Survival Strategies For Parenting The Child & Teen With Bipolar

Survival Strategies for Parenting
Children with Bipolar Disorder

of related interest
Asperger’s Syndrome
A Guide for Parents and Professionals
Tony Attwood
Foreword by Lorna Wing
ISBN 1 85302 577 1
Pretending to be Normal
Living with Asperger’s Syndrome
Liane Holliday Willey
Foreword by Tony Attwood
ISBN 1 85302 749 9
Eating an Artichoke
A Mother’s Perspective on Asperger’s Syndrome
Echo Fling
Foreword by Tony Attwood
ISBN 1 85302 711 1
Finding Out about Asperger’s Syndrome,

High Functioning Autism and PDD
Gunilla Gerland
ISBN 1 85302 840 1
Learning to Live with High Functioning Autism

A Parent’s Guide for Professionals
Mike Stanton
ISBN 1 85302 915 7
Parenting the ADHD Child

Can’t Do? Won’t Do?
David Pentecost
ISBN 1 85302 811 8
Attention Deficit/Hyperactivity Disorder

A Multidisciplinary Approach
Henryk Holowenko
ISBN 1 85302 741 3
The ADHD Handbook

A Guide for Parents and Professionals
Alison Munden and Jon Arcelus
ISBN 1 85302 756 1
Survival Strategies for Parenting
Children with Bipolar Disorder
Innovative parenting and counseling techniques
for helping children with bipolar disorder
and the conditions that may occur with it
George T. Lynn MA, MPA, CMHC
Jessica Kingsley Publishers

London and Philadelphia
All rights reserved. No paragraph of this publication may be reproduced, copied or
transmitted save with written permission of the Copyright Act 1956 (as amended), or under
the terms of any licence permitting limited copying issued by the Copyright Licensing
Agency, 33–34 Alfred Place, London WC1E 7DP. Any person who does any unauthorised
act in relation to this publication may be liable to prosecution and civil claims for damages.
The right of George T. Lynn to be identified as author of this work has been asserted by
him in accordance with the Copyright, Designs and Patents Act 1988.
First published in the United Kingdom in 2000 by

Jessica Kingsley Publishers Ltd,
116 Pentonville Road, London
N1 9JB, England
and
325 Chestnut Street,
Philadelphia, PA 19106, USA.
www.jkp.com
© Copyright 2000 George T. Lynn

Cover illustration Via Kellor-Davis
Library of Congress Cataloging in Publication Data

A CIP catalog record for this book is available from the Library of Congress
British Library Cataloguing in Publication Data

A CIP catalogue record for this book is available from the British Library
ISBN 1 85302 921 1
Printed and Bound in Great Britain by

Athenaeum Press, Gateshead, Tyne and Wear
Contents
Acknowledgements 8
Introduction: The Broken Necklace Rage 9
I. Bipolar Disorder in Children

Dealing with sudden rage, aggressive depression, oppositionality,
and crazy thinking
1. Enter the Warrior: How to Identify the Presence
of Bipolar Disorder in Children 18
2. The Brain Chemistry of Bipolar Disorder
and the Drugs Used to Treat It 40
3. Martha’s Story: Understanding and Managing Rage in
Children with Early-Onset Bipolar Disorder 50
4. Tom’s Story: Charting a Change Strategy for a Teen
with Bipolar Disorder 73
5. Compassion Makes a Big Difference: The Empathy
Factor in Children with Bipolar Disorder 87
6. Innovative Non-Pharmacological Treatment Approaches
for Bipolar Disorder, ADD, and Depression in Children 110
(Written in collaboration with Walter Crinnion, ND.)
II. Asperger’s Syndrome and Bipolar Disorder in Teens

Managing inertia, school resistance, stimulus-craving,
and lack of common sense
7. The Hermit: Asperger’s Syndrome – Helping the Brilliant,
Anxious and Oppositional Child Find His Way
and Express His Gifts 120
8. Sean’s Case: Helping a Child with the Dual Diagnosis
of Bipolar Disorder and Asperger’s Syndrome 145
III. Soothing the Hurt of Tourette Syndrome and Bipolar Disorder
9. Tourette Syndrome: The Wild Heart of the Restless Explorer 164
10. A Shoulder to Scream On: How to Help Children
Living with the Fiery Extremes of Tourette
Syndrome and Bipolar Disorder 178
IV. ADHD at Its Extremes

11. A Matter of Degree: How to Know the Difference
between ADHD and Bipolar Disorder 190
V. Hard Decisions
Schools, professionals, psychiatric hospitals, and police involvement
12. How to Choose the Best Neurologists, Psychiatrists, 198
Therapists, Schools, and Teachers for the Child with Wild
and Extreme Behavior
13. The Hardest Decisions: How to Make Police Involvement
or Psychiatric Hospitalization Part of Your Healing Plan 209
Conclusion: When All Is Said and Done:
Six Keys to Personal Wellness for Families of Children
with Bipolar Disorder 219
Appendix: Ten Essential Online Sites 223

References 225
Index 231
To my clients,
be they Warrior children or their parents,
who have illuminated me with their ingenuity and love
and left me awe-struck with their grit!
Acknowledgements
This work would not have been completed without the assistance of my wife
Joanne Barrie Lynn. Joanne has reviewed each chapter with a sharp and loving eye
and given the work the mark of her powerful ability to get to the point and give
people practical help. She lives this work with me as a parent and conceptual col-
laborator and I am deeply grateful that she is in my life.
Then there are my personal, professional, and online friends, all of us children
of the Net who have delighted in many evenings of rapid-fire exchange of notes,
opinions, inspirations, and personal suffering on this topic, pro and con. These
include Thorn Hartmann, Martha Hellander, Carla Nelson, and Carol Bruce.
This work also shows the influence of several powerful thinkers, researchers,
physicians, and therapists who have taken on the task of understanding children
with Bipolar-like challenges, Tourette Syndrome, and Asperger’s Syndrome.
These pioneering leading lights include Dr David Comings, Dr Kenneth Blum,
Dr Hagop Akiskal, Dr Joseph Beiderman, Dr Charles Popper, and Dr Daniel
Amen.
I would like to express particular appreciation for the information provided by
the people at the National Institute of Mental Health’s Stanley Foundation. I await
each issue of the Stanley Foundation Newsletter with the anticipation of a little boy
waiting for his Boy’s Life to come in the mail. You can tell that the professionals at
Stanley care and are excited about their work. Each issue has documented some
new breakthrough in the research, understanding, and treatment of Bipolar
Disorder that has enabled me to be more effective as a therapist and a writer.
Finally I want to thank Helen Parry, my editor at Jessica Kingsley Publishers,
for her guidance in helping me make this book more accessible to children with
Bipolar Disorder and their parents.
8
Introduction
The Broken Necklace Rage
Johnny is five years old. Most probably his diagnosis would be early-onset Bipolar
Disorder but he has not yet been diagnosed. He has obsessions. He rages at the
drop of a hat, and out of nowhere. Usually a small frustration sets off his rages.
He is staying with his grandmother, whom I shall call Carol, at her home in the
country. This morning Johnny is working intently on a beaded necklace. He
brings it to show Carol and drops it by mistake. This little setback sets him off and
he goes into a terrible rage, crying, laughing, spitting, running, frothing at the
mouth. Carol clears the area and finally gets him to a quiet place sitting at the
kitchen table.
He pounds the table again and again. ‘I’m so sad, I’m so sad!’ he screams. So
much discomfort and dark mood for such a little kid. It blasts out of him like a
wave.
Carol knows what to do. Though his anger is frightening, she is moved by his
sadness and her heart opens to him. She makes sure that he is safe, there is nothing
nearby that he can throw or break. She sits with him and tries to be (to use her
words) ‘very quiet in my heart.’ She is a gardener and so she knows how to be
quiet, centered in her heart, and in enjoyment of nature and peaceful meditative
work. She sits with Johnny and listens to him, speaking only when moved to
speak. Eventually he calms down, and as he does she begins to talk about the
opportunity for new beginnings when things fall apart. He is soothed by her
words. They work together to reconstruct the necklace to Johnny’s satisfaction
and eventually the world is right again.
Being in control of an out-of-control situation

Carol’s actions show a deep sense of wisdom about what you need to do to help a
child who has extreme behavior problems related to a mood disorder. She realized
he was partially out of control of his behavior, that she was not the target, that he
felt miserable, that he would have to get through it himself, and that keeping a
quiet, loving heart was what she needed to do.
9
10 / SURVIVAL STRATEGIES FOR PARENTING CHILDREN WITH BIPOLAR DISORDER
She told me that this incident and many others have informed her that her
grandson has a compelling need for perfect beauty and has a zero tolerance for
frustration. It wasn’t anything his parents were doing to him or any fault of his
own. As his grandmother she knew that his mother, her daughter, also had these
traits. Her daughter and her grandson had the hearts and souls of artists, but
became inconsolable when things didn’t go just right. And she knew that the best
way to balance this lack of control was to be very mindfully and peacefully in
control of herself.
My intention is that this kind of consciousness comes through to you in the
pages of this book. I am a psychotherapist who has worked with hundreds of
adults and children with issues caused by being born with a brain chemistry pre-
dilection for emotional excess that is termed Bipolar Disorder. I try to do justice to
what my clients have taught me about their experience and what they need to do
to have successful lives.
This book summarizes lessons I have learned from these kids and their parents
about how biochemistry forms their personalities, and what the most successful
parents have done to make life better for their children and themselves.
Bipolar Disorder is often diagnosed with Tourette Syndrome,

Asperger’s Syndrome, or ADHD
Bipolar Disorder in children may exist as a stand-alone issue or it may be accom-
panied by another disorder. Many of the kids I treat in counseling for BD also
meet the diagnostic criteria in the Diagnostic and Statistical Manual IV − the primary
reference used by professionals − for one of three other disorders of childhood: a
third of these kids show features of Asperger’s Syndrome or Tourette Syndrome.
All show features of Attention Deficit Hyperactivity Disorder (ADHD) though
only about a third of kids with a primary diagnosis of ADHD show Bipolar-like
features.
Bipolar Disorder (BD)

