Question: Why does my child refuse to take a shower or bath, even when others might make fun of them because there is an odor?

Answer:

Many children go through phases where personal hygiene may take a back seat to other issues being addressed developmentally. Some parents become quite concerned when they note that their children appear disinterested in bathing. To most parents’ relief, most children and adolescents outgrow their need to boycott bathing and personal care. Yet in other cases, like when mental illness is active, the situation is quite different. In these cases, children and teens aren’t being merely “lazy” or “stubborn” about their personal hygiene habits, and it isn’t a choice or a willful behavior. This inability to maintain appropriate hygiene habits is a symptom of their illness. 

There are many medical reasons that contribute to why a person, even a child, will not perform basic personal and grooming tasks. In a depressive episode hygiene can be a lot of work and becomes overwhelming to think about, plan, and follow through on. It takes a ton of energy and organizational planning to bathe, trim fingernails or toenails, or to brush teeth multiple times a day. Signs of depression include fatigue and loss of energy and the ability to organize, and plan also decreases with depressive episodes. The impact of being tired and devoid of energy means they don’t have the available reserve to physically get in the shower, wash their bodies, shampoo their hair, brush their teeth, and change in and out of clothes. The process of changing underwear can seem like a daunting and difficult task. 

Another sign of depression is a loss of interest in things the person previously cared about. There may have been a time before a depressive episode where a young child or teen cared about what others thought regarding their appearance. However, during a depressive episode this social pressure or expectation no longer carries any meaning for the child or teen because they are no longer interested in acceptance from their peers and isolation is more appealing during depression. The “they will shower when their friends and classmates start making fun of them” approach is often ineffective because the child living with depression has long since stopped caring what peers and important adults in their lives think. 

Irritability is a significant symptom of depression in children and teens. You see, when we are very tired, can’t think and plan as clearly, and have lost interest in those around us, we become irritable. What might seem to a parent like a simple request for a five minute shower or to run the brush through some tangled hair can be overwhelming for a child or teen who is depressed. But to a child who is depressed and irritable it doesn’t feel like a simple or reasonable request at all and all the feelings of worthlessness, frustration, and irritability overwhelm them, like getting knocked down by a wave at the beach, and they find themselves behaving in ways they’d rather not, like screaming horrible things at their loved ones.

In manic episodes the reasons for not attending to personal care needs are different yet have some overlapping similarities. Mania also deprives the individual of the ability to attend and to focus that is necessary for bathing and other personal hygiene habits. When they experience a flight of ideas when they can’t settle on any one idea or activity, or they get stuck in “mission mode” and can’t be distracted or redirected away from a driven behavior it might become impossible to engage in hygiene routines. If a child experiences rapid-cycling and is having abrupt mood changes many times a day, those episodes are going to disrupt their ability to plan, or follow through on a plan made by others. In those cases, refusal to bathe can look like an oppositional and/or defiant response. 

In the absence of other symptoms, neglecting and avoiding personal hygiene and grooming may serve as an indicator that the child is not stable. Hygiene can be one of several measures to track symptoms and how well or how stable a person living with bipolar is at the moment in time.