CMHRC’s archive of questions and answers has been curated especially for our community. These FAQ’s represent commonly asked questions about mood disorders, bipolar disorder, and its newly identified phenotype, dubbed “FOH”.
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When a child is diagnosed with a chronic physical illness, such as living with juvenile diabetes, their parents typically do everything they can to learn absolutely everything about diabetes, what the signs and symptoms of high or low blood sugars are, how to properly administer insulin, and the appropriate accommodations their child needs in their varied settings. In fact, parents of children with diabetes are often provided counseling on nutrition and medications, support and encouragement, and educational classes for how to manage the disease day to day. They are given reading material, online resources, a 24 hour nurse line, and a myriad of kits and age appropriate materials for their children. As with any serious medical condition, parents want to learn all they can in order to meet their child’s needs, see their child thrive, share the best possible quality of life, and achieve stability and wellness.
But when a child is diagnosed with a mental health disorder these comprehensive support systems aren’t offered or implemented, and families are often left feeling confused, without the information and resources they need to understand how to best help their children.
We have to remember that living with a mental illness is living with a serious medical condition. Families need the same level of information and support in order to understand the challenges they and their child are facing in regards to the illness. When a child is diagnosed with a mental health disorder it’s essential for parents to be able to learn as much as they can with as much support as possible.
For example, if a child lives with bipolar then knowledge of the symptoms of depression, mania, mixed mood episodes, and ultra rapid cycling is vital. These kinds of episodes need to be identified as symptoms and differentiated from willful behaviors so they can be treated appropriately by family and caregivers. The symptoms also need to be reported accurately to the child’s providers in order to help inform treatment decisions. It simply isn’t appropriate to expect that parents and caregivers should understand how to do this without education, coaching, support, and encouragement.
Children and adolescents benefit when their parents and caregivers partner with physicians to make decisions about what medications are going to best manage symptoms. This requires parents to have knowledge about terminology, how symptoms present, which medications treat their child’s illness and which are contraindicated, what symptoms each medication is targeting, and how to assess what impact those medications are having.
Additionally, parenting approaches can be adapted to specifically address the symptoms to decrease stress within the home for everyone living there. It is also important for parents to understand what a mental health emergency looks like, how to manage it, and who to contact. Having the right treatment plan, as early as possible, is critical to achieving better outcomes sooner.
But again, parents aren’t magically granted these fundamental skills when a diagnosis and a prescription are given. Currently it’s still up to parents to find their own support system, education, and resources for managing at home. But you’re not alone and don’t have to reinvent the wheel. CMHRC is here to help.
CMHRC provides families and providers with all the support, education, resources, and encouragement needed to ensure you and your child are able to learn, manage, and thrive.
In 2010 the APA Board of Trustees approved and announced changes for the upcoming release of DSM-5. Some changes were made in order to address a controversy among psychiatric experts about whether or not children should be diagnosed with bipolar disorder.
Starting in the 1990’s and early 2000’s more psychiatrists began recognizing and treating children living with bipolar. But the psychiatric community was contentiously divided on this practice. Some medical and psychiatric professionals were unhappy about the increase in pediatric bipolar diagnoses. They cited multiple concerns, including the fact that they didn’t want children to have to cope with a lifelong diagnosis (which bipolar is), the stigma associated with bipolar, and the serious medication used to treat bipolar.
As a result, pediatric onset bipolar disorder had become a controversial idea. So, the DSM committees looked for a way to both mitigate the controversy and to limit diagnosing of children with bipolar disorder. This resulted in a new diagnosis that could be given to children who otherwise would have been diagnosed with bipolar:
This new disorder is called Disruptive Mood Dysregulation Disorder or DMDD for short.
The DSM Committees concluded that since some children met the criteria for bipolar disorder with clear episodes of mania (even if they are short), but other children experienced chronic or frequent irritability and/or temper outbursts, there must be two different disorders. What the experts failed to take into account is that frequent irritability and/or temper outbursts can also be signs of both depression and mania in children.
During the public comment period that followed the announcement of DMDD as a new DSM-5 pediatric diagnosis many people objected and submitted concerns. Those who expressed dissenting opinions included such notable organizations and individuals such as the National Alliance for Mental Illness (NAMI) and Dr. Demitri Papolos, author of the Bipolar Child and the research director at the Juvenile Bipolar Research Foundation (JBRF).
One notable concern was this new diagnosis didn’t actually bring the medical community any closer to an effective and reliable treatment for the symptoms children continue to experience. In fact, many children diagnosed with DMDD are prescribed treatment plans that include medications that are specifically not supposed to be prescribed to patients with bipolar disorder, and can cause symptoms to become worse, not better.
Another problem with the committee’s justification for DMDD relates to its concern about prescribing significant mood stabilizers to children. You see, kids are already being prescribed medications (such as antipsychotics) that have serious side effects, which include significant weight gain, increase in cholesterol levels, and an increased risk for type 2 diabetes. So, the questions around prescribing weren’t resolved with the introduction of DMDD.
There are serious outcomes as a result of delaying a bipolar diagnosis in children in favor of DMDD. When a child actually has bipolar disorder, diagnosing DMDD and providing DMDD focused treatments delays the introduction of effective treatments targeted at the causes and effects of bipolar symptoms. This means that neuroprotection is delayed and children don’t have the chance to develop improved functioning across all aspects of daily living.
A misdiagnosis can rob children of their childhood.
At this particular point in time, DMDD is one of the diagnoses of choice for children who express high levels of irritability and temper outbursts. Since both of these symptoms are also signs of depression, mania, and anxiety in children, without also looking to see if there are other symptoms of bipolar a lot of kids wind up being misdiagnosed and given the wrong medications. It is vital that children living with bipolar be identified as early as possible in order to have the best outcomes.
Targeted medications, effective psychotherapies, appropriate accommodations and modifications in academic settings, non-pharmacological solutions, and support to caregivers can positively impact the trajectory of bipolar in young children, emphasizing the need for a more timely and accurate diagnosis.
When a child is diagnosed with a chronic physical illness, such as living with juvenile diabetes, their parents typically do everything they can to learn absolutely everything about diabetes, what the signs and symptoms of high or low blood sugars are, how to properly administer insulin, and the appropriate accommodations their child needs in their varied settings. In fact, parents of children with diabetes are often provided counseling on nutrition and medications, support and encouragement, and educational classes for how to manage the disease day to day. They are given reading material, online resources, a 24 hour nurse line, and a myriad of kits and age appropriate materials for their children. As with any serious medical condition, parents want to learn all they can in order to meet their child’s needs, see their child thrive, share the best possible quality of life, and achieve stability and wellness.
But when a child is diagnosed with a mental health disorder these comprehensive support systems aren’t offered or implemented, and families are often left feeling confused, without the information and resources they need to understand how to best help their children.
We have to remember that living with a mental illness is living with a serious medical condition. Families need the same level of information and support in order to understand the challenges they and their child are facing in regards to the illness. When a child is diagnosed with a mental health disorder it’s essential for parents to be able to learn as much as they can with as much support as possible.
For example, if a child lives with bipolar then knowledge of the symptoms of depression, mania, mixed mood episodes, and ultra rapid cycling is vital. These kinds of episodes need to be identified as symptoms and differentiated from willful behaviors so they can be treated appropriately by family and caregivers. The symptoms also need to be reported accurately to the child’s providers in order to help inform treatment decisions. It simply isn’t appropriate to expect that parents and caregivers should understand how to do this without education, coaching, support, and encouragement.
Children and adolescents benefit when their parents and caregivers partner with physicians to make decisions about what medications are going to best manage symptoms. This requires parents to have knowledge about terminology, how symptoms present, which medications treat their child’s illness and which are contraindicated, what symptoms each medication is targeting, and how to assess what impact those medications are having.
Additionally, parenting approaches can be adapted to specifically address the symptoms to decrease stress within the home for everyone living there. It is also important for parents to understand what a mental health emergency looks like, how to manage it, and who to contact. Having the right treatment plan, as early as possible, is critical to achieving better outcomes sooner.
But again, parents aren’t magically granted these fundamental skills when a diagnosis and a prescription are given. Currently it’s still up to parents to find their own support system, education, and resources for managing at home. But you’re not alone and don’t have to reinvent the wheel. CMHRC is here to help.
CMHRC provides families and providers with all the support, education, resources, and encouragement needed to ensure you and your child are able to learn, manage, and thrive.