The conventional definition of this disorder is that it involves extreme mood
cycling between a hyperenergized, grandiose, elevated mood, and deep depres-
sion. In my practice I see this clear split type of Bipolar Disorder in teenagers, but a
different variety of the problem in younger kids. The young child with early-onset
Bipolar Disorder has problems with sudden wild rage and aggressive depression.
He talks nonstop at the drop of a hat. As a very young child he may do dangerous
things like run into the street. He is continually irritable. This type of Bipolar
Disorder has been described by Dr Hagop Akiskal, a leading authority on
childhood Bipolar Disorder, as a ‘rapid-cycling, mixed-state’ form of the disorder
and is the one most in evidence in my client families (Akiskal 1995). Two and a
INTRODUCTION / 11
half million adults in the US are diagnosed with Bipolar Disorder and given the
fact that there is a powerful inheritability factor for the condition, close to that
number of children are probably afflicted with BD.
Asperger’s Syndrome (AS) and Bipolar Disorder

Half of the children whose condition is severe enough for them to require psychi-
atric hospitalization and who are diagnosed with Asperger’s Syndrome meet the
criteria for a mood disorder such as depression or Bipolar Disorder. The child
with Asperger’s Syndrome as a stand-alone issue tends to be very oppositional,
obsessive, and anxious, with a very poor understanding of human emotion. From
an early age he is physically awkward and hypersensitive to noise and light. He
has a difficult time understanding what people say to him. He may also be intel-
lectually brilliant, especially in the sciences. Fluoxotine (brand name (b.) Prozac)
is often used to soothe the anxiety of the child with Asperger’s Syndrome but if
this child also has Bipolar Disorder, the Prozac might make him more agitated or
manic. For this reason, it is important to be able to detect the Bipolar/AS dual
diagnosis.
Tourette Syndrome (TS) and Bipolar Disorder

Tourette Syndrome is diagnosed by the presence of vocal and motor tics
(semi-voluntary movements and utterances) that have been symptomatic for at
least a year. Early-onset Bipolar Disorder occurs in about a third of the cases of
Tourette I treat in my counseling practice and is noted by the presence of rage and
mood swing. A similar percentage of children originally diagnosed with
Asperger’s Syndrome are later diagnosed with TS. Bipolar Disorder, Tourette
Syndrome, and Asperger’s Syndrome share the common features of high anxiety,
impulsivity, and obsessionality that mark more severe behavioral challenges in
children.
Many Tourettic children suffer from low-level depression and have rage fits.
But there are major differences between the ones who carry TS as a stand-alone
issue and those who also have Bipolar Disorder. I explain these differences in
Chapters 9 and 10.
Attention Deficit Hyperactivity Disorder (ADHD) and Bipolar Disorder

By conservative estimates, five million children in the US are diagnosed with
ADHD which is noted by the presence of hyperactivity, disorganization, and
impulsivity. Twenty-two percent of those admitted to psychiatric hospitals are
later diagnosed with Bipolar Disorder (Butler et al. 1995). ADHD is present in 85
percent of the cases of Tourette Syndrome. It is present in better than 90 percent
of those kids diagnosed with Bipolar Disorder. These figures add up to a huge
degree of ‘comorbidity’ (the term psychiatrists use to designate the presence of

more than one disorder) between ADHD and other conditions.
Why call all these disorders ‘attention differences’?

In Survival Strategies for Parenting Your ADD Child: Dealing with Obsessions, Compul-
sions, Depression, Explosive Behavior, and Rage (Lynn 1996), I describe children with
the diagnoses of Bipolar Disorder, ADD, Tourette, and Asperger’s Syndrome as
‘Attention Different’ (AD) because their basic issue is that they pay attention differ-
ently than do people with ‘neurotypical’ brain chemistry. The term ‘deficit’
describes a quality of brokeness that does not give us a vision of what we need to
do to help the child. We are stuck looking at pathology with nowhere to go. The
Attention Different moniker helps us see the child’s potential.
Whereas a non-AD child will pay attention to what adults around him direct
him to attend to, be it his schoolwork, his chores, or the performance of some task,
the Attention Different child marches to his own drummer by fate and circum-
stance. As an AD child, the child with Bipolar Disorder is captivated by − pays
attention to − extreme internal stimuli such as his mood states of elation, and
depression. Or his focus may be captivated by his excessive energy, sense of
pressure, or agitation.
The child with Asperger’s Syndrome is powerfully self-absorbed, paying
attention only to his own thoughts and anxieties, because paying attention to
things in the outer world is so difficult. These children typically cannot stand to
be talked to directly (direct communication is felt as overwhelming). Or the child
may be unable to attend to normal sensations in his body and so feels terrifyingly
numb. To escape this feeling, he cuts himself or causes himself pain.
The Tourettic child pays attention to the flickering commands of his muscula-
ture to tic this way or that or utter strange sounds. Or he may be captivated by the
inner commands of his obsessing mind. And like the child with Bipolar Disorder,
he experiences things with great, even terrifying intensity. It is difficult for him to
screen out or file away unpleasant experience.
The attention of the child with ADHD is captivated by a rapidly changing
inner collage of images, colors, feelings, and thoughts. And a profound
undersensitivity to stimulation may create a craving for novel or dangerous experi-
ences. For that moment, he feels alive.
Neurologist and author Dr Oliver Sacks (Sacks 1989, p.6) says that the chal-
lenges of people with peculiar brain chemistry are always balanced by compensa-
tory abilities. It is sometimes difficult to identify these personal resources in our
children, vexed as we are with their distressing behavior. But we begin this
process by expanding our focus away from the problems and pathology, to look at
the patterns or archetypes that identify children with these conditions.
INTRODUCTION / 13
The archetypes of Attention Different children

The term ‘archetype’ is based on the Greek to mean ‘a perfect model’ and ‘one of a
kind.’ The great twentieth-century psychologist Carl Jung used the term to
describe essential aspects of the human personality (Jung 1971, p.57). For
example, decisiveness and wisdom taken together were said to form the ‘King’
archetype. Love and leadership ability working together form the ‘Queen’
archetype. Love, caring, and passion are qualities seen in the ‘Lover’ archetype.
I begin the chapters which describe the core temperaments of children with
Bipolar Disorder, Tourette Syndrome and Asperger’s Syndrome with a brief
mention of archetypal qualities of the diagnosis. Writer Thom Hartmann’s apt
description of ADD as a throwback to the ‘hunter’ personality (Hartmann 1993)
cued me to look for archetypes in other conditions on the AD spectrum.
Hartmann believes that the ADD Hunter archetype may be a throwback to human
culture when hunters were vital to the survival of the tribe.
The use of archetypal description helps us see the positive as well as the
negative in our Attention Different children. We see that the qualities of
impulsivity, wide focus, and the enjoyment of extreme stimulation are functional
for hunting, and, indeed, for many ‘pursuits.’ You’d be a lousy hunter if you
couldn’t move fast, shift gears fast, and go for it!
It is likewise useful to apply the archetypal model to Bipolar Disorder and the
two patterns of extreme behavior that may be seen with it – Asperger’s Syndrome
and Tourette Syndrome. My young clients have taught me that their most patho-
logical-looking behavior can express an archetype, and looking at the situation
this way, I see solutions.
The Warrior archetype in Bipolar Disorder

There was a time in human history when the presence of the Warrior was essential
to survival of the culture. The fierce energy of the Bipolar child encapsulated in
this archetype is seen in the child’s most shattering losses, as his hot temper trashes
his important relationships. In Chapter 3, I describe how this state of perpetual
conflict and crisis gives him a little shot of energy, a little shot of relief from the
chronic depression he experiences. It is this same fiery energy that gives him the
will to reach his goals despite the cannon-shots he takes from his unexpected
shifts of mood.
Balancing these challenges are the Warrior’s gifts for fearless exploration of
the darker aspects of human nature. Children with Bipolar Disorder are often
gifted with the potential for remarkable artistic and intellectual brilliance, espe-
cially in the written or performance arts. These children spend a lot of time
breathing the rarefied air of extremity and excellence. Candidates in history
include George Gordon, Lord Byron, Frederick Nietzsche, Edgar Allan Poe,
Virginia Woolf, Frederick Chopin, Gerard Manley Hopkins, James M. Barrie, and
many other poets and writers. Children in this archetype often leave me
jaw-dropped in astonishment at their wisdom and accomplishment.
The Hermit archetype in Asperger’s Syndrome

The scientific gifts of the Asperger’s Hermit archetype have always been an
integral part of the progress of the human race. The Asperger’s child is so anxious
that he may become an iconoclastic loner. He is captive of the unbearable social
stress that he experiences and his need for absolute predictability. His personality
shows the early marks of the ‘absent-minded-professor’ temperament. Parents of
Asperger’s kids will say that their child was born ‘grown up’ in terms of his seri-
ousness about life.
The oddness and isolation of the Asperger’s child which is seen in his Hermit
archetype gives birth to his brilliant gifts. Albert Einstein may be one example of
an Asperger’s breakthrough thinker.
Asperger’s children are compelled to look at things with great intensity and
they get to know the object of their focus to its very core. This inherently scien-
tific way of approaching the world may be how the child will make his living later
in life. If he can get through his childhood, his social acquaintances will be among
the scientists, specialists, and ‘computer nerds’ who share his preference for total
commitment to their interest areas.
The personality of the Restless Explorer in Tourette Syndrome

Know the Tourettic child and you know the archetype of the Restless Explorer.
Tourette Syndrome, with its wild rejection of convention, strange moods, and
obsessionality, harkens back to the ancient shamans, the medicine people who
could communicate with spirits through the rituals and ceremonies that they
devised. TS could also express, in the words of Dr Mort Duran, a Tourettic neuro-
surgeon and internationally known authority on the condition, the action of ‘evo-
lutionary neurology.’ Duran points out that many of the tics seen in Tourette
Syndrome look a lot like the behaviors animals use to communicate with each
other. Up to the spirits and down to the animals, TS takes us on a voyage into
unknown potential in human consciousness.
Tourettic children may be extremely restless and physically overcharged. They
love to explore. They can be luminescent with energy, unforgettable. They are
attracted by the forbidden, the closed doors, and by the power of nature. They
might be shamans in a primitive culture, or Wolfgang Amadeus Mozart in the
eighteenth century, or the inventive geniuses in our own time. The child with
Tourette Syndrome is a person who is comfortable living on the edges of social
propriety. His gifts will express this kind of creative and innovative perspective.
INTRODUCTION / 15
The archetypes are creative descriptions, not prescriptions

