by
O'Reilly & Associates, Inc. For book orders/information, call
(800) 998-9938. Permission is granted to print and distribute this
excerpt for noncommercial use as long as the above source is
included. The information in this article is meant to educate and
should not be used as an alternative for professional medical care.
Discipline is difficult when a child has any type of mental or neurological illness. Not only do the old rules not always apply, you have to be flexible about behaviors that are due to your child's illness. Because bipolar disorders wax and wane, this is particularly hard to do if you want to maintain consistency. If your child is a rapid cycler, the challenge of responding properly is even bigger.
The best strategy is to be proactive. Use preventative measures like the mood and behavior diary, consistent medical care, and daily structure to reduce the opportunity for mood swings and associated problem behavior. Eliminate sources of serious danger from your home.
When your child is well, discuss measures you should take when he is not able to help acting out. Set up a system of signals he can use to let you and his teachers know when he needs extra help in controlling his behavior. These can help you gracefully remove him from a situation, such as a Little League game or classroom, before things get out of hand.
Set up a safe place at school and at home where he can take a "self time-out" when stress starts to build up too high. At school, this may be a resource room, a quiet office, or the library. At home, it may be your child's room or a cushy living-room chair. When you're out in the community, your car can become a refuge, or you can search out a public restroom, restaurant booth, or park bench. Most people prefer a feeling of being safely enclosed when they're on the verge of losing it. Some kids find that full-body pressure seems to calm the storm, and may benefit from being held by a parent, swaddled tightly in a blanket, or under a mattress, heavy blanket, or sofa cushions.
Your child's physician may be able to prescribe a tranquilizer or other medication for use as needed in emergencies. Make sure you thoroughly discuss when, how, and how often this medication can be used. If you don't have emergency medication available, an over-the-counter antihistamine like Benedryl can sometimes help calm a raging, sleepless, anxiety-plagued child temporarily. Obviously, you don't want to make this a regular practice.
Most parents and school behavior experts have found that positive consequences are more effective than negative consequences at keeping kids with bipolar disorders on track. Many behavioral classrooms use a "token economy" to encourage good behavior. Each improvement or positive action merits a star or other mark on a chart, or a physical token such as a poker chip or paper chit. When a certain number of stars, chips, chits, or other tokens have been earned, there's a reward. Classroom rewards may include computer time, play time, having lunch with the teacher, or small items like stickers or nifty pencils.
You can adapt the token economy system for use at home, tying an allowance, event, special time with parents or siblings, or other desired reward to earning a certain number of tokens. Try not to set the bar too high, of course. Start out with easily achievable goals and small rewards, and work up from there. Try not to take away tokens for negative behavior--just firmly refuse to give tokens for anything but positive, desirable behavior.
Children shouldn't expect a treat for every good deed, of course. Your goal should be to eventually make a hug, smile, or positive statement about the behavior reward enough, and, in the long term, to make the warm inner feelings your child gets from behaving well and helping others to be a sufficient incentive. Giving rewards for good behavior goes against the grain for many parents. It may help to remember that bipolar kids don't always get those good feelings from good behavior. In fact, controlling their own behavior and complying with requests can be anxiety-producing, even almost painful. By adding a tangible incentive, you're chipping away at a disordered nervous system that has previously been reinforcing the wrong behavior, and working against the desired behavior.
Be sure to catch your child being good whenever you can. Too often discipline stresses and even reinforces bad behavior by giving it more attention than the positive things children and teenagers do. Be more lavish with your praise when warranted than you are with your disapproval and anger.
Sometimes parents need to take a self time-out. We've all had those days when a long string of minor misbehavior and stress adds up to a major blow-up over some little thing, like a ball thrown in the house or a spilled soda pop. Model the same stress-busting techniques that you encourage your child to use, whether it's deep breathing and counting to ten, or going to your room for five minutes . Your example is probably the best teaching tool you have.
Many parents have found Ross Greene's excellent book, The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children to be very helpful. Greene encourages parents and teachers to employ what he calls the basket system: use the mental device of several baskets to sort your rules in order of importance. Rules and chores that go in Basket A are the essentials. The rest go in Baskets B, C, and so on, in order of descending importance. Greene stresses the need to pick your battles carefully when dealing with a child who is oppositional, tantrums or rages easily, and has out-of-proportion reactions to small disagreements or requests. It's good advice, especially when your child is in the throes of a depressed, manic, or mixed state.
We have found that listening to our child's requests, or sometimes demands, is very important! Our style of managing our children has been a complete turnaround from how we raised our children "before bipolar." We have really tried to listen and pick our battles carefully. --Bob, father of 18-year-old Shannon (diagnosed bipolar I disorder)
The more you learn about the behaviors associated with bipolar disorders in children, the easier it will be to divide purposeful bad behavior from behaviors that are due to the illness itself. Even if the outcome of the behavior is the same--a broken window, for example--consequences may have to vary a little. For instance, whenever a window is broken, restitution is the natural and logical consequence. If the window was broken during a blind rage during a depressed or manic episode, however, a lecture or an immediate demand for payment will probably just make the situation worse. A child who is out of control is unlikely to be able to listen. Simply state what the consequence is, and mention that you'll talk about it later when the child is feeling better.
You can expect for there to be some disparity between your child's behavior at home and at school. Many kids with bipolar disorders work so hard to hold it together at school that they fall apart at home. By adding some accommodations at school that take the pressure off a bit, you may be able to achieve a happy medium. Until then, do your best to keep after-school time, weekends, and vacations structured for low stress.