Dissociation is the act of disconnecting from some part of the brain, body, senses, memories, or environment. During a dissociative episode the body is able to compartmentalize discomfort or distress by detaching from the source of the stress. It is a normal and common occurrence most people experience and can happen when scrolling through social media and “losing track of time”, or when the “mind wanders” while driving and the person doesn’t actively remember the details of their drive, which is often referred to as being on “autopilot”.
For those who experience trauma, cumulative stress, anxiety, and other effects of mental illness, dissociating is the body’s way of coping and protecting itself from real or perceived danger.
Dissociation can take on different forms. Three common forms children living with FOH report are
Depersonalization is feeling detached from parts of your body such as a hand or arm, but it can also include feeling detached from one’s emotions. In this case, an individual might not “feel real” or the experiences they are having don’t feel as though they are actually happening to them. It can feel like being an outside observer of oneself and the body is a completely separate entity from that person.
Derealization is feeling detached from one’s surroundings or environment, and things don’t appear real. A six year old identified living with the bipolar phenotype FOH described it as feeling as if other people were fake, he wasn’t sure if maybe his parents were robots.
Another form of dissociation is localized amnesia. It is memory loss that can occur for a very short amount of time (minutes to an hour).
When people live with mental illness, it is common for the mind to attempt to cope with overwhelming stress or trauma through experience depersonalization, derealization, and to a lesser degree localized amnesia.
Living with FOH is traumatic, especially before accurate diagnosis and treatment. Very real and traumatic features of this medical condition include remembering or re-experiencing gory graphic nightmares, being unable to control aggressive and irritable mood outbursts, feeling paranoia, severe anxiety, obsessive or intrusive thoughts, and fearing that something bad is going to happen to oneself or loved ones.
It’s common for children who have experienced an energized explosive rage episode not to recall the damage that was caused as a result of their illness.
Every part of the brain and body is impacted by this illness, and it impacts how they see themselves, how others view them, their relationships, and their ability to function throughout the day. Instinctively people who live with chronic stress and trauma “shutdown” (dissociate) to escape these kinds of situations and experiences. Dissociating is not a choice or willful behavior. On the contrary, it causes further distress. Feeling as if the world around you is not real, or body parts are not real, can lead to panic, anxiety, or additional trauma.
Learning there is an explanation for the symptoms, and understanding FOH, provides a path to a recovery process through knowledge, healing , and hope.
The goal is to learn more adaptive ways to cope with the illness to reduce symptoms of bipolar and FOH, and as a result reduce or resolve dissociative symptoms.
Suggestions for helping to cope with dissociative symptoms include:
One tool currently available for mood tracking is CMHRC’s Toolkit. This tool helps track overall mood, specific symptoms, medications, and even the weather. Using the Toolkit helps patients and caregivers get a clear picture of when, why, and how disruptive dissociative episodes occur and impact daily life. Parents can also encourage their children to keep a journal to compare the individual’s experiences with those that are observed by others.
Parents and caregivers can join supportive communities, like CMHRC’s membership program, to meet face to face with other parents who live with the same mental health disorders. This connection not only helps parents understand their child’s illness better, but support group meetings are a place where caregivers can share information on effective therapies, interventions, school accommodations, cooling products, and other issues that help families transform from living with unrelenting symptoms to finding the peace and harmony they need to thrive.
Mindfulness activities such as meditation, visualization, progressive muscle relaxation, deep breathing, and grounding techniques help keep individuals in the moment and connected to their bodies as they navigate daily life with unpredictable symptoms.
elf-care is essential for both patients and caregivers. An easy way to do this is to build enjoyable activities into your weekly schedule so they are more likely to happen and are not dependent on mood fluctuations.
Proactive cooling measures reduce overheating and can assist in avoiding a medical emergency or an urgent overwhelming cascade of symptoms.
One of the three pillars of good and effective treatment includes working with a therapist who specializes in early onset pediatric bipolar and has knowledge on dissociative symptoms. It is important to disrupt the dissociative symptoms as soon as they begin to occur. This helps to stop dissociative experiences when they happen, and to reduce their use as the default coping mechanism when a stressful trigger is presented.
Through the use of these tools it is possible to find relief and reduce symptoms.
Unfortunately, there’s still a fair amount of controversy over whether or not children can be diagnosed with bipolar disorder. Many people assume (or have been taught) that kids can’t have bipolar disorder because their symptoms don’t match the ones that are listed in the DSM for bipolar I or bipolar II. But those criteria were written to describe adult symptoms not childhood symptoms.
While there are some children who will exhibit adult symptoms such as clearly defined episodes of mania, grandiosity, or depression that last for days or weeks at a time, most children don’t follow this pattern. Most children with bipolar experience very frequent mood changes, which occur multiple times a day, and which never last long enough to meet the adult criteria. Additionally, their manic episodes might be hard to identify because they seem irritable and angry rather than excited and happy. Other times manic episodes, because they can be so short in duration, appear to be evidence of the distractibility and hyperactivity associated with ADHD.
But kids with bipolar disorder are usually very bright, creative, kind, and loving when they are stable, and they suffer tremendously as a result of their symptoms. They are often very ill and require treatment that works. Their symptoms are typically include:
Unfortunately, as a result the related confusion kids with bipolar disorder are often left undiagnosed, or just as bad, misdiagnosed with multiple other diagnoses such as ADHD, DMDD, ODD, or GAD*. These misdiagnoses often result in treatment with antidepressant ‘SSRI’ medications or stimulants which can worsen their symptoms.
Many mental health providers won’t even consider giving a child a diagnosis of bipolar disorder even when the symptoms are present because either they incorrectly believe they have to wait until the child is in their mid-to-late teens before making the diagnosis, or because they consider bipolar “too serious” a diagnosis to give a child because it is a life-long condition which requires significant medication management with mood stabilizers. These circumstances often lead to delays in treatment, and on average it can take 10 years for a child with bipolar disorder to be properly diagnosed.
If you think you or your child may be suffering from childhood onset bipolar disorder and need help understanding how to differentiate bipolar disorder from other mental health diagnoses CMHRC is here to help. Consider engaging the CMHRC Diagnostic Consultation Service where you can speak with a professional who can provide clarity regarding the diagnosis and can answer your questions. Schedule a consultation today.
*Attention Deficit Hyperactivity Disorder; Disruptive Mood Dysregulation Disorder; Oppositional Defiant Disorder; Generalized Anxiety Disorder.
While often difficult to distinguish between, there are some distinct differences between mood and thermoregulatory symptoms which get easier to understand the longer you’re looking at them.
First of all, it’s important to remember that everyone experiences mood fluctuations throughout the day, and that is considered completely normal. Even for kids and adults with mood disorders, minor mood changes throughout the day are nothing to worry about. However, with clinically significant mood disruptions those changes in mood occur rapidly, unexpectedly, and without a clear cause. They include symptoms of depression and mania (or hypomania).
As for the thermoregulatory disturbances that go along with Fear of Harm, they trigger symptoms that can look like mood disruptions, but they really aren’t. Those symptoms are governed by the temperature disruptions and include fear, anxiety, hypervigilance, aggression, and sleep disruptions.
But let’s start with understanding thermodysregulation, which is the body’s inability to correctly regulate its temperature. This is a physical phenomena that may be independent from the mood disruptions explained above.
The ratio between proximal and distal body temperature is a measure of how well the body is shifting core heat to the skin so that it will be dissipated. Clinical signs of a disturbance in this system may sometimes manifest in the following ways:
This disruption in body temperature regulation leads to several other symptoms.
Sleep/Wake Disturbances, which are categorized in three different ways:
Fear/Anxiety, which is triggered because the part of the brain that controls temperature regulation is the same part of the brain that controls the activation of the fight or flight instinct. As a result, children with thermoregulatory disturbances experience a triggering of their fight or flight response when it’s not needed, causing them to feel intense anxiety and fear. The child is on constant alert, looking for threats and dangers, causing separation anxiety, fear of germs, fear of intruders, or of the dark to be pushed to debilitating degrees. They create elaborate rituals at bedtime, mealtime, or bath time to help them feel safe.
Functioning in a near constant state of fight or flight also results in distorted reactions to normal stimuli. They experience threats that don’t exist, either by misperceiving something neutral in their environment as threatening, or by feeling excessively defensive from feeling embarrassed, misunderstood, unheard, dismissed, or rejected.