These archetypal descriptions must not be taken as prescriptive: ‘If you take this
seriously, then the Bipolar Warrior should be sent to military school!’ Wrong! I do
not use these terms in any diagnostic or prescriptive sense. I use them to denote
patterns of energy that I see in certain kids. I find that when I speak to these
energies, they speak back. If I am able to track the Warrior-like intensity of
contempt for people and the desperate loneliness in the words of a Bipolar
teenager, he may let me talk with him for a moment and in that time he will really
listen!
We make progress only with the full participation of the wild and extreme
beings in our culture. Using the archetypal device is one way to identify the
powerful patterns of extremity that these children bring to us. It is a way to keep a
positive focus in our interventions and parenting strategy. No child ever improved
himself by focusing on his deficits. To be able to change, we must be able to move
toward something.
SHAWNA’S SEARCH FOR PEACE

Shawna is a bright 12-year-old girl who appeared with me and her mom on the
Maury Povich show in 1998. The show was about children with rage problems
and was titled ‘Little Terrors.’ Shawna was such a child. Povich asked her to draw a
picture of what she felt about her rage problems. She drew herself with a devil on
one shoulder saying ‘Go ahead, explode!’ and an angel on the other saying ‘No.
Don’t. Be kind to your mom and don’t put her through this again.’ Flipping over
the poster board, Shawna drew a computer topped with a menorah, the Jewish
nine-candle icon that represents peace and miraculous redemption. Shawna knew
that her road to this place was through her work in the world of computers where
she had extraordinary gifts. To Maury Povich’s credit, he realized this also and
gave her a brand-new computer setup on the show. This was not in the script − he
was simply moved by the power of her story.
It is our job, in our roles as parents or professionals, to help kids like Shawna
experience this place of inner peace often enough to remember how to get there
themselves. This book is dedicated to providing some practical perspectives and
strategies for achieving that purpose.
You help a child like Shawna or like Johnny to the degree that you help them
become more resourceful in getting what they want out of life. Every child who
experiences the stress of Bipolar Disorder and its associated conditions has
hidden strengths that can be brought to the task of having a successful life.
My young clients can be very resourceful in finding ways to deal with their
challenges. I have learned that if I wait long enough, and can be as quiet in my
heart as was Johnny’s grandmother Carol, they will come up with the solution to
the problem. Sometimes it’s hard to wait, because the child seems so lost in his
own defense mechanisms of denial, oppositionality, and distorted thinking. But if

there is a solution to be found, it will be the child himself who will find it. Care-
givers must approach the situation with the quiet reverence, patience, and watch-
fulness that Carol exemplified in her loving treatment of her grandson.
Part One
Bipolar Disorder in Children

Dealing with sudden rage, aggressive depression,
oppositionality, and crazy thinking
CHAPTER 1
Enter the Warrior

How to Identify the Presence
of Bipolar Disorder in Children
‘The profile of the child at risk for bipolar illness suggests that whatever emotion
– negative or positive – these children experience, they seem to experience it
intensely or passionately. Their behavior is likewise dysregulated and dis-
inhibited.’
Dr Hagop Akiskal
The archetype: The Warrior

The child with Bipolar Disorder occupies the Warrior archetype and possesses the
gifts and challenges of that temperament. He is a risk taker. He is the opposite of a
‘cool character,’ and has a ‘hot’ personality which relishes the clean decision of
combat. He makes quick judgments. He wants to know what’s in it for him. If you
cross him or disagree with him, he will challenge you and will attempt to
dominate you.
THE GIFTS
The Warrior thrives on intensity. He will create a fight just to make things interest-
ing. He has the wisdom gained from experiencing the highs and lows of
existence. He may have gifts in literary and creative artistry. He has a powerful will
to achieve his goals and does well in academic areas. He is fierce as an enemy.
THE CHALLENGES
He can be his own worst enemy. The excess of fire in the temperament of the
Warrior is his biggest challenge. He can become powerfully isolated from others
because of his rage and impulsivity which may flare out of nowhere. His
self-centeredness and hunger for stimulation and excitement can make him a
monster in the eyes of others. In his moments of depression, he may decide to take
his own life or undertake other forms of self-destruction to escape the depression.
18
ENTER THE WARRIOR / 19
Jessie: Profile of a child living the Warrior archetype

She is seventeen. Her name is Jessie. At four, she showed signs of being obsessional
about things. She could not sleep unless her toys were lined up just so. She always
had to even up everything. She had night terrors – vivid half-awake, half-asleep
nightmares as if she were on a bad acid trip that defied attempts by her parents to
wake her up. The worst of it were her rages which began around age five. They
would emerge like sudden, violent windstorms at the least frustration and could
go on for an hour or more. Enraged she spit, hit, frothed at the mouth, laughed,
cried, attacked her parents, tore up her prized teddy bear and toys. Enraged, she
was a little wild creature. Her parents had to hide sharp objects as she would take
them and gouge their things or attempt to throw heavy objects at windows or the
TV screen. She complained that she could not get voices out of her head that told
her to do destructive things.
Despite these disturbances, Jessie held it together at school and was fiercely
determined to get good grades. She excelled in literature and writing and was very
creative. But after school she could get crazy. The rages would come at this time
along with the suicide threats and the attacks on her parents. A couple of times, at
age nine, she had grabbed the steering wheel of her parents’ car and tried to turn
the car into oncoming traffic. She was extremely impulsive. Nothing her parents
did stopped her from doing exactly what she wanted at any particular time. She
tried to light the house on fire. She went after Jester, her family’s beloved Toy
Collie, with a knife and would have killed the dog if her father hadn’t been there
to wrestle the weapon away from her. She showed little remorse for her actions
and seemed to be entirely self-centered.
Hitting puberty, she became more obsessional and more aggressive. Her
parents felt relief when she was out of the house. When she was home, she would
stalk them for hours, swearing at them and taunting them. She appeared to crave
their angry response and would come out of the blue with an insult in an attempt
to start a fight. At age fourteen, she fell into a depressive funk. She could not get
out of bed in the morning. Nothing interested her. Her parents were taking it one
day at a time – trying to get through to their miserable, brilliant, totally
self-centered daughter.
At fifteen, her parents sent her to a residential school in Utah that had other
boys and girls with her problems. The therapeutic milieu, structure of the place
and the absence of opportunities for her to hurt herself worked to help her
stabilize her life. It was there that her psychiatrist was able to find the right mix of
medication to help her after diagnosing her with early-onset Bipolar Disorder.
Her doctor prescribed one of the newer anticonvulsant medications along with
lithium and her mood stabilized greatly. The addition of an antidepressant medi-
cation brought her out of the funk she had been in for years. At the time of this
writing, Jessie is finally acknowledging the presence of Bipolar Disorder in her
personality. There is a good possibility that she will be able to attend college in a
couple of years. Things are beginning to look up.
Physicians are beginning to accept the fact that children like Jessie may be
suffering from a disorder that, up until a few years ago, was thought not to occur in
children her age. She shows a pattern of behavior that she shares with many adults
now diagnosed with Bipolar Disorder.
What Bipolar Disorder in adults looks like

The Diagnostic and Statistical Manual IV (DSM-IV), the diagnostic guide used by
psychiatrists, defines Bipolar Disorder by the presence of manic or hypomanic
states and depressive states, which alternate in various patterns.
Hypomania and mania

Hypomania is a term which describes a mild form of the inappropriately elevated
mood of mania. In hypomania the person’s mood is overenergized – ‘elevated,
expansive, or irritable,’ to use the DSM-IV language – but the person is not
disabled by this mood ‘high’ and does not suffer from ‘marked impairment in
function.’ In fact, many persons with Bipolar Disorder report that they value the
hypomanic phase, as it is a time when they are most productive, as if they are
running on ‘high test’ gasoline and enjoying the feeling.
One person who experiences hypomania describes the experience (from a
pamphlet published by the National Institute of Mental Health):
At first when I’m high, it’s tremendous. Ideas are fast, like shooting stars you
follow until brighter ones appear. All shyness disappears, the right words and
gestures are suddenly there. Uninteresting people, things become intensely inter-
esting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible.
Your marrow is infused with unbelievable feelings of ease, power, well-being,
omnipotence, euphoria. You can do anything. But, somewhere this changes.
For some people the change is to a manic state. In the DSM-IV, a manic episode is
defined as ‘a period of abnormally and persistently elevated, expansive, or
irritable mood, lasting at least 1 week (or any duration if hospitalization is
necessary)’ and ‘in which the mood disturbance is severe enough to cause marked
impairment in functioning.’ Other characteristics include talkativeness, mind-
racing, distractibility, wild pursuit of goals, and excessive concern with ‘pleasur-
able activities that have a high potential for painful consequences’ – sexual indis-
cretion, gambling, etc.
The fast ideas come too fast and there are far too many. Overwhelming confusion
replaces clarity. You stop keeping up with it – memory goes. Infectious humor
ceases to amuse. Your friends become frightened. Everything is now against the
grain. You are irritable, angry, frightened, uncontrollable, and trapped.
Depression
Dr Michael Norden, a Seattle-based expert on Seasonal Affective Disorder, a form
of depression, uses the acronym ‘APES SWIM’ to define the key somatic/psycho-
logical characteristics of depression (Norden 1995, p.7). When these symptoms
are severe, the person is said to be suffering from ‘major depression.’
Somatic symptoms
A: appetite or weight reduction or increase (5% in a month)
P: psychomotor retardation or agitation (moves slowly, or is jittery)
E: energy reduction (fatigue)
S: sleep reduction or increase
Psychological symptoms
S: suicidal ideas or thoughts of death
W: feelings of worthlessness or inappropriate guilt
I: interest or pleasure decreased in most activities
M: mental ability, concentration, focus, decision-making, decreases
The depressed state is described well by another Bipolar patient:

I doubt completely my ability to do anything well. It seems as though my mind
has slowed down and burned out to the point of being virtually useless. I am
haunted with the desperate hopelessness of it all. Others say ‘It’s only temporary,
it will pass, you will get over it,’ but of course they haven’t any idea of how I feel,
although they are certain they do. If I can’t feel, move, think, or care, then what on
earth is the point?
The six variations of Bipolar Disorder

The DSM-IV describes two different variations of Bipolar Disorder. These two
types differ in that they define different combinations of mood strength and
frequency of mood shift.
(In the graph parentheses seen below, ‘M’ stands for ‘mania’ or ‘hypomania’
and the ‘D’ represents ‘depression.’ A small ‘d’ or ‘m’ represents a mild or insignifi-
cant amount of the mood type. The strength of mania and depression is graphed
from a baseline of ‘normal’ or ‘stabilized’ mood.)
Bipolar I Disorder is described as the presence of a single episode or several

episodes of mania, hypomania or depression with no incidence of major depression.
Bipolar I might be described like this:
(Md)
baseline
Mood shifts but there is no major depression.
Figure 1.1
Bipolar II Disorder is described as the presence of recurrent major depressive

episodes with hypomanic interludes in between the dives into depression. In order
to meet the criteria for Bipolar II, there can never have been a manic episode in the
person’s history.
(mD)
baseline
Major drops into depression with no mania.
Figure 1.2
Four other types of Bipolar Disorder have been identified.