Make sure that consequences you apply for misbehavior, willful or otherwise, fit the description of "natural and logical consequences." Bipolar children have a passion for fairness that often escalates into yet another battle if the punishment does not fit the crime. Parent Effectiveness Training (PET) and similar programs for helping parents of nondisabled children improve their discipline strategies won't fit your needs entirely, but they can help you learn more about identifying natural and logical consequences.
Physical punishments such as hitting or spanking really have no place in managing the behavior of a person with bipolar disorder, regardless of age. They simply teach that pain and force are a good way to impose your will on others, and that's not a lesson you want to teach someone who already has problems with impulsivity, limit-setting, and aggression.
If you're having a hard time managing your child's behavior without getting physical, you're not alone. Almost every parent of a child with a bipolar disorder has crossed the line sometime, and felt tempted to do so many more times. Reach out for help to increase your repertoire of techniques through consultation with a behavior expert, or with parenting training that is geared toward working with mentally ill children. You should be able to access help through your school district, a government mental health agency, a hospital with a psychiatric care department, or private programs.
Also try to build a personal support system made up of friends and family members, an online or in-person support group, or even a telephone crisis line for parents. It's tough to discipline any strong-willed child, and having someone to talk to can really help you keep up the struggle without resorting to violence. This advice goes double for single parents.
Children and teens with bipolar disorder may themselves be physically abusive when in a depressed, manic, or mixed state, or even when a regular confrontation escalates into a tantrum or rage. Your first duty is to protect yourself and others from harm. This can mean removing the child to a time-out area, sending a teenager to her room (and possibly locking her inside), using protective physical holds, and in some cases seeking emergency medical and/or law enforcement help.
Knowing how to physically control your child safely is a must. Improper physical restraint can injure or even kill. Ineffective holds only end up causing harm to you or others in the vicinity. Surprisingly, your relative size doesn't make much difference if you know the right techniques. Call the nearest colleges and find one that offers a psychiatric nursing program. Ask them about Professional Assault Response Training (PART) or similar programs that teach psychiatric nurses how to protect themselves from violent patients. The PART program is usually a two-day course, and can teach you several physical control techniques that will be both effective and safe for your child or teenager. You may also be able to access PART training or a similar course through your local mental health department, a hospital that has a psychiatric staff, or even a police department. Your child's teacher or classroom aide may also need to have this training.
Note for professionals: Professionals need to be very sensitive to the safety needs of families with aggressive, even violent bipolar children. Parents and siblings should never have to endure physical attacks, nor can they bear up under constant and extreme verbal abuse for long. When safety is at stake, it's best to treat the patient aggressively and rapidly, up to and including referring her for day treatment or hospitalization. Remember that while a child's aggressive behavior may be tolerable to you in a 45-minute office visit, the patient's family must endure the same behavior (or worse) day and night.
Don't underestimate a child's power to harm himself or others while in a depressed, manic, mixed, or psychotic state. Such children have been known to set deadly fires, injure or kill pets, attempt to stab or strangle family members, and attack with a level of violence and physical strength that surprises adults. The risk of suicide, even at ages as young as three or four, is also very real. Many parents of bipolar children report that their child has attempted to jump from a moving vehicle, run into fast-moving traffic, or leap out of a window. The same parents also report that their pleas for help have not always been taken seriously by professionals, even when they report these frightening incidents. The calm child you see in your office may indeed be the raging maniac the parent is describing--that disparity in behavior from day to day, even minute to minute, is the essence of bipolar disorders.
However, if you are using physical holds or locking your child in a room for protection, you do run the risk of being investigated by child protective services. In fact, some troubled young people use allegations of child abuse to get revenge on their parents. Your best strategy is to be proactive: consult with your child's medical team, and have them put their emergency recommendations in writing. Get training, be careful, stay calm and kind, and if you are contacted by the authorities, bring in your experts to help.
Other people with a bipolar disorder turn their violent impulses on themselves, banging their heads on walls, slicing their arms, or otherwise harming their own bodies. This isn't a discipline problem, it's a medical issue. Usually these self-injurious behaviors (SIB) are not suicide attempts, but physical expressions of inner pain. Nevertheless, they can cause serious self-harm.
Let your child know that she can talk to you about these impulses and behaviors, and that there will never be any shame or punishment attached to SIB. Medication changes can usually help, but therapeutic relationships with parents and/or professionals are the key to reducing and eventually eliminating self-injurious behaviors. Sometimes SIB in young children is related to another health condition, such as ear infections. It can be a good idea to eliminate these possibilities before you change or start psychiatric medication.
Verbal abuse is also very common during depressed or manic phases, and may occur at other times as well due to the increased impulsivity and thought errors that characterize bipolar disorders. To the best of your ability, simply end the conversation, and refuse to react to taunts and insults. Realize that these words are coming out unbidden, and that your child will probably be shocked at what he has said later. Don't demand an apology on the spot, as it will only escalate the situation. Wait to discuss the verbal abuse later, when your child is well and calm. Don't be accusatory, just let him know that your feelings were hurt--and that you love him anyway.
Disciplining teenagers is difficult under the best of circumstances, but it's doubly so when your adolescent has mood swings and the other behavioral challenges associated with bipolar disorders. The techniques that worked when your child was younger may seem babyish now, and physical control is tougher when your child is larger and more wily about telling lies, slipping out of the house at night, and acting independently in the world. Keep applying proactive measures to protect your child, family, and community as best you can. Don't be afraid to call in reinforcements--the parents of your child's friends, your neighbors, teachers and other school personnel, mental health professionals, sometimes even the juvenile authorities--if your teen's behavior is bringing him into conflict with the law.
When things get tough, don't try to go it alone.