Aggression can be tricky because all children can be aggressive at times and it can be difficult to differentiate clinically significant aggression from either normal childhood behaviors, or from other diagnoses.
It’s developmentally normal for young children to have tantrums. However, in a child triggered by thermodysregulation their tantrums continue for many years past what is considered developmentally normal. The tantrums also can last for several hours and are accompanied by physical and verbal aggression, such as screaming, throwing things, slamming doors, putting holes in walls, kicking, hitting, biting, and scratching. These behaviors escalate with the child’s age to include cursing and verbal threats.
Parents know when their child’s tantrums are unusual and deviate from the developmentally normal outbursts that occur in early childhood.
Aggression is also shown in other ways such as defiant and oppositional behavior and refusals to follow simple instructions, complete expected tasks, and do basic chores such as teeth brushing, showering, homework, and getting dressed. Requests can be met with verbal abuse which can quickly escalate into tantrums, leaving parents, siblings, and caregivers feeling as though they are walking on eggshells all of the time.
So what does mood stability look like then?
Generally speaking, mood stability while someone is still experiencing thermoregulatory disturbances and their accompanying symptoms, would look like this:
This is a question people ask all the time about kids and bipolar. The truth is that in the DSM (Diagnostic and Statistical Manual of Mental Disorders) the symptoms listed for bipolar disorder reflect the way the disorder impacts adults. There isn’t any specific criteria written in there for children except for two small “notes”:
This brief notation minimizes the degree to which irritability plays a significant role in the depressive, manic, and hypomanic mood states of bipolar disorder as well as in anxiety.
The short answer is that kids and teens with bipolar disorder often don’t have the capacity to understand what is happening to them when symptoms hit. This can cause them to be reactive and irritable with an elevated stress response when they are symptomatic.
From the outside, to adults who are present, this may seem to be irrational or can be perceived as willful, intentional, disrespectful, or manipulative chosen behaviors. But this is most certainly not the case. For the child or adolescent with bipolar disorder, ‘FOH’, or other mood disorders they are actually the victim of their illness and the active flare-up of symptoms over which they have no control. Treating this symptomatic irritability as a choice, and meeting it with discipline or punitive consequences does nothing to support the child, nothing to reduce the symptom flare-up, and nothing to modify the so called “behaviors”. Additionally, it actively damages the child or adolescent’s self-esteem, reinforcing the misperception that they are a “bad kid” because they have an illness.
The longer answer involves understanding the exhausting and spiraling impact of the stages of the stress response and the fact that individuals with bipolar disorder are constantly being thrown into this stress response due to their overly-taxed stamina reserves.
The Alarm Stage triggers the fight-flight-freeze response which can cause any of those three responses to occur. This can happen regardless of whether or not the trigger is perceived or understood by others.
The Resistance Stage starts as the fight-flight-freeze response starts to diminish. But the body is still on high alert, waiting for any other threats that might be on the heels of the first. If threats (even misperceived ones) are happening one after the other, and have overlapping recovery periods, then the body stays on high alert all of the time and continues to produce stress hormones that keep the cycle going. Signs of an ongoing resistance stage are:
The Exhaustion Stage is the logical consequence of the previous two stages. In this stage the avalanche of ongoing stress drains the child or adolescent’s mental, physical, and emotional resources. At this point stress tolerance drops even further, with an inability to cope with even the smallest of setbacks, and levels of anxiety, fatigue, and depression all rise.
It’s easy to see how these factors combine to make irritability a hallmark, and often misunderstood, feature of bipolar disorder and its symptom presentation.
Thermoregulatory Sleep Dysregulation Disorder
Fear of Harm (of FOH for short) is the name given to a specific set of symptoms that appear in about ⅓ of all people with bipolar disorder. That’s about 250,000 children and nearly 2 million adults who are estimated to have FOH. Its symptoms can be debilitating and devastating to live with. One thing that makes it unique in the world of mental health is that it has a physical symptom that actually makes it much easier to identify that you might realize.
FOH was first identified by researchers at the Juvenile Bipolar Research Foundation who were looking at the symptoms of about 6,000 kids who had been diagnosed with bipolar disorder. What they saw was that in addition to the classic depressive and manic symptoms of bipolar disorder, the kids with this new set of symptoms also showed elevated anxiety and fearfulness which seemed to mimic a trauma response and included hypervigilance and believing they were in danger when they weren’t.
These kids also had incredible trouble with all aspects of sleeping, including falling asleep, staying asleep, waking up in the morning, and they often had horrible nightmares that would continue to traumatize them during the day with recurring images from the dreams.
Most interestingly, these kids also had difficulty keeping their body temperature regulated and they spent a lot of time overheated and angry. Further examination of these symptoms made the researchers realize that they were actually looking at a symptom cluster that showed a new diagnosis.
Because one of the hallmark symptoms of this disorder is the incredibly high levels of fear the researchers started calling the new type of bipolar disorder “Fear of Harm” for short.
After 15 years of research into the causes and treatments for Fear of Harm it’s undergone more than one name change, and who knows what the DSM committee will decide what to call it once it makes its way to their collective desk. But one thing that has stayed the same is that it can be identified based on the symptoms that appear in addition to the classic bipolar symptoms of mania and depression.
Those additional symptoms are what became the identifying diagnostic criteria and are listed in a list, like this:
Of course, while every child is slightly different, and each child with FOH can experience each symptom in a wide range of intensities and frequencies, there are certain strong through-lines in the presentation. Clinicians who are seasoned and familiar with how to diagnose and treat Fear of Harm can usually help to identify it accurately based on the presence (or lack thereof) of the objective, physical, and physiological symptom of temperature dysregulation.
Coming up soon we’re going to go over all of those symptoms in detail so you know what to look for, so don’t miss the rest of the series!
There are 7 criteria that are used to help diagnose Fear of Harm. In this series we’re going to cover the first 5, which are all observable. In this installment we’ll look at the 1st symptom, called “Episodic and Abrupt Transitions in Mood States”, which includes:
So, this first symptom really includes a lot of the classic bipolar disorder symptoms that most people can already identify. The difference for kids is often in how they show up, or in how quickly they resolve. But, either way, they include rapid and unexpected changes in mood, with emotional excitability, sensory sensitivities, and symptoms of depression and mania, or hypomania.
One of the things can can make it difficult to understanding childhood onset bipolar disorder (versus adult onset bipolar disorder) is how fast depressive and manic episodes cycle in kids as opposed to adults. In adults, it’s not uncommon for depressive or manic episodes to last for weeks or months at a time. In fact, the diagnostic criteria in the DSM that doctors and therapists use states that manic episodes must be “present most of the day, nearly every day, lasting at least 4 consecutive days,” or in the case of depressive episodes that they “have been present during the same 2- week period… most of the day, nearly every day”.
However, with children these manic and depressive episodes don’t usually present this way. Kids with bipolar disorder experience these episodes so quickly that it’s actually called “rapid cycling”. This means that the moods are quickly cycling between manic and depressive with symptom breakthroughs multiple times during a single day.
In adults the depressive episodes of bipolar disorder include sad or empty feelings, with a lack of interest in activities they used to enjoy. But it’s important to remember that in children, symptoms of depression and mania most often present as:
When kids exhibit these symptomatic behaviors they are most often misinterpreted and experienced by parents and caregivers as oppositional and/or defiant behavior.
Mania and hypomania in children can appear as:
Excessive excitability,
Again, these symptoms often get misinterpreted by the adults around them as evidence of ADHD. But in both cases these are more likely symptoms of a mood disorder, bipolar disorder, and/or Fear of Harm.
There are 7 criteria that are used to help diagnose Fear of Harm. In this series we’re going to cover the first 5, which are all observable. In this installment we’ll look at the 2nd symptom, called “Fear of Harm”, which includes:
So, this 2nd symptom is the criteria that gives its name to how we refer to this disorder, and “fear of harm” is what it sounds like: it’s the child’s intense and exaggerated fear that they, or someone they love, will be harmed or killed, usually in some violent and terrifying way.
Now while yes, everyone has things that they are afraid of, and yes, kids get scared, these fears go beyond anything that would be considered developmentally normal childhood fears. These fears are experienced as enormous and distorted reactions to normal things that the child experiences in their environment. They will see threats that do not exist, either by misperceiving something neutral in their environment as threatening, or by feeling excessively defensive as a result of feeling embarrassed, misunderstood, unheard, dismissed, or rejected.