Though the DSM-IV does not yet list varieties of Bipolar other than the types
listed above, psychiatrists and other practitioners refer to four additional types
drawn from the work of Young and Klerman (1992). Again, frequency of mood
shift and the character of that shift define these types:
Bipolar III – Cyclothymic Disorder – manifests as cycling over short intervals
between hypomania and mild depression. Cyclothymia is not diagnosed if there is
evidence of major depression. In Cyclothymia highs are less high, and lows are
less low than in the Bipolar I or II varieties.
(md)
baseline
(a typical 48-hour cycle)
Figure 1.3
Cyclothymia may be expressed in rapid cycling on a daily basis, beginning with a

depressive phase in the morning and leading into a manic phase in the late
afternoon and evening.
Bipolar IV – antidepressant-induced hypomania – is not yet listed in the DSM-IV
but will probably be in the next edition of the manual. This diagnosis defines a
condition in which hypomania is induced by the administration of antidepressant
medications such as fluoxotine (b. Prozac) or fluvoxomine (b. Luvox), and the
tricyclic class of antidepressants such as desipramine (b. Norpramine) or
imipramine (b. Tofranil).
(Md)
baseline return to baseline after discontinuance

Figure 1.4
Tricyclic use is especially associated with the development of the disorder. It is

unknown how these drugs cause the onset of mania but the fact that all of them
act to raise serotonin in the brain suggests upregulation of this neurotransmitter is
involved. This effect can occur in both children and adults.
Bipolar V – major depression with a family history of Bipolar Disorder: a significant
proportion of patients with Bipolar Disorder may begin their lifetime of mood
problems with depression.
(mD)
baseline
Figure 1.5
Depression as a stand-alone issue will show the symptoms that Dr Norden

describes above. Depression comes to adults as a stand-alone condition (in which
the person has never experienced hypomania or mania) or in some form of Bipolar
Disorder.
Bipolar VI – Unipolar Mania – is a rare form of Bipolar Disorder and if it appears
for the first time after the age of 40, the person should be screened for medical or
neurological causes. Brain dysfunction including seizure conditions or other
kinds of organic brain diseases may be involved. Some children will experience a
short-duration Unipolar Mania (a day or less) which then fades away but which
may be a forewarning of the development of Bipolar Disorder later.
(Md)
baseline
Figure 1.6
Bipolar Disorder in children mixes the manic and depressive states together to
form aggressive depression.
Bipolar Disorder, termed ‘early-onset Bipolar Disorder’ when it occurs in
children, is most often seen as a ‘mixed-state,’ ‘rapid-cycling’ type of affective
illness in kids as young as four years old (Wozniak and Biederman 1995). The
child will move from a relatively normal mood or an anxious and sad state to
become wild, rageful, and unpredictable. Early-onset Bipolar Disorder may be
diagrammed as follows, with low points on the line corresponding with the
emergence of the most aggravating symptom: rage.
(MD)
baseline
Figure 1.7
This pattern shows all the marks of Cyclothymia (Bipolar III) but lacks the clear
split between hypomania and mild depression seen in that disorder. Bipolar
Disorder IV, that variation caused by administration of antidepressant medication,
will also show this extreme rapid-cycling pattern along with the child’s loss of
control and violent behavior.
Very few Bipolar Disorder-diagnosed children score high on the ‘elevated
mood’ criteria of the standard diagnosis. Perhaps not wildly optimistic, these kids
show the quality of mania in children described by eminent researcher Dr Hagop
Akiskal as ‘extreme irritability, mood lability [rapid, unpredictable mood change],
emotional storms, sudden wild behavior, and explosive anger’ (Akiskal 1995,
p.756).
The drop into the depressive stage is heralded by a worsening of the aggressive
and irritable aspects, what is called ‘dysphoria’ (from the Latin for ‘bad mood’), of
the syndrome and the emergence of rage. This drop often occurs suddenly, taking
parents by surprise.
The ‘space-out’ or ‘little seizure’ of Bipolar Disorder in kids

Anecdotal evidence from my clients suggests that Bipolar Disorder may share
many of the features of a seizure disorder. In a seizure, loss of consciousness
occurs, accompanied by involuntary motor muscle movements. This is caused by
brain neurons firing randomly over an area of the brain that has been damaged by
trauma, or a result of disease – a brain scar will ‘light up’ when a seizure is viewed
with brain-scan technology.
The ‘kindling effect’ of depression is seen in the fact that the depressions a
person experiences in his youth will be milder than the ones he experiences in
adulthood. This happens as a result of the build-up of minuscule damage the
depressive pattern inflicts on neurotransmitter pathways. The kindling effect
shows that depression damages the brain in the same way as does brain trauma.
Fortunately there is also evidence that people can heal themselves from this kind
of injury through the use of medication and psychotherapy. Depression is a
serious health challenge, but healing from it is possible.
Though there is not a lot of current research on the subject, the theory that
depression and seizure activity have a lot in common is strengthened by the fact
that when children with early-onset Bipolar Disorder experience rage, they may
show several physical changes which also occur to a child who is in the midst of a
brain seizure. These effects include:
• a loss of awareness that may be severe enough to stop a child in her
tracks, rendering her totally without a clue as to who she is or what she
is doing
• amnesia of what she does during rage
• dilation of the pupils as she warms up to a rage.
My clinical experience leads me to believe that kids who have these seizure-like
effects tend to have more severe cases of early-onset Bipolar Disorder. A caveat is
in order: the presence of these symptoms is not diagnostic of the presence of
Bipolar Disorder but does indicate that at some level the brain is going through
physical changes as well as psychological ones when Bipolar symptoms become
florid.
Knowledge of these subtle shifts in physical appearance enables parents to
detect when the child is going through an acute change in brain chemistry.
Parental stress is reduced because parents can anticipate the sudden wild change
in behavior a few moments before it happens. This enables them to implement a

plan to deal with it.
Markers of Bipolar Disorder in children and teens

A considerable body of research has been done to identify markers of early-onset
Bipolar Disorder in children (Biederman 1998; Biederman et al. 1995; Post
1999). Here are 16 characteristics I have compiled from my clinical observations
and from this research. It is important to point out that this is not a diagnostic
template. To be diagnosed with Bipolar Disorder, both mania or hypomania and
depression must be present. The points listed below enable you to assess if these
states are present in a child’s psyche either as separate phenomena or in the mixed
state often seen in Bipolar Disorder in children.
1. Presence of mood shift or a mixed-state mood disorder

The problems of children with Bipolar Disorder are directly related to their shift
in mood from hypomania or normal mood to depression on a cyclical basis.
Younger children tend to cycle rapidly through a mixed state of aggressive depres-
sion. Older kids may have more clearly split phases of hypomania and depression.
But it is the cyclical nature of the disorder that distinguishes it from other condi-
tions, such as ADHD or Tourette Syndrome.
Quite a number of Bipolar children will get better for periods of time.
Symptoms wax and wane from day to night, from doctor’s office to home, from
school to home, from week to week or month to month, with periods of relative
normalcy. When symptoms wane, the child and parents may believe that he has
gotten over his mood disorder and that they can withdraw medication. Physicians
advise against this practice as withdrawal of medication may throw a child into
severe expression of his Bipolar symptoms.
How to determine if mood shift is present in young children Keep a journal

in which you note change in the child’s mood state. Major indicators
include (for the depressed state): loss of appetite, increase in irritabil-
ity, rage, inability to focus, lethargy, sadness, obsessions, compul-
sions, and phobias. For the hypomanic shift look for increases in
overarousal at night, pressured speech (see definition below for this
factor), hyperactivity, and risky or destructive behavior.
2. A predisposition to rage
Rage is usually kicked off by a requirement to follow a rule or to stop some
behavior. It is a signature feature of Bipolar Disorder in children. Rage occurs
from an early age. It is unstoppable, and goes on for over a half-hour. It may be
violent and often results in exhaustion. The child does not remember what
happened during the fit of rage. Dr Charles Popper of the Harvard Medical
School, an authority on Bipolar Disorder in children (Popper 1989, p.6), says that
this rage ‘could not be imitated by an adult without becoming exhausted in a few
minutes.’
How to assess if rage is indicative of Bipolar Disorder Note the presence of

the factors described above in your child’s rage and read Chapter 2
for a detailed explanation of how rage manifests itself in kids with
Bipolar challenges. See the checklist in Chapter 3 to identify factors
that indicate that rage expresses the mixed-state, energized aggres-
sive depression of pediatric Bipolar Disorder.
3. Anxious hyperactivity and wild behavior (younger children)

Akathisia, the feeling of restless inner tension, inability to keep the legs still, is
another feature shared by both ADHD and Bipolar kids. Anxiety is fear without
meaning − a child dreads something but doesn’t know what it is. Put anxiety and
akathisia together and you get the kind of easily irritated, jumpy hyperactivity
that is particular to Bipolar Disorder in children. You get the feeling that their
engine is racing, but the driver is asleep!
The wild behavior characteristic of BD will often be accompanied by the
expression of panic (Chen and Dilsaver 1995) or hallucinations. Oftentimes
behavior will be preceded by extreme anxiety. In many cases, the child will report
a loss of awareness of his surroundings and will seem dazed when rescued from
some activity that was threatening his well-being. Young children will run into the
street or try to jump out of a moving car. Teens will get into risky and dangerous
behavior involving law-breaking, promiscuity, or drugs after a period of uncom-
fortable agitation.
As the child enters the depressive phase and becomes overwhelmed with dark
or foreboding thoughts, his anxiety may escalate quickly and he will run
screaming from the scene. Or he may devolve into rage.
How to determine if anxious hyperactivity and wild behavior are related to

Bipolar Disorder Keep careful notes on when the child becomes
agitated and hyperactive. Typically, he will cycle through this phase
on a daily basis with the problem getting worse at night. Children
with ADHD do not cycle through hyperactivity but are consistently
overenergized and are usually helped with stimulant medication.
Look for the presence of what psychiatrists term ‘flight of ideas’, the
manic tumble of thoughts one over the other that causes pressured
speech – fast verbal delivery in which the child changes topic so
many times that the listener is left breathless.
4. Impulsivity and impaired judgment

Younger children with Bipolar-like challenges will demonstrate these characteris-
tics by stealing things at school, pushing other kids around, or playing with
dangerous objects. Teens may impulsively become involved in law-breaking, con-
duct-disordered-type behavior (vandalism, crimes against people, lack of
remorse), abuse of drugs, and dangerous sexual behavior. They will not under-
stand the connection between the impulsive act and its consequences.
Children with BD challenges behave impulsively to assuage feelings of
depression and deadness (they get a ‘rush’ from the activity that is experienced as
energizing) or because when they are hypomanic, their good judgment fades
completely. Though children with ADHD behave impulsively, children with BD
challenges will doggedly persist in dangerous and destructive behavior, and will
ignore or deliberately circumvent attempts of caregivers to control deviant
behavior.
How to assess for the presence of Bipolar-related dangerous impulsivity and

impaired judgment Keep a journal and note the presence of two char-
acteristics of impulsivity seen in this population: (a) the child
commits an act that is destructive, illegal and dangerous, and (b) the
child shows very poor judgement – he does not see how the act
could lead to its consequences. Look for mood swings as a causative
in impulsive action.
5. Inattention and distractibility

In Bipolar Disorder, a child’s descent into the depressed and dysphoric state is
accompanied by a loss of cognitive ability – his brain ‘locks up.’ The child loses the
ability to focus and make decisions. One of my 16-year-old clients who was
diagnosed with Bipolar Disorder told me that when his cycle shifted down, his
mind would go into a ‘space out’ from which he could not rouse himself. If this
happened in the middle of a test at school, he would forget every bit of prepara-
tion he had made for the examination, his mind would go blank and he would
stare at the page feeling helpless and unable to form any appropriate reaction to
the task at hand.
Unlike the loss of focus that occurs in ADHD, Bipolar brain lock is not treated
effectively with stimulant medication. In ADHD, focus is poor because inhibitory
nerves in the frontal cortex, the executive structure in the brain, underfunction. In
Bipolar Disorder a more profound effect occurs as the entire decision-making
apparatus shuts down. This is a generalized reaction and is similar to how the
brain reacts to extreme stress. This loss of cognitive function points to the efficacy
of stress management as the primary method for decreasing the damage that
Bipolar Disorder can do.
How to assess if Bipolar Disorder is contributory to inattention Note in your

journal if the child’s inattention waxes and wanes with his mood
shift. Ask him if he loses focus when he is depressed. Note if his
focus seems to increase when he is very energized (possibly hypo-
manic).
6. Extreme irritable self-centeredness and combative behavior

It is a normal part of development for young children to be self-centered. The
‘terrible twos’ of childhood are a normal manifestation of structure-building for a
child – he must first establish and consolidate a sense of himself apart from his
mother before he can proceed to more complex development, and feel strong
enough to negotiate his interests with others and see their side of things. In the
child with early-onset Bipolar Disorder, the child remains in the ‘terrible twos’
attitude well into his teens. Though children with ADHD also show an unusual
self-centeredness, their issues usually revolve around a sense of frustration at
being unable to focus. Their oppositionality expresses the belief that ‘I am not in
control, I am scared, and I draw the line here!’
Children with Bipolar Disorder seem incapable of seeing the other’s perspec-
tive in a situation. This may or may not be a function of the quality of empathy.
They will argue incessantly or deliberately twist an argument to justify their
position on an issue. These children may be unable to engage parts of the

prefrontal cortex which enable people to have ‘observer perspective’ on their
actions – to rise above the situation and so see their own part. And kids with BD
may be extremely irritable all the time. They do not laugh. This is an expression of
the merciless psychological pain of depression. They project this depression into
all their interactions. They are extremely unpleasant people to be around in their
depressed phase.
How to identify the presence of extreme irritable self-centeredness as a compo-

nent of Biopolar Disorder Keep a journal of your child’s behavior and
note the number of times a day that she is able to laugh or seems to
have fun. Do you look forward to times when she is absent from the
house as if she were an abusive adult? These intuitive measures are an
indication that she is depressed and your mood is being affected by
hers.
7. Sleep issues: Night-time overarousal and morning underarousal

Typically the child will not be able to get to sleep until very late and will
sometimes stay awake until the early morning hours. Teenagers may drop into a
rock-and-roll trance at night, cranking up the Marilyn Manson and going online
to talk with other insomniac, possibly Bipolar, teens in other parts of the world.
The teen may get slightly manic, oftentimes pressing to be allowed to go for
midnight walks or bicycle rides. Quite a few of the teens I have spoken with say
that they like the ‘coolness’ of the night and the fact that there are fewer people
around. Michael Norden (Norden 1995) talks about the fact that the brains of
people who are depressed are very sensitive to heat and so it makes sense that
children with Bipolar Disorder enjoy the overall cooling effect of the night air.
How to assess for the presence of a sleep disorder Keep a sleep log for your
child in which you note how much sleep she needs when she doesn’t
have to get up at a particular time. Weekends and school holidays are
a good time to document her sleep habits. Some children need very
little sleep. Some need a lot. Most need much more (12–14 hours a
night is not uncommon) when they hit their teen years. If she cannot
get out of bed until the afternoon, becomes hyperenergized or
tyrannical at night, or likes to stay up all night, there is a possibility
that she is experiencing an affective disorder such as depression or
Bipolar Disorder.
8. Seemingly malevolent enjoyment of knives, fire and dangerous behavior

Children with ADHD diagnosis also show an attraction for these implements. But
the ADHD child is less at risk from hurting himself or others. He can learn knife
and fire safety and come to terms somewhat with the craving for stimulation that
drives dangerous behavior. He will most often get hurt because of inattention.
The Bipolar child, on the other hand, will involve herself in these activities
with a purpose which is often grandiose or seems malevolent. She will imagine
the use of fire to attack a kid who torments her at school or she will keep knives
around the house to, as one kid put it to me, ‘give myself a sense of security.’ Many
of the behaviors included within the diagnosis of Conduct Disorder in the
DSM-IV (312.89) may be seen but these are not diagnostic of the presence of
Bipolar Disorder.
How to identify the presence of Bipolar Disorder in fire and knife play
Observe your child’s behavior with these items. A child with ADHD
may act clueless about his motivation for dangerous play and getting
into trouble. The child with Bipolar Disorder may fantasize that use
of these materials gives her power or protects her. She may show a
disregard for the rights of others and be slow to experience remorse
for her actions. Look for the quality of intentionality and planning
to detect BD.
9. Morbid cognition and suicidal thinking

Many children with the diagnoses of Unipolar Depression, Bipolar Disorder, or
ADHD comorbid with depression have gory thoughts that they cannot control –
thoughts about hurting people close to them or seeing themselves dead. In my
client research I find that children with seizure phenomena (brown-outs, pupil
dilation, etc.) show more of this ideation. Morbid fantasy is a part of Bipolar
Disorder and has been reported for centuries by people with the condition.
Children with ADD may talk about suicide without the intention to follow
through. Just talking about it gives them the feeling that they have some control
over a situation that seems totally beyond their control. However, suicide is a
leading cause of death of people with Bipolar disorder. For this reason, it is very
important to assess if the suicidal comment expresses BD-related depression. A
child who obsesses about death may be helped with psychotherapy. One who is
actively contemplating suicide needs a range of supports that may include
inpatient hospitalization.
How to assess the danger or suicide for children and teens with Bipolar
Disorder
1. The child has verbalized that suicide may be an acceptable
choice for him to escape the misery that he is experiencing.
2. The child has discussed the means he might use to kill
himself.
3. The child has given away precious toys; is tying up his
affairs.
4. The child manifests a high degree of anxiety and agitation and
at least one of the preceding factors is in evidence and/or:
5. The child becomes calm, happy, and seems at peace with
himself after a period of psychological agony.
10. Effects of stimulant or antidepressant medication

Children with Bipolar Disorder, without comorbid ADHD, often get more manic,
rageful, agitated, and driven after taking stimulant medication. These same effects
may also occur after taking antidepressant medication. Antidepressants in the
tricyclic class (see p.23) and the Selective Serotonin Reuptake Inhibitor (SSRI)
class such as fluoxotine (b. Prozac) and fluvoxomine (b. Luvox) can also be prob-
lematic. Symptoms usually abate when the medication is withdrawn.
Stimulant and antidepressant medication may be used to treat issues of inatten-
tion, impulsivity, and depression in a child with Bipolar Disorder, but his mood
must first be stabilized. The mood stabilizer class of medications is most often
used, including lithium, or a medication from the newer generation of mood sta-
bilizers such as Depakote. Once mood is stabilized physicians may advise the use
of a stimulant or antidepressant medication at low dose, and will observe for
desired improvement without exacerbation of mania or hypomania. See Chapter
2 for more detail on medication used to treat BD in children.
How to assess if medication reaction indicates the presence of Bipolar