As a result of these fears kids often create elaborate rituals at bedtime, mealtime, bath time, and transition times. These rituals are often seen by adults as avoidance strategies and those adults find the delays they cause intolerable. But the truth is that these rituals are created by kids to protect themselves from the harm they believe surrounds them.
These kids can struggle with debilitating levels of separation anxiety, fear of germs, fear of intruders, or of the dark. These fears severely limiting their ability to function normally in school, at home, and in the community.
Also a part of the symptom called “fear of harm” is a PTSD like symptoms constant hypervigilance that leave the child on constant alert, looking for threats and dangers they are convinced are there waiting to harm them, even when the environment is neutral or even entirely safe.
Everything from simple limit setting to minor correction or redirection can be misperceived as threatening, or as a loss, and result in aggressive and reactive responses that seem to outsiders as disproportionate or inappropriate to the situation. But seeing threats where they don’t exist plagues those with Fear of Harm, encouraging their fears and perceptions of danger.
There are 7 criteria that are used to help diagnose Fear of Harm. In this series we’re going to cover the first 5, which are all observable. In this installment we’ll look at the 3rd symptom, called “Thermoregulatory Disturbance”, which includes:
Honestly, this may be the most important symptom on the criteria list because it’s a physical symptom that is objectively measurable. But, you’ve probably never been told that it could be related to a mental health condition. This symptom relates to the body’s inability to correctly regulate its temperature. It’s what’s called a “biological marker” and Fear of Harm is basically the only psychiatric disorder that has one.
The amazing thing about having a biological marker is that it means that you can target and treat a biological symptom. When that happens it helps to control the other, behavioral symptoms, and helps the person stabilize and manage their mood and behavior.
So, what do thermoregulatory disturbances look like? Well the most noticeable might be that kids (and adults) with Fear of Harm often feel hot, and sweat, when the climate around them doesn’t call for it, like in normal room temperatures. These neutral ambient temperature environments don’t feel so neutral to those with Fear of Harm. Normally body temperatures dip at bedtime, to help induce sleep, and rise in the morning to facilitate waking. But with Fear of Harm people may go from feeling excessively hot in the evening to cold in the morning, disrupting not only body temperature, but sleep patterns as well.
Some other tell-tale signs of temperature dysregulation are:
In this series we’re going to cover the first 5, which are all observable. In this installment we’ll look at the 4th symptom, simply called “Aggression”, which includes:
The behaviors that go along with the criteria of aggression can be difficult to differentiate from either regular frustration, anger and aggression, or from normal childhood behaviors, or from other diagnoses that have already made their way into the DSM.
Generally speaking people are pretty familiar with the idea that a toddler might have a tantrum over either rational or irrational things. We’ve all seen memes with a photo of a screaming toddler holding a blue sippy-cup, captioned by the parents, “he wanted the blue sippy-cup”. Those tantrums are considered to be developmentally normal and usually only last a few minutes. A few may run as long as an hour, but in kids who don’t have a psychiatric diagnosis longer tantrums are rare.
But, in a child (or adult) with Fear of Harm these tantrums can, and will, last much longer nearly every time. These tantrums can easily last 30, 60, or 90 minutes at a time and they are often (not always) accompanied by physical and verbal aggression. Screaming, throwing things, slamming doors, putting holes in walls, kicking, hitting, biting, and scratching are all a part of the tantrums and these behaviors escalate with the child’s age to include cursing and verbal threats.
Parents know when their child’s tantrums are unusual and are different from the developmentally normal outbursts that occur in early childhood.
Additionally, aggression in Fear of Harm is shown in other non-tantrum related ways such as:
Requests to do chores, transition from one activity to the next, or mild redirection can result in verbally abusive responses which can then quickly escalate into tantrums, verbal or physical fights. This leaves parents, siblings, and caregivers feeling as though they are walking on eggshells, never certain what interactions will be fraught with aggression and the potential for violence.
These outbursts also leave the person with Fear of Harm confused and afraid because they don’t want to behave this way and don’t know why they did. They are often filled with regret, remorse, and shame afterwards and they berate themselves for being unable to control this overwhelming and involuntary symptom.
In the end this aggression leaves those with Fear of Harm and their families feeling exhausted, burned out, and hopeless.
In this series we’re going to cover the first 5, which are all observable. In this installment we’ll look at the 5th symptom, simply called “Sleep Disruptions”, which includes:
Again, we have a symptom that most people don’t think of as having anything to do with mental illness, but the truth is that sleep problems are often an early indicator of mental health struggles and kids with FOH usually begin displaying sleep difficulties in infancy. Many parents report that their children never slept properly, even as babies. Some kids may not develop the ability to truly sleep through the night until after they start treatment, which, in some cases, isn’t until the children are in their teens or are adults.
We are able to identify these sleep/wake disturbances in three different ways:
Something to remember about nightmares and night terrors is that while nightmares are consciously remembered after waking, night terrors on the other hand most often aren’t. But night terrors are just as traumatic because during a night terror the body and brain are reacting to the frightening dream events and images as though they were really happening, creating trauma in the brain. Night terrors are also traumatic for parents and family members who observe them. Often with night terrors the patient appears to be awake, walking, talking, screaming, and crying, trying to get away from the threat they are dreaming about. Children will often cry out for their parents, begging for help, while simultaneously pushing their parents away, recoiling in fear. While the child will most likely not remember the night terror in the morning, as a parent, if you’ve been awake with your child through the night terror, you most certainly will remember.
These sleep disruptions combine to make sleep and bedtime incredibly difficult for families. Kids have an incredibly difficult time “winding down” in the evenings and preparing for bed. When most people are starting to feel tired out from their day, those with Fear of Harm are having their energy ramp up, and find themselves wide awake and unable to settle down just as sleep should be setting in. This makes bedtime a mess, as the child experiences the combination of rising energy levels, anticipatory dread about being unable to fall asleep, and anticipatory fear of the nightmares they know are coming.
Yes, there are, and once you get the main symptoms down and know what you’re looking at it’s time to take a deeper dive into what FOH can look like. So, let’s go with Part 1! (Keep an eye out for part 2 next week!)
Low frustration tolerance: Feeling thwarted or being limited can feel like a major threat to kids with FOH. The child wants something, and not being able to have it, or having to wait for it, creates an overwhelming feeling of anxiety. This anxiety triggers frustration and aggression that can derail simple activities like waiting their turn, being unable to figure out a homework assignment, or being asked to wait 15 minutes for dinner to be served before eating. This low frustration tolerance leads to all sorts of symptoms that get mistaken for willful behaviors.
Executive function: It’s not uncommon for kids with FOH to have underdeveloped executive functioning skills. These are the skills required for planning, remembering, paying attention, solving problems, reasoning, inhibition, flexibility, transitioning, and self monitoring. They can look like this:
These difficulties, especially when adults and teachers expect FOH kids to be functioning like their peers, creates all sorts of additional anxiety and obstacles for these kids.
Fixations and goal oriented behaviors: Cravings, “Mission Mode”, and an absolute unrelenting need to have, do, or say can overtake a kid with FOH in an instant. Cravings can include demands for excessive sweets, carbs, chips, and other starchy processed foods. “Mission Mode” can appear as an intense need to start and maintain a project no matter what time it is or what else is on the agenda.
Irritable behavior: Irritability can look like being forever “on-guard”, vigilant for any possible sources of danger or threat. This causes the child with FOH to be reactive and negative in those reactions. Parents describe this state as one in which they have to constantly walk on eggshells, being careful not to trigger behaviors even when they don’t have any idea what those triggers might be. But this kind of irritability is never far from the surface and when it escalates it can quickly turn into episodes of rage.
So here we are again for part 2 of these characteristics. Let’s dive right in!
Self-esteem fluctuations: Kids with FOH often have a distorted sense of self which can, at almost any moment based on their mood, vary from a tremendously negative self perception (often because of depression) to a wildly inflated sense of self that makes them arrogant, overly confident in themselves, and feel superior to others (often caused by hypomania or mania). Depression can also bring with it feelings of shame and worthlessness while mania can result in delusions of superpowers.
Increase in energy throughout the day: Kids with FOH often don’t have a lot of energy in the morning finding it really hard to get out of bed. But this energy escalates during the day making it harder and harder for them to control themselves, their bodies, their thoughts, and behaviors. Most often by dinnertime they’re experiencing a difficult time, which causes many parents to call it “the witching hour”. Kids’ energy peaks around bedtime making it objectively difficult for them to settle down and get to sleep.