Disorder Keep a medication journal and document the presence of
any of the factors described above in the child’s demeanor after
taking medication. Look for agitation, irritability, or wild behavior.
11. Tyrannical behavior

The child does not acknowledge the moral authority of parents – their ‘right to
rule’ in the family. The child tries to run the family his way. From an early age,
children who show features of early-onset Bipolar Disorder are often extremely
oppositional. Things have to go the child’s way, or a major screaming fit and
tantrums ensue. Parents must always walk on eggshells around the child, and
anything can set off this hypercritical, oppositional, self-centered reaction as if no
one existed except the child himself. Parents may try to mollify the child by
avoiding putting requirements on him. But eventually some request is made and
the child explodes into a foul-mouthed attack on the parent. Things go great if
they’re going his way.
How to assess if tyrannical behavior is indicative of Bipolar Disorder In

your journal note the presence of tyrannical behavior. Does he
explode when he hears the word ‘No’? As a teenager, does he try to
run the household and dictate how his parents should deal with his
siblings? Is he relentlessly egocentric and verbally abusive? If other
indicators of BD are present, the case is strengthened that tyrannical
behavior may be an expression of the aggressive depression of
Bipolar Disorder.
12. Hallucinations and other psychotic phenomena

Auditory hallucinations, ‘hearing voices,’ are more common than visual hallucina-
tions and often border on obsessive fixation. The child will complain that he has a
song playing in his head that he can’t get rid of, or that he hears voices telling him
to do things, or that he experiences horrific thoughts involving dismemberment
or doing harm to someone close to him. It is important to understand that these
thoughts rarely lead to actual commission of the horrific deed. Most often they
simply make the child feel extremely ashamed or crazy for having them.
Another common manifestation is the child’s possession of ‘ideas of reference’
– psychological jargon for magical thinking, such as having the ability to hit a ball
over a 50-story building, or that he has a special connection with good and evil
spirits.
Bipolar Disorder in children may manifest itself as fears of the devil and as the
need to perform certain rituals to stay safe. Many children with Bipolar Disorder
suffer from obsessions and compulsions (Kruger et al. 1995). Some – not all –
children with Bipolar Disorder behave cruelly toward animals. The impulse to do
so is usually described with the same emotional tone that is used when describing
why they trashed a favorite object in a rage: ‘I felt like I had to do it.’
How to talk to younger children about hallucinations Ask the child if he is

‘hearing voices’ in his head telling him to do things. For visual hallu-
cinations ask ‘Do you sometimes see things that are not there?’ Nor-
malize the child’s experience by telling him that ‘Some people’s
thoughts are turned up a little too loud, like turning up the volume
on the TV. People without this problem can turn down the volume,
but you have a harder time doing this.’
13. Sexual hyperacuity

Inappropriate kissing, public masturbation, rubbing against adults, and groping
adults may become problematic (Fristad, Weller and Weller 1992). Loving, firm
re-education in the inappropriateness of these gestures without shaming the child
is in order.
Many Bipolar children are tormented by obsessions about sex and about how
bad they are to have these obsessions. Both hypersexuality and hyperreligiosity
can be seen in the same child and this can cause deep confusion and misery. Adults
must listen to the child and reassure him that he is much more than his obsessions.
If obsession becomes compulsion, adults must draw firm boundaries to protect
the child and people around him. This will probably include medication and may
include behavioral and psychological therapy.
How to assess the connection between sexual hyperacuity and Bipolar

Disorder in a child or teen Keep a journal which documents your child’s
inappropriate sexual behavior. Note the presence of the factors
described above. Sexual misbehavior may also be the result of
physical or sexual abuse of a child. Seek the assistance of a therapist
to assess if trauma or Bipolar-related brain chemistry is causative.
Realize that teenagers are drawn to sexual exploration and the three
‘danger’ factors for it are that it is experimental, spontaneous, and anony-
mous. Teens with Bipolar Disorder are especially vulnerable to social
environments in which these three factors are present.
14. Severe energy reduction in the depressed phase

Dr Hagop Akiskal says that bipolarity in teenagers is often seen as ‘lethargic
hypersomniac retardation’ (Akiskal 1995, p.757) – the child sleeps too much and
acts dull and stupid during the day as a result. The term ‘retardation’ is strong
language that describes the appearance of the depressed child when he stops
trying to accomplish things in his life and pulls back into his shell.
Some researchers, noting that depression has the look of Chronic Fatigue
Syndrome (Croft et al. 1993), suggest that getting an Epstein – Barr titer (the
check for CFS) on a child with serious lethargy problems might be in order. The
exact link between depression and CFS is not known, but children with
early-onset Bipolar Disorder often show symptoms of this kind of lethargic
affective state when they hit their teens. It may be treated pharmacologically and
with psychotherapy.
Medical tests often show a link between a malfunctioning thyroid gland and
the powerful sense of internal pressure that people with Bipolar Disorder experi-
ence. Many physicians routinely ask for a lab report to determine if hyper- or
hypothyroidism is a contributor to manic behavior.
How to assess if a child’s lethargy is caused by Bipolar Disorder Younger

children with Bipolar Disorder are less likely to show the deep
lethargy associated with Bipolar Disorder. But these factors may
become very evident in teens whose intelligence seems to disappear
into a ‘Beavis and Butthead’ persona in which the child’s responsive-
ness is severely dulled.
15. Affective illness in the family

Volumes of research suggest that Bipolar Disorder is very inheritable (Goodwin
and Jamison 1990). If ancestral Bipolar Disorder occurred at an early age, there is
an increased probability that it will be genetically communicated as early-onset
Bipolar Disorder. Conversely, the younger the age of the child when early-onset
BD symptoms show up, the greater the likelihood of a significant family history
with the disorder.
16. Difficult or premature birth

Dr Daniel Amen’s SPECT (Single Photon Emission Computed Tomography)
brain scan research on children with what he terms ‘Explosive ADHD’ (children
with temporal-lobe abnormalities, early-onset Bipolar-like qualities, and a
problem with rage) shows that many of these kids had a difficult birth or were
delivered with obstetric forceps (Amen 1995). There is very little research to link
affective illness with brain trauma inflicted at birth. But I have validated Dr
Amen’s hypothesis by interview with parents of my pediatric Bipolar clients, and
so far better than 80 percent report this factor to be present.
Another factor may be low birth weight. Forty percent of the children I treat
for Bipolar Disorder in counseling are reported to have been born prematurely.
The Bipolar checklist for children and teens
1. PRESENCE OF MOOD SHIFT OR A MIXED-STATE MOOD DISORDER
(a) As clear hypomanic and depressed states.

(b) As a mixed state of aggressive depression.
(c) With hypomania or energized aggression emerging at night.
(d) Will be less problematic at school and more problematic at home.
(e) May wax and wane, with symptoms disappearing for days or weeks.
2. A PREDISPOSITION TO RAGE
(a) Lasts over half an hour.

(b) Results in disorganization and regression.
(c) Cannot be imitated.
(d) May include psychotic behavior, affect, and ideation.
(e) May be preceded by soft signs of seizure activity, dilation of the pupils,
amnesiac states, and auras.
3. ANXIOUS HYPERACTIVITY AND WILD BEHAVIOR (YOUNGER CHILDREN)
(a) Child is easily irritated, jumpy. Hyperactivity is present.

(b) Predilection to run away screaming (into traffic) or jump out of a
moving car.
(c) May be accompanied by visual or auditory hallucinations.
(d) May presage emergence of rage.
4. IMPULSIVITY AND IMPAIRED JUDGMENT
(a) In younger children, shows in chronic behavior problems at school.

(b) In teens, shows itself in conduct-disordered behavior (lying, shoplifting,
vandalism), sexually dangerous behavior and drug abuse.
(c) Child lacks the ability to foresee the consequences of his behavior.
5. INATTENTION AND DISTRACTIBILITY
(a) Attention and cognitive ability drop in the depressive phase, but are fine
in more normal consciousness.
(b) Inattention is caused by the rush of ideas that occurs in the hypomanic
phase.
(c) Poor decision-making occurs in hypomanic phase, but no problems
making decisions in non-manic states.
6. EXTREME IRRITABLE SELF-CENTEREDNESS AND COMBATIVE BEHAVIOR
(a) The child is extremely oppositional.

(b) Appears incapable of seeing another’s position in an argument.
(c) Does not show empathy or sensitivity to others’ feelings.
(d) Does not take ownership of dysfunctional behavior when confronted.
(e) The child relishes power struggles and seems pleasantly energized by
arguing with others.
7. SLEEP ISSUES: NIGHT-TIME OVERAROUSAL AND MORNING UNDERAROUSAL
(a) Energized at night and underaroused in the morning.

(b) In hypomanic phase, sleeps much less; in depressed phase, much more.
8. SEEMINGLY MALEVOLENT ENJOYMENT OF KNIVES, FIRE

AND DANGEROUS BEHAVIOR
(a) Enjoys playing with knives and/or fire.

(b) Shows intentionality to damage others’ property.
(c) Shows evidence of grandiosity (exaggerated feeling of own power or
vengeance fantasies in connection with knife or fire play).
(d) Demonstrates presence of conduct-disordered behavior: law-breaking,
bullying, dangerous acts.
9. MORBID COGNITION AND SUICIDAL THINKING
(a) Presence of unwanted fantasies about hurting people he loves.

(b) Gory thoughts about death and dismemberment.
(c) The child has said things like ‘Maybe the world would be better off
without me.’
(d) Has talked about the means that could be employed to suicide.
(e) Has stated the intention to do so.

(f ) Has tried to give away favorite toys.
(g) Possesses other characteristics listed above and acts agitated.
10. EFFECTS OF STIMULANT OR ANTIDEPRESSANT MEDICATION (CIRCLE ONE OR

BOTH)
(a) Becomes agitated, depressed, or manic after taking stimulants.

(b) Becomes agitated, depressed, or manic after taking antidepressants.
11. TYRANNICAL BEHAVIOR
(a) Things must go the child’s way or a major tantrum ensues.

(b) Has always considered himself equal to parents and does not accept
parents’ right to have authority in his life.
12. HALLUCINATIONS AND OTHER PSYCHOTIC PHENOMENA
(a) Visual hallucinations (seeing things that aren’t there).

(b) Auditory hallucinations (hearing one’s thoughts, sometimes as if an
amplified voice is speaking into the ear).
(c) Cruelty to animals is in evidence.
(d) The child reports ideas of reference (he believes he possesses magical
powers, etc.).
(e) Hyperreligiosity is present.
(f ) Insight is gravely impaired; the child is unable to see his own part in
the situation.
13. SEXUAL HYPERACUITY
(a) The child has obsessive thoughts about sex.

(b) Inappropriate touching (especially in younger children).
(c) Inappropriate sexual comments or other behavior are present.
14. SEVERE ENERGY REDUCTION IN THE DEPRESSED PHASE
(a) When depressed, the child is very depressed. Severe impairment.

(b) May show thyroid gland abnormalities in medical tests.
(c) May show abnormalities in an Epstein–Barr titer suggestive of Chronic
Fatigue Syndrome.
15. AFFECTIVE ILLNESS IN THE FAMILY
(a) Child developed BD-type symptoms at an early age.

(b) There is a history of affective illness (disorder or depression) in the
family.
16. DIFFICULT OR PREMATURE BIRTH
(a) Yes
(b) No
Scoring key
This is a self-awareness checklist. It is not meant to be used as a diagnostic instrument but is a
method for developing understanding of the components of Bipolar Disorder that are seen in a
majority of cases.
The only essential diagnostic question at issue under present guidelines is
point 1. A child has to show mood shift between manic (or hypomanic) and
depressed states in order to be considered to have manic-depressive illness, or she
must evidence the mixed-state aggressive-depression profile for early-onset
diagnosis.
Check any responses that apply to the child you are evaluating. If you checked
in the affirmative on any of the choices (a, b, c, d, etc.) for ten or more of the points
seen as 1 through 12 (and have checked point 1), there is a probability that the
child suffers from Bipolar Disorder and you should pursue formal diagnostic eval-
uation with your doctor. Points 11 through 16 describe features of BD often seen
in children but which do not show up as primary features in current research.
Two essential survival strategies for parenting the child

with Bipolar challenges
Bipolar Disorder is an inherited neurological condition that the child did not ask
to receive. Most children with Bipolar challenges want the things that all kids
want – to feel safe and successful in life. Here are two core strategies for helping
your child realize these values:
1. Help her strengthen her own natural boundaries

Children with Bipolar-like problems with rage and violence do have personal
boundaries and can pull their punches, though this may be difficult for them.
Many children with BD challenges punch holes in walls, but few will put their
fists through a window. This behavior suggests that these children are able to
control themselves somewhat. But, given the limitations they possess in terms of
ability to see the big picture, to form valid conclusions about it, and to manage
their own stress and mood swing, it takes enormous strength to exercise this
control.
Parents help the child to the degree that they reward even little gestures of
moderation and reasonable behavior. They help her develop character strength
when they note and affirm every time she is able to put boundaries around her
own wild emotional reaction. And they stick to their consequences. They require
her to repair the wall and compliment her for doing a good job of it.
And they provide boundaries on her actions that are strong enough to contain
her attack. They do not let her run the house or manipulate them and they do not
protect her from the natural consequences of her actions. If she breaks the law, she
1
answers for it. If she attacks a family member, 911 is called. This is a central
theme of this book: that children with Bipolar challenges who survive to
adulthood have had the benefit of tough love, of strong, take-it-to-the-limit
parenting. If adults drop their responsibilities out of exhaustion, the child will
spin free and may be consumed by her own disorder or end up in the penal system.
The Warrior archetype in a child will set up a battlefield in her home and her
parents, like it or not, will have to engage her and contain the anarchy in her tem-
perament. This is a crucible experience for families. Some survive. Some do not.
2. Listen with your heart and your head

Your best bet is to get on problems early, keep your cool, and take your child’s
Bipolar-related challenges seriously. She is disabled for the time being. You do
what you have to and try to keep your heart open and see the soul of a very young
child in her. The example of the wise grandmother which I described on the first
page of the Introduction is relevant here. One must be ‘very quiet’ in one’s heart so
as to allow the child to express the pain she feels inside. Try to approach the
situation with this sense of peace and presence while you maintain the proper
boundaries and consequences for violence.
A single mother of a Bipolar teen told me she decided years ago that her job as
a mother was going to be more of a marathon than a sprint. She knew her son’s
condition would not go away. As he moved through his teen years, she joked
ruefully, she seemed to be running her marathon across machine-gun fire. But the
experience was bringing something positive out in her. This was her ability to stay
grounded, deliver the tough love required of the situation, and let herself off the
hook for not being perfect all the time. I was inspired by her self-acceptance. As a
parent it is important to love yourself this way to get your child through the
extreme turbulence of his childhood so that he can grow up to give and get love
himself.
1 In the UK the number for the emergency services is 999.

CHAPTER 2
The Brain Chemistry of Bipolar Disorder

and the Drugs Used to Treat It
If I were a member of a futuristic culture, I would be a Klingon – you know, the

warrior race from Star Trek. I like the way they relate to things. They are very
aggressive and manipulative but there is a sense of honor too. You know where
you stand.
A 16-year-old boy with Bipolar Disorder
Bipolar Disorder expresses the dominance of the limbic brain

in a child’s life
The human brain is made up of three structures, each having a specialized
function. These are the base brain, the limbic brain, and the cortex.
The base brain, also known as the reptilian complex or R-complex (the oldest
brain structure, which we share with reptiles), is responsible for our instinctive
action and defense, the operation of our involuntary nervous system and muscula-
ture, and the body’s fight-or-flight response to stress.
The limbic brain is so named because it wraps around the head of the spinal
column and base brain like a limb. It is also called the ‘animal brain’ because
non-human animal species possess a limbic brain that is functionally similar to
ours. The limbic system is responsible for receiving and comparing sensory infor-
mation in memory, and contains the structures that initiate emotional and sexual
behavior.
The cortex or roof brain is the structure tasked to thinking, decision-making,
and evaluation of sensory input. The most advanced and sophisticated brain ‘cir-
cuitry’ is contained in the frontal lobes of the cortex – termed the ‘prefrontal
cortex.’ This is where the capability for ‘executive action’ and complex deci-
sion-making resides. This is the location of control centers for higher conscious-
ness and the editing of action to fit social and cultural mores.
In Bipolar Disorder, and Tourette Syndrome, the child possesses an overpow-
ered limbic brain and an underpowered cortical brain that fails in its job to inhibit
impulse to action (Strakowski, DeBello and Sax 1999). The result is that this child
41
must struggle greatly with his ‘animal’ or ‘wild’ instincts to adapt to the demands
of culture and school.
Sensory cortex
Prefrontal cortex
thinking and
behaviour
inhibition
Base brain
or “reptillian” brain
Limbic brain
emotions
Figure 2.1
All three of these brains operate within the framework of two great neurotrans-
mitter systems that function throughout the nervous system: (a) the aminergic
system which is responsible for our waking consciousness, and (b) the cholinergic
system which regulates the involuntary functions in the body and takes us into
sleep by shutting down the cortex. Neurotransmitters are brain chemicals that
switch different parts of the brain on and off. A good example is the effect of
stimulant medication such as Ritalin to upregulate the neurotransmitter dopamine
in nerves which are important for attention in the brain. The drug ‘switches on’
the inhibitory neurons so that the child can screen out distraction.
The neurotransmitters that coordinate the function of the aminergic system are
serotonin, a mood-calming brain chemical; dopamine, which powers both excit-
atory and inhibitory nerves; and norepiniphrine, which powers adrenaline and
the body’s muscles and nervous system. The primary neurotransmitter that coor-
dinates the function of the cholinergic system is acetylcholine. As the body moves
into sleep, acetylcholine pathways from the base brain energize forward to even-
tually reach the prefrontal cortex and shut it down, thus bringing on sleep.
The left and right frontal lobes, sitting over the left and right eyes respectively,
have specialized roles to play in the experience of emotion. Studies show that the
left frontal lobe is specialized for the experience of positive emotions, the right
frontal lobe is specialized for the experience of negative feelings and for tasking
THE BRAIN CHEMISTRY OF BIPOLAR DISORDER AND THE DRUGS USED TO TREAT IT / 43
the body’s reaction to stress. In depression and Bipolar Disorder, the right frontal
lobe may be overactive and may flood consciousness with negative, fear-based
thoughts. The frontal lobes connect with two structures in the limbic brain called
the amygdala and thalamus to make up the brain’s emotional circuit.
The amygdala (from the Greek word for ‘almond-shaped’) compares messages
from the different sense organs with the thalamus, to orchestrate emotional
reactions to stimuli. The thalamus is responsible for the integration of sensations,
emotions, a sense of pain and sexual feelings and the transmission of these stimuli
to the motor cortex, the part of the brain tasked to movement and response. It is
probably the hypersensitivity of neurons in the area of the amygdala and thalamus
in children with neuropsychological conditions that causes their emotional
extremes and hypersensitivities to external sensory experience (Strakowski et al.
1999) One example is the child’s oversensitivity to the feeling of clothing or to
sensations of heat and cold. This hypersensitivity also creates a chronic sense of
internal stress, the ‘driven’ feeling, seen in both Bipolar Disorder and ADHD.
In Bipolar Disorder, limbic oversensitivity causes an inappropriate excitatory
reaction to stimuli. Parents of children who rage as a result of the presence of
Bipolar Disorder say that they feel they are walking a tightrope around their
child’s mood swing. One little stressor, one little remark taken the wrong way, can
upset the apple cart and throw the child into a dysphoric mood. Oversensitivity of
the thalamus, hypothalamus, and amygdala, which are tasked to moderating
emotion, puts continual pressure on the thinking brain, the cortex, resulting in a
lowered ability to inhibit impulsive action. The result is a natural predilection to
overreact to everything.
How Bipolar Disorder and early-onset Bipolar Disorder phenomena

manifest in the limbic wave
In Survival Strategies for Parenting Your ADD Child (Lynn 1996), I suggest that dis-
tressing behaviors such as rage, obsession, and wildness are a result of a wave of
energy that sweeps over the limbic brain and overpowers or contaminates the
ability of the thinking brain, the cortex, to compensate. I termed this take-over of
consciousness the ‘limbic wave.’ This take-over follows a wave pattern that begins
slowly, builds to a crescendo, and releases pressure in explosive affect and a rapid
drop-off of energy after the explosion, sometimes resulting in sleep.
Limbic wave begins Energy discharges Exhaustion