Gore and violence: This characteristic can lead people to think that kids and adults with FOH are somehow dangerous, even though that’s not the point at all. There is often a fixation with the terrifying, gory, violent imagery that appears in the FOH nightmares. They intrude during the day and the child can’t escape reliving those nightmare images over and over again. To process them and the feelings they bring up, these ideas often get expressed in imaginative play, drawings, creative writing, and casual conversation. They rarely represent things the child or adult intends to do, but rather the things they are afraid might happen to them.
Sensory sensitivity: FOH involves so many sensory issues that kids with FOH are often diagnosed separately with a sensory sensitivity integration disorder. These sensitivities can be experienced in a lot of different ways, such as:
In an ongoing state of heightened fight-or-flight these irritations that other might see as minor can contribute significantly to anxiety and distress leading to emotional dysregulation.
While often difficult to distinguish between, there are some distinct differences between mood and thermoregulatory symptoms which get easier to understand the longer you’re looking at them.
First of all, it’s important to remember that everyone experiences mood fluctuations throughout the day, and that is considered completely normal. Even for kids and adults with mood disorders, minor mood changes throughout the day are nothing to worry about. However, with clinically significant mood disruptions those changes in mood occur rapidly, unexpectedly, and without a clear cause. They include symptoms of depression and mania (or hypomania).
As for the thermoregulatory disturbances that go along with Fear of Harm, they trigger symptoms that can look like mood disruptions, but they really aren’t. Those symptoms are governed by the temperature disruptions and include fear, anxiety, hypervigilance, aggression, and sleep disruptions.
But let’s start with understanding thermodysregulation, which is the body’s inability to correctly regulate its temperature. This is a physical phenomena that may be independent from the mood disruptions explained above.
The ratio between proximal and distal body temperature is a measure of how well the body is shifting core heat to the skin so that it will be dissipated. Clinical signs of a disturbance in this system may sometimes manifest in the following ways:
This disruption in body temperature regulation leads to several other symptoms.
Sleep/Wake Disturbances, which are categorized in three different ways:
Fear/Anxiety, which is triggered because the part of the brain that controls temperature regulation is the same part of the brain that controls the activation of the fight or flight instinct. As a result, children with thermoregulatory disturbances experience a triggering of their fight or flight response when it’s not needed, causing them to feel intense anxiety and fear. The child is on constant alert, looking for threats and dangers, causing separation anxiety, fear of germs, fear of intruders, or of the dark to be pushed to debilitating degrees. They create elaborate rituals at bedtime, mealtime, or bath time to help them feel safe.
Functioning in a near constant state of fight or flight also results in distorted reactions to normal stimuli. They experience threats that don’t exist, either by misperceiving something neutral in their environment as threatening, or by feeling excessively defensive from feeling embarrassed, misunderstood, unheard, dismissed, or rejected.
Aggression can be tricky because all children can be aggressive at times and it can be difficult to differentiate clinically significant aggression from either normal childhood behaviors, or from other diagnoses.
It’s developmentally normal for young children to have tantrums. However, in a child triggered by thermodysregulation their tantrums continue for many years past what is considered developmentally normal. The tantrums also can last for several hours and are accompanied by physical and verbal aggression, such as screaming, throwing things, slamming doors, putting holes in walls, kicking, hitting, biting, and scratching. These behaviors escalate with the child’s age to include cursing and verbal threats.
Parents know when their child’s tantrums are unusual and deviate from the developmentally normal outbursts that occur in early childhood.
Aggression is also shown in other ways such as defiant and oppositional behavior and refusals to follow simple instructions, complete expected tasks, and do basic chores such as teeth brushing, showering, homework, and getting dressed. Requests can be met with verbal abuse which can quickly escalate into tantrums, leaving parents, siblings, and caregivers feeling as though they are walking on eggshells all of the time.
So what does mood stability look like then?
Generally speaking, mood stability while someone is still experiencing thermoregulatory disturbances and their accompanying symptoms, would look like this:
The “Fear of Harm” (FOH) phenotype of bipolar disorder, currently referred to by researchers as Thermoregulatory Sleep Dysregulation Disorder, is revolutionary because it’s the first mental illness to have a biological symptom that can be used to identify and confirm the diagnosis. This biomarker is seen as a disruption in the body’s thermoregulation system. This means that the body can’t regulate its temperature properly, which leads to a bunch of different physical and psychiatric symptoms that are often mistaken for willful behaviors. Some of these symptoms include sleep problems and intense and exaggerated fear and aggression.
The part of the brain that is supposed to control body temperature is related to the part of the brain that controls the triggering of the fight-flight-freeze response. “FOH’s” thermoregulatory disturbance confuses the fight-flight-freeze instinct, triggering it, and making the person feel like they are being threatened with danger even when there isn’t actually any danger in the environment. This results in those physical and emotional symptoms we mentioned earlier.
When the body’s can’t properly control its temperature it impacts sleep, resulting in a whole host of sleep disturbances including trouble falling asleep, staying asleep, and getting up in the morning.
Thermodysregulation also disrupts the transition between REM and non-REM sleep and results in what are called parasomnias such as nightmares, night terrors, sleep-walking, sleep-talking, and bedwetting. All of these parasomnias, especially the violent and gory nightmares cause significant ongoing trauma.
Researchers at the Juvenile Bipolar Research Foundation (JBRF) first identified this biomarker and have also uncovered ways to manage this temperature dysregulation to help reduce symptoms.
The most effective way to manage thermodysregulation is to keep environmental temperatures steady throughout the day. This is best done by avoiding significant temperature fluctuations in the environment which confuse the body’s already malfunctioning system. Some examples of problematic environmental temperature fluctuations include temperature high/low differentials of greater than 25 degrees F in a single day, average daily temperature differential greater than 25 degrees F from one day to the next, and temperature differentials between indoor and outdoor temperatures of 25 degrees F or more.
Essential treatment recommendations include staying indoors in that temperature controlled environment during extreme weather conditions such as temperatures above 90 degrees F and below 30 degrees F. They also include staying indoors in a temperature controlled environment during seasonal changes when outdoor temperatures can change dramatically from day-to-day or within the same day.
Additional techniques used to maintain a stable and body temperature include submerging the whole body in tepid water between 78-85 degrees F, using ceiling and standing fans, wearing cooling clothing, as well as regularly eating ice cold food and drinks.
For more information on:
*CMHRC does not receive any commissions or fees for sharing these recommendations from families.
Parents have often shared that when their child is struggling with a mental health problem they don’t know who their “real child” is anymore. The symptoms their child is living with impact their moods, their behaviors, and their ability to interact with everyone around them. Parents can sometimes feel as though they are the only ones who ever see the “real child” (and that they don’t see that child enough). They can also feel as though they are grieving the loss of the child they used to know before the onset of the mental illness. One parent, in an online support group for parents of children living with bipolar, poignantly asked, “How do you grieve a child who is still living?”
Whether a parent’s reaching out online, through social media, to a friend, or sitting across from a therapist in a session the answer is always the same:
Your child is still there.
It may be difficult to truly “see” them because of their symptoms,
but it is important to remember:
A child is not their illness.
For starters, problematic behaviors are not what defines the child’s character. Most often, those behaviors are the observable symptoms of their illness. This can be hard to remember in the moment when those symptoms drive behaviors that produce chaos in your home, at their school, and within your family.
It’s true that these symptoms may overshadow traces of the child’s true self, but that doesn’t mean that those things that made them who they were are gone. Those core characteristics are usually still there, like a light hidden under a bushel. But when the weight of the active symptoms lifts that light is still there, ready to shine.
There’s no hard and fast rule to follow to be able to tell when your child is symptomatic versus when they are just misbehaving or being difficult. Although, you can watch our video entitled, “Is it “misbehavior” or a symptom?” which is located on our members only learning videos page.
Unfortunately, the only way to remove that “bushel” and get your child’s light to shine through is by getting them accurately diagnosed and access to effective treatment. But, once the targeted treatment plan is in place, parents will begin to see whether or not their at home interventions and treatment efforts are reducing the observable symptoms. Over time, the “real” child will emerge.
Remember, it takes time to heal, for you as well as for your child. Many children living with a mental illness have been misdiagnosed and treated for other mental health disorders that they don’t have. Which means there is a good chance a child diagnosed with bipolar disorder or Fear of Harm, for example, will have likely been taking stimulants for ADHD, an antidepressant for depression or anxiety, antipsychotics for suspected DMDD, medication to assist with sleep, or all of the above and more. All of these things wouldn’t have correctly addressed the symptoms of bipolar. Given these false starts and the trauma they may have caused, there’s still recovery that needs to happen before you can fully reap the benefits of being on the right treatment path.
Parents who ask questions, search for information, and talk with other parents of children who live with mental illness are more likely to make more informed decisions regarding treatment plans. When children are receiving the appropriate care they begin the process of healing, symptoms decrease, the disorder becomes more manageable, and the child who was always there is finally able to emerge and shine.
Even when those who live with mood disorders or bipolar who are stable, ups and downs happen for a variety of reasons. There is a normal ebb and flow to these disorders and learning to recognize early signs that indicate a mood shift can reduce the likelihood that a full blown mood episode is imminent. It’s important to consider a reliable and secure system that assists in recording and tracking moods, medications, seasons, weather, temperature, and other factors which can contribute to mood variability*.
An effective tracking system will help reduce the intensity, frequency, and longevity of bipolar symptoms over time. Using accurate and reliable data will provide the information doctors, therapists, parents, and patients need to make those evidenced based adjustments to treatment.
Over the years people living with mood and bipolar disorders learn how their body responds to seasonal and weather changes. It has been noted how the changes in the season greatly impacts the specific type of mood episodes. For example, many adults living with bipolar will say they experience depressive episodes in the winter and in spring and summer they are more likely to experience hypomania or manic episodes. This isn’t true for all persons living with bipolar and there are some people where the reverse is true, summer ushers in a depressive episode and fall or winter provides an increase in energy. For others, temperature, humidity, and/or time of day play key roles in how their body responds to their environment. When a younger child or teenager is newly diagnosed with bipolar it takes time to learn and recognize these patterns. Being able to identify the patterns quickly is key to providing interventions that will lessen the impact of those changes.
It’s common for parents of teenagers who live with a mood disorder and also have a menstrual cycle to observe fluctuations in moods based on where their child is in that monthly cycle. Discussing hormone therapy options (such as the “birth control pill”) with a prescribing healthcare provider, and having PRN medications during specific times in their cycle, can alleviate some of those symptoms.
Puberty, regardless of gender, can be a time of rapid and intermittent growth spurts. These sudden changes in the brain and the body can contribute to significant shifts in stability to more pronounced disrupted mood episodes. Parents who are aware their child has entered into a growth spurt, or have observed traits consistent with the onset of puberty, can discuss with their child’s physical and psychiatric doctors what adjustments can be made to the treatment plan.
In school the second semester, or second half of the school year, is a time of increased mood instability or dysphoric mood disturbances. The second half of the school year starts in the middle of winter, immediately following a break for the holidays, and in a season highly correlated with depressive mood episodes. This second semester in middle and high school is also typically a time of increased academic demands, which can be an overwhelming stressor. Parents and educators can work together to make appropriate accommodations in the 504 plan or IEP such as decreased or eliminated homework in order to help the student with a mood disorder be more supported and therefore more able to succeed.
More often than not, multiple factors contribute to a spiral into a disrupted mood episode. Increased academic stressors, an argument with a best friend, changing brain and body chemistry, and fluctuating weather patterns could create “the perfect storm” and trigger a disrupted mood episode.
But without being able to track the mood changes and symptom presentation parents and patients may not realize that an episode of depression or overwhelming anxiety is about to descend, leaving the child and family unprepared.
Sometimes adjustments in medication are necessary, and sometimes non-pharmacological interventions, otherwise known as “lifestyle changes”, can be made that can make a big difference.
During these times of increased anxiety, irritability, and mood instability, parents can decrease demands and lower expectations.
One parent of a 16 year old daughter living with both bipolar and Fear of Harm shared that when she notices her child spiraling she treats her the same way she would a person who had come down with a purely physical illness like the flu.
She allows her daughter to stay home from school, doesn’t expect her to do her chores, and tries to minimize stressors as much as possible. Many parents of kids with mood disorders, bipolar disorder, and FOH agree that minimizing stress and taking a break from school helps their child to reset and resume their typical schedule sooner, rather than attempting to push through a difficult episode.Children learn to recognize when their brain and body need to rest, how to advocate for their needs, and what forms of self care work best for them. Modeling for children how to responsibly track their moods and then make adjustments using that data and evidenced based approaches gives them the opportunity to develop healthy skills that set them up to thrive throughout their lives.
*CMHRC offers members access to a daily tracking system that records customized symptom presentation and severity, medication compliance, overall behavior and mood, and weather. It’s called the Member Toolkit and can be accessed by anyone with an active CMHRC membership.
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.
Driving for many teens is a rite of passage and can mean a lot to them. For a teenager this means they can more easily get a job, drive themselves to and from personal appointments, help run errands for the family, visit friends, go on dates, and it represents a step towards adulthood.
But while the state determines the chronological age a teen is legally allowed to apply for a driver’s license, not every teenager is ready at that age.
Most parents have expectations and rules regarding driving for their children, regardless of whether they are neurotypical or neurodivergent. Common expectations may include things like good school attendance, good grades, completed chores, and the ability to independently pay or contribute to gas or insurance costs. Common rules may include limiting the number of friends allowed in the car, not driving while using the cell phone, being home by a set curfew, and not receiving any speeding tickets.
When a child lives with a medical condition or mental health disorder, additional considerations may need to be present in order for driving to be safe for your teenager and others who share the road with them.
When parents find themselves trying to assess if their teen who lives with a mood disorder is ready to drive, there are some important factors to consider that can help increase safety. Here are some questions parents should ask themselves as well as tools they can use to help track moods and symptoms.
1. Is your child taking their medication everyday as prescribed by their doctor?
It is not unusual for teenagers to want to be like everyone else and resist the idea they have a serious illness which requires mindful and careful monitoring. The teen years are about developing more independence and agency regarding everyday choices. It’s normal for them to want to exercise more control over their body. But sometimes they may conclude because they feel better they no longer need medication.
Teenagers want to be like their friends and most of their friends are not taking medications to manage a serious illness. Parents need to have a system in place to ensure their children are continuing to take medication as prescribed. Teenagers should also know all the medications they are taking and what each medication does. If they are in an emergency situation there may be an urgent need for medical professionals to have their current medications, the name of their prescribing doctors, and the pharmacy they use.
2. Is your teenager attending all of their doctor and mental health visits?
It is important for teens and young adults to keep all doctor appointments, provide input during visits, and be an active participant for therapy sessions. The more engaged your child is in their healthcare, the more likely they will see the benefits of compliance to treatment plans and interventions. Having a rule that in order to drive your teen must attend and participate in doctor and therapy appointments also means there are professionals outside of your family who are also observing and assessing mood stability. Doctors and therapists can help provide additional options to managing moods.
3. Is your child’s mood stable?
Your teenager can share with you how they are feeling and you can observe their symptoms. For most people, moods are a persistent or semi-persistent state of being that can last minutes, to hours, to days, and even weeks. Moods are heavily influenced by biology, physiology, environment, and mental state.
When you have a child who lives with a mood disorder and is also driving, tracking their moods over time can help you and your teenager determine if it is safe for them to be behind the wheel.
It is important a driver is not easily distracted, anxious, sad, depressed, scared, irritable, easily annoyed, or engaging in impulsive risky behaviors.
4. How do you and your child keep track of moods, symptoms, and medication compliance?
Having a mood tracker, such as the CMHRC Toolkit, that carefully records symptoms, moods, and medication compliance over time helps parents assess if their child is ready to be a responsible driver. CMHRC’s Toolkit is an excellent tool to track if medication, other interventions, and factors may be contributing to specific mood shifts or prolonged undesirable mood episodes. CMHRC’s Toolkit provides graphs and visual representations of changes in mood, symptoms, medications, and other interventions that can provide you with insight into what changes or adjustments can be made to decrease symptoms.
Teenagers who live with mood disorders, bipolar, or Fear of Harm can have jobs, volunteer, date, have friends, drive, and engage in healthy adolescent activities. Just like teenagers who live with juvenile diabetes and have to manage their blood sugars, kids with mood disorders also have to learn how to manage their symptoms so they can enjoy this time in their life.
Parents of children living with bipolar and/or Fear of Harm should be cautious when they’re referred to, or are contemplating, parenting classes.
When a child is diagnosed with a “behavioral disorder” parents are often immediately referred to these kinds of classes by well meaning psychiatrists, therapists, and school counselors. The goal is for them to learn how to “manage their children” who have been diagnosed with a behavioral disorder.
But mood disorders, bipolar disorder, and Fear of Harm aren’t
actually behavioral disorders, and the use of that term is
not really accurate when discussing disorders that have a biological basis.
As a result, the traditional behavior management techniques that are taught in traditional parenting classes can intensify and escalate the symptoms of a mood disorder, bipolar disorder, or Fear of Harm. Worse, that escalation can potentially create an explosive situation. Simply put, what works for neurotypical children isn’t going to be the solution for children living with mood disorders. Desperate parents find themselves trying everything and anything suggested to them in these classes, but often have very little success.
This is why we at CHMRC use a different approach in our parenting class*.
As we said, bipolar is not truly a “behavioral” disorder. A growing body of research is showing that bipolar is more likely a metabolic or energy disorder. The behaviors we see children, teens, and adults with bipolar exhibiting when they’re unstable are not willful behaviors, they are observable symptoms of a biological disorder.
Children living with mood disorders, like bipolar, are not being lazy or manipulative.
No amount of tough love, being consistent, or natural consequences given
are going to change the physiological and biological cause.
But, this doesn’t mean parents should do nothing in the face of these symptoms. In fact, there are known interventions, counseling techniques, and strategies for discipline, limit setting, and rewards that specifically address mood disorder and bipolar disorder symptoms. All of these focus on targeting symptoms with safety, emotional regulation, and connection as their primary goals. But most traditional parenting classes are geared towards managing emotions and behaviors from neurotypical children who do not have to battle the overwhelming symptoms of a mood disorder every minute of every day.
For example, imagine a child with bipolar disorder who is experiencing a mixed mood episode and is screaming they want to heat up the leftover pizza and they won’t eat the meatloaf baked for dinner. What can a parent or caregiver do? Continuing to say no, ignoring the child, sending them to their room, or trying to reason with them often escalates an already tense situation and exacerbates the mood episode. Holes in the wall, tipped over chairs, broken dishes, screaming, or rolling around on the floor would be a typical response to a parental “no”.
Most parenting classes won’t tell you that, perhaps surprisingly, the healthy response in this situation actually involves the child getting the pizza. But our experts at CMHRC know that regulating the mood as quickly as possible, getting them out of their brain’s limbic system’s fight or flight response, is what is actually most important. Some unhealthy responses that delay regulation and escalate an already intense situation include:
These traditional parenting techniques will only reinforce during an involuntary mood episode that the brain and body must stay on maximum alert and they will not be able to de-escalate.
It is only when the child is regulated that they can be available to make choices and have control over their actions. Until then, they are stuck in an involuntary, survival driven, storm of symptoms they have no control over.
CMHRC’s Palliative Parenting* approach uses compassion and empathy to recognize that meeting the child’s needs is what promotes stability, cooperation, and less chaotic family life.
Well intentioned healthcare providers, teachers, family, and friends encourage and promote unhelpful parenting practices, that while they may work for neurotypical developing children, will not be successful for a child who is physically and emotionally dysregulated. If a child is living with asthma we would learn the steps to keep them healthy and alive. Interventions, strategies, and education that focus on early onset pediatric mood and bipolar disorders are key. Parent support groups*, attended by parents who are also raising children with this specific condition, are an excellent way to learn strategies and approaches to help a child who is constantly dysregulated and what interventions are working for other families. It is also an avenue for further education on what additional appropriate resources are available.
*CMHRC’s Palliative Parenting Classes are available now. Click here for more information.
Children living with mental illness know the ups and downs that come with living with a chronic illness. Parents and their children know the one consistent thing about living with mental illness is that it’s inconsistent. There can be good times, not so good times, and very very bad times, all of which can last anywhere from days, to weeks, to months. For those individuals who have been diagnosed with a mood disorder in childhood, they are likely to experience more frequent mood episodes, and while it may appear as if the student with bipolar is doing well because they “look good” and are interacting with peers, they may in fact be masking. Masking is a term that refers to the act of camouflaging true emotions or mental health symptoms in an effort not to disappoint or frustrate others. It’s practiced frequently by people living with mood disorders.
A 504 Plan or Individualized Education Program (IEP) is a necessity for students living with mood disorders due to the inconsistent nature of mood episodes.
There is strong evidence that mood episodes (including major depressive episodes and hypomanic or manic episodes) impact working memory, making the process of memory and serial recall very difficult. These and other effects of a mood episode can last long after the episode has transitioned into a more stable state (known as euthymic or the state of living without mood disturbances). Medications used to manage mood disorders can have side effects which impact processing, cognition, and sleep-wake cycles. There is also a genetic correlation between bipolar, dyslexia, dyscalculia, dysgraphia, as well as auditory and visual processing disorders all of which significantly impact learning.
This means students will need accommodations and modifications to how they access their education in order to help them meet their academic needs. It’s important that these accommodations and modifications are in place because students living with mood disorders such as bipolar often have difficulty identifying and verbalizing their needs in the moment. This can be the result of masking, anxiety, medication side effects, a comorbid disorder, or the lasting effects of mood episodes.
The bottom line is that children with mood disorders are highly complex. Even when moods are managed well by medications there are many other factors to consider. Good grades and completing homework assignments on time isn’t a good forecast on what to expect in the near future when it comes to mental illness. What a student with a mood disorder was capable of yesterday isn’t a good forecast of how capable they will be tomorrow.
504 plans and IEPs create an equitable educational environment where each individual student, living with their specific conditions, can succeed. Additionally, the goal is for the parents, teachers, and students to all partner together to improve educational outcomes for students living with disabilities. These interventions don’t offer students with disabilities advantages over other students who don’t have a 504 plan or IEP. These federally protected tools allow all students to exercise their right to a Free Appropriate Public Education (FAPE) and support them to be as successful as they possibly can be given their biological and mental health challenges.
Parents are protecting their children’s right to an appropriate education as guaranteed by the federal law called the Individuals with Disabilities Education Act (IDEA) when advocating for an appropriate 504 and/or IEP. Bipolar and other mental illnesses are often invisible disabilities, but they are still a federally protected category under the IDEA, with recognition requirements equal to physical disabilities such as blindness or deafness. Even though people can’t tell by looking at someone if they are living with bipolar, how much they struggle, or their level of functioning on any given day it doesn’t mean they aren’t struggling. When a child lives with a mood disorder and has the support they need, then they have the right tools in place to make success in school possible.
If you’re struggling to have your child’s needs met by their school you’re not alone. CMHRC is in the process of developing a guide for families as they attempt to navigate the process of developing and implementing IEPs and 504 Plans. Stay tuned for more information about when this resource guide will become available.
This is a great question, and many people have trouble telling mania and hypomania apart at first because they are really quite similar. So let’s start by looking at the ways that they are alike, before we talk about how they’re different.
Hypomania and mania are very similar in terms of the thoughts, feelings, and behaviors that go along with them. They include:
In the DSM they describe both hypomania and mania as “a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy.”
The way they differentiate the two is based on how long the episodes last. For mania they say the episode needs to last for at least 1 week, whereas for hypomania they specify it lasts for at least 4 days.
We can see how this isn’t really a clear difference, nor is it explained in a way that is very useful when you’re at home with someone who seems to be either manic or hypomanic. So an easier, less clinical, way for family and friends to tell the difference is that you can think of hypomania a little like it’s “mania-lite”.
Hypomania is going to be a little bit less intense than mania. For example, the symptom of decreased need for sleep might mean with hypomania that the individual is sleeping only 4 or 5 hours a night, whereas with full blown mania they’ll might not be sleeping at all.
In children the time frames given are also pretty unhelpful because kids can rapid cycle through mania, hypomania, and depression in a matter of hours. So, the 4 days vs. 1 week measurement isn’t going to have any practical application.
An more obvious indicator in kids can be that with hypomania you may find that they can, with some effort, be redirected and you can get their attention for short periods of time. With full mania that becomes much more difficult and they often spin-out like a top with either silly, giddy, euphoria or irritable, angry, rages until they’ve exhausted themselves. Parents often describe that during mania their child gets “the look” on their faces and when they look into their child’s eyes they report their child “isn’t there”.
During mania episodes, parents often find their first and only concern is the safety of their child and the people around them because mania kids can often engage in the symptom of activities that have a high potential for painful consequences.
That’s a fairly long answer, but put simply, you can think of the difference between hypomania and mania as the difference between a pot of water that’s just started to simmer (hypomania), and a pot of water that’s at a rolling boil (mania). One’s a lot easier to turn down than the other.
This is a great question, and many people have trouble telling mania and hypomania apart at first because they are really quite similar. So let’s start by looking at the ways that they are alike, before we talk about how they’re different.
Hypomania and mania are very similar in terms of the thoughts, feelings, and behaviors that go along with them. They include:
In the DSM they describe both hypomania and mania as “a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy.”
The way they differentiate the two is based on how long the episodes last. For mania they say the episode needs to last for at least 1 week, whereas for hypomania they specify it lasts for at least 4 days.
We can see how this isn’t really a clear difference, nor is it explained in a way that is very useful when you’re at home with someone who seems to be either manic or hypomanic. So an easier, less clinical, way for family and friends to tell the difference is that you can think of hypomania a little like it’s “mania-lite”.
Hypomania is going to be a little bit less intense than mania. For example, the symptom of decreased need for sleep might mean with hypomania that the individual is sleeping only 4 or 5 hours a night, whereas with full blown mania they’ll might not be sleeping at all.
In children the time frames given are also pretty unhelpful because kids can rapid cycle through mania, hypomania, and depression in a matter of hours. So, the 4 days vs. 1 week measurement isn’t going to have any practical application.
An more obvious indicator in kids can be that with hypomania you may find that they can, with some effort, be redirected and you can get their attention for short periods of time. With full mania that becomes much more difficult and they often spin-out like a top with either silly, giddy, euphoria or irritable, angry, rages until they’ve exhausted themselves. Parents often describe that during mania their child gets “the look” on their faces and when they look into their child’s eyes they report their child “isn’t there”.
During mania episodes, parents often find their first and only concern is the safety of their child and the people around them because mania kids can often engage in the symptom of activities that have a high potential for painful consequences.
That’s a fairly long answer, but put simply, you can think of the difference between hypomania and mania as the difference between a pot of water that’s just started to simmer (hypomania), and a pot of water that’s at a rolling boil (mania). One’s a lot easier to turn down than the other.
The word “prodrome” is a medical term that means “an early symptom indicating the onset of a disease or illness.”
It’s used by medical professionals to note early signs and symptoms of an illness before all the major symptoms of the illness are fully present. These early signs are often called prodromal symptoms.
Typically, the early symptoms of a disorder are initially blamed on other more common diseases or illnesses. For example, increased energy, talking fast, interrupting friends and teachers at school may be early signs the child might be developing Attention Deficit Hyperactivity Disorder (ADHD). Then, as it becomes clear that attention is not sustained on tasks, the child has increased forgetfulness, experiences restlessness, and has trouble sleeping, the parent may be asked to complete assessment tools designed to assist providers in diagnosing ADHD. Because ADHD is the most common developmental disorder in childhood, and because its symptoms appear to overlap with symptoms of bipolar, a mood disorder is often overlooked in favor of an ADHD diagnosis.
Prodromal symptoms of bipolar can occur years before the full onset of the illness. Just because all the symptoms are not fully present doesn’t mean that the child isn’t experiencing serious difficulties with daily living.
It is important to understand the prodrome and keep bipolar in mind during treatment planning, especially if there is a family history of major depression, bipolar, schizophrenia, or addiction. Not including bipolar, or emerging bipolar, as part of the possible picture creates a potential for complications. Early consideration of bipolar could preserve the rest of a person’s childhood and contribute to better long term outcomes.
When there is one parent living with bipolar there is approximately a 30 percent chance the child will also inherit the disorder*. If both parents live with bipolar then there is between 60 and 75 percent chance their child will inherit the disorder*. A thorough medical, psychological, social, and family history should help guide the provider in treatment plan development and implementation with the goal to reduce the symptoms the child is experiencing. An assessment like this takes time but consideration of biological, psychological, and social factors, and how they intersect to impact overall functioning is essential. This helps guide the medical team or provider when making suggestions for managing symptoms and developing a treatment plan.
Dr. Demitri Papolos, co-author of The Bipolar Child, advocates in his book that if there is a family history of bipolar, it is important to treat the child with medications targeting bipolar before attempting to manage and treat other disorders. That includes if the child is in the prodromal stage and is not yet experiencing all the signs and symptoms of bipolar.
Dr. Charles Popper, author of Diagnosing Bipolar vs. ADHD, reminds us that “All of the features of ADHD can be seen in mood disorders at times, so ADHD is a diagnosis reached only after ruling out a mood disorder.”
The reason these two renowned professionals caution treatment for bipolar first is that medications used to manage disorders such as ADHD, generalized anxiety, and depression can cause significant and serious issues in children who live with bipolar. If a child is not living with bipolar and has a trial period of a mood stabilizer, and there is no improvement in reducing symptoms, then the likelihood of significant issues from those medications is minimal in most cases. Targeting other disorders when symptoms are the result of prodromal or emerging bipolar can increase the risk of prolonged mania, depression, anxiety, irritability, aggression, mixed and psychotic episodes. The risk of not considering prodromal symptoms can greatly impact the trajectory of treatment and quality of life when a child or teenager is experiencing early onset bipolar.
* The Bipolar Child by, Demitri Papolos & Janice Papolos
The word “prodrome” is a medical term that means “an early symptom indicating the onset of a disease or illness.”
It’s used by medical professionals to note early signs and symptoms of an illness before all the major symptoms of the illness are fully present. These early signs are often called prodromal symptoms.
Typically, the early symptoms of a disorder are initially blamed on other more common diseases or illnesses. For example, increased energy, talking fast, interrupting friends and teachers at school may be early signs the child might be developing Attention Deficit Hyperactivity Disorder (ADHD). Then, as it becomes clear that attention is not sustained on tasks, the child has increased forgetfulness, experiences restlessness, and has trouble sleeping, the parent may be asked to complete assessment tools designed to assist providers in diagnosing ADHD. Because ADHD is the most common developmental disorder in childhood, and because its symptoms appear to overlap with symptoms of bipolar, a mood disorder is often overlooked in favor of an ADHD diagnosis.
Prodromal symptoms of bipolar can occur years before the full onset of the illness. Just because all the symptoms are not fully present doesn’t mean that the child isn’t experiencing serious difficulties with daily living.
It is important to understand the prodrome and keep bipolar in mind during treatment planning, especially if there is a family history of major depression, bipolar, schizophrenia, or addiction. Not including bipolar, or emerging bipolar, as part of the possible picture creates a potential for complications. Early consideration of bipolar could preserve the rest of a person’s childhood and contribute to better long term outcomes.
When there is one parent living with bipolar there is approximately a 30 percent chance the child will also inherit the disorder*. If both parents live with bipolar then there is between 60 and 75 percent chance their child will inherit the disorder*. A thorough medical, psychological, social, and family history should help guide the provider in treatment plan development and implementation with the goal to reduce the symptoms the child is experiencing. An assessment like this takes time but consideration of biological, psychological, and social factors, and how they intersect to impact overall functioning is essential. This helps guide the medical team or provider when making suggestions for managing symptoms and developing a treatment plan.
Dr. Demitri Papolos, co-author of The Bipolar Child, advocates in his book that if there is a family history of bipolar, it is important to treat the child with medications targeting bipolar before attempting to manage and treat other disorders. That includes if the child is in the prodromal stage and is not yet experiencing all the signs and symptoms of bipolar.
Dr. Charles Popper, author of Diagnosing Bipolar vs. ADHD, reminds us that “All of the features of ADHD can be seen in mood disorders at times, so ADHD is a diagnosis reached only after ruling out a mood disorder.”
The reason these two renowned professionals caution treatment for bipolar first is that medications used to manage disorders such as ADHD, generalized anxiety, and depression can cause significant and serious issues in children who live with bipolar. If a child is not living with bipolar and has a trial period of a mood stabilizer, and there is no improvement in reducing symptoms, then the likelihood of significant issues from those medications is minimal in most cases. Targeting other disorders when symptoms are the result of prodromal or emerging bipolar can increase the risk of prolonged mania, depression, anxiety, irritability, aggression, mixed and psychotic episodes. The risk of not considering prodromal symptoms can greatly impact the trajectory of treatment and quality of life when a child or teenager is experiencing early onset bipolar.
* The Bipolar Child by, Demitri Papolos & Janice Papolos
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