(facial grimace) (rage/wildness) (remorse)
Figure 2.2
In Survival Strategies, I applied this model to the experience of rage but it also
accounts for the rapid shift in mood seen in Bipolar Disorder and the descent into
intense irritability and rage seen in early-onset Bipolar children.
The children I treat with early-onset Bipolar Disorder tell me that as their
mood changes, a feeling of darkness descends, and a deep sense of discontent
comes over them that no one else can see. As the limbic brain wave builds, there is
a loss of the ability to think and make decisions.
Hallucinations are also experienced during the limbic wave. Children will
often report that they feel unpleasantly dreamy or disconnected from reality, as if
they are in a bad dream. These states of consciousness are probably associated
with sleep disturbances and point to a dysfunction in the brain between the
aminergic and cholinergic neurotransmitter systems. Dr Allan Hobson, a
researcher on the relationship between sleep and mental disorders, hypothesizes
that Bipolar Disorder may be related to the imbalance in these two systems in such
a way that the person is experiencing a waking bad dream 24 hours a day – never
quite asleep or awake at any particular time (Hobson 1995). It makes sense that
just as the limbic system is contaminating consciousness residing in the cortex, the
cholinergic system is contaminating the aminergic system, resulting in the
person’s feeling of being in a waking dream.
Research on the limbic system indicates that the brains of people with Bipolar
Disorder are often influenced by cholinergic neurochemicals during the day – the
dreaming brain takes over in waking consciousness. As this happens, neurotrans-
mitter levels of the brain chemicals that govern wakefulness, especially dopamine
and serotonin, decrease. This change happens throughout the limbic brain and as
the wave moves through the brain, it creates an involuntary sense of being pulled
to sleep which is sensed as enormously aggravating and crazy-making by the
child. The whole process is akin to having a ‘bad trip’ on LSD, though the
dramatic hallucinatory activity of a drug-induced trance is not present.
The limbic brain is the lord of sleep and the animal emotions in us, but when
this animal consciousness takes over a child’s waking mind, the feeling is horrible
and he explodes in rage or dysphoria, seeking a target for what he is feeling, in an
attempt to gain a sense of control over the experience.
Drugs used to treat Bipolar Disorder and related conditions

Medication used to treat Bipolar Disorder helps the brain restore its emotional
equilibrium so that it is not swamped by rapid mood swing and an excess of bad
feelings or agitated, hypomanic energy (Wilens 1998). Generally, medications
help the child restore the dominance of her cortical brain over the limbic system.
Five classes of medication are used in this process, which are usually administered
in stages to stabilize the child.
1. Mood stabilizers
These are the primary medications used to treat Bipolar Disorder. They are called
‘mood stabilizers’ in that they reduce mania and hypomania seen in the condition.
In the mixed-state early-onset manifestation of BD, they greatly calm rage. The
mood stabilizer lithium carbonate has been the gold standard for the treatment of
Bipolar Disorder in teens and adults for many years. Because of side-effects
(weight gain, cognitive dulling, acne) it has taken a back seat to the use of the
anticonvulsants for treatment of early-onset Bipolar Disorder. There is some
evidence that lithium is more effective for the ‘traditional’ manic-depressive
cycling types of BD (Bipolar I and Bipolar II Disorders) in which clear states of
depression and mania occur. The anticonvulsants are more effective for treating
rage issues associated with atypical aggressive depression and rage seen in
children who develop Bipolar Disorder. Lithium administration also requires
blood draws to titrate to therapeutic levels and prevent liver and white blood cell
toxicity.
The anticonvulsant medications stabilize mood but, unlike lithium, do not
generally reduce depression (Sobo 1999). This being said, these medications may
be greatly helpful in early-onset BD, because they take the aggressive teeth out of
the child’s depression and help her calm. These drugs include divalproex sodium
(b. Depakote), carbamazepine (b. Tegretol), lamotrigine (b. Lamictal), and
gabapentin (b. Neurontin). Tegretol may be as effective in controlling rage but
does not have the power of mood stabilization that Depakote has, and Tegretol
may increase the power of other medications the child is taking. Neurontin and
Lamictal are new medications and there is very little research on long-term effects
or adverse side-effects of these drugs, though research at the Stanley Foundation
is showing that Lamictal may also have an antidepressant effect (Post 1999). The
Foundation, however, cautions against the use of Lamictal for children under 16
because of a potentially lethal skin rash side-effect.
As of this writing a new anticonvulsant, topiramate (b. Topamax), is showing
promise for both mood stabilization and reduction of the tics seen in Tourette
Syndrome.
Most of the anticonvulsant medications require blood work to ensure that the
drug is at therapeutic levels and that the child’s white blood cell count and liver
toxicity levels are within acceptable range. Overdose can result in destruction of
the immune response and can be lethal.
The anticonvulsants are also used to treat seizure disorders. I have discussed in
the previous chapter the fact that psychosomatic presentation of rage in many
Bipolar children has the appearance of the seizure phenomenon – there is an aura
and a loss of memory about what happens during the rage. There is an explosive
episode, and a diminution. I have found that parents of kids with Bipolar chal-
lenges are relieved to see the similarities between their child’s behavior and that of
people who suffer from some forms of epilepsy. This way of looking at the
disorder helps them see that though the child can appear to be intensely malevo-
lent, it is her neurology, not her personality, that is causing the behavior. When the
neurological issue is treated, the child may return to relative normalcy. She may be
affectionate, pleasant, and helpful instead of maniacal, vicious, and abusive.
2. Antipsychotic medications
Also called ‘neuroleptics’ because they downregulate the brain’s use of serotonin
and dopamine. This enables the person to screen out intrusive thoughts or
emotions that can take over consciousness. Drugs in this classification include
risperidone (b. Risperdal) and olanzapine (b. Zyprexa). Antipsychotic drugs are
used to resolve the child’s most severe symptoms and restore some calm to his life.
They reduce mania, psychotic thinking, hallucinations, and the paranoid behavior
that a child with BD may experience. The down side of using this class of medica-
tion is that there is risk of developing Tardive Dyskinesia, which is a painful and
disfiguring facial tic, or dystonia (painful large-muscle cramping). Though these
effects are usually remedied by discontinuance of neuroleptic medications and are
most often seen after long-term use, in about 3 percent of cases, TD remains after
medication discontinuance. Neuroleptic medication may be continued well
beyond the acute phase if psychotic symptoms continue, or if there is a previous
history of symptoms being exacerbated every time neuroleptics, antidepressants
or other psychotropic medications are discontinued.
3. Antidepressant medications
Used to soothe the brain’s vigilance centers, relieving depression and permitting
the release of neurochemicals associated with good mood. Antidepressants and
stimulants should only be given after administration of a mood stabilizer for BD
kids. The Selective Serotonin Reuptake Inhibitors (SSRIs) such as fluoxotine (b.
Prozac), setraline (b. Zoloft), or citapram (b. Celexa) raise brain serotonin levels
and thus help the child put a break on impulsivity. Atypical antidepressants that
have the ability to energize focus while raising brain serotonin levels (and
soothing depression) such as buspirone (b. Wellbutrin), or venlafaxine (b. Effexor),
may strengthen the editor function of the frontal lobes while decreasing
dysinhibition of the limbic brain. Wellbutrin has been shown to be free of the
aggravating side-effect of mania for many BD children.
4. Stimulants
Used to strengthen the ability of the cortex to regulate attention and emotional
states. ADHD-related impulsivity is treated with these drugs. Stimulant medica-
tion is used to strengthen the brain’s ability to inhibit the excitatory response and
improve attention and focus by improving the function of a little structure that sits
over the right eye in the right frontal lobe called the orbitofrontal cortex. Stimu-
lants such as dextroamphetamine (b. Dexedrine), or metaphenyidate (b. Ritalin),
which are used to treat ADHD may also be useful in treating the more serious
behavior problems associated with frontal-lobe dysfunction such as dangerous
impulsivity, an absence of common sense, and lack of conscience. Read Chapter 5
for more detail on the association between these issues and Bipolar Disorder in
children and teens.
5. The benzodiazepines
Bipolar Disorder may be treated in its acute phase (when symptoms emerge with
great force, such as in rage or panic) with anti-anxiety agents in the benzodiaz-
epine class, such as alprazolam (b. Xanax), and lorazepam (b. Ativan). These medi-
cations have been shown to have significant anti-manic effects, but they are not
mood stabilizers. They should be monitored closely with an eye to discontinuing
them two or three weeks after symptoms are under control, because children with
affective disorders are especially susceptible to addiction to this class of medica-
tion.
The pharmacology of rage

Rage as manifested in Bipolar Disorder expresses the depressive aggression, the
‘sudden wild behavior and explosive anger’ described by Dr Hagop Akiskal
(Akiskal 1995). The parenting of children with rage issues is the subject of the
next chapter.
The suddenness of rage is a clue that medications used to control seizures (such
as Depakote, Tegretol, or Neurontin) are primary candidates for its treatment.
Other medications in the antipsychotic class, such as Risperdal or Zyprexa, are
also used. One of the benzodiazepines such as Xanax and Ativan may be pre-
scribed in the acute stage of Bipolar Disorder, with discontinuance occurring as
soon as symptoms diminish.
Medications which block the release of adrenaline such as clonodine (b.
Catapres), or quanfacine (b. Tenex), or propranolol hydrochloride (b. Inderal) are
effective in reducing rage for many children. These medications turn down the
energy of the nervous system and calm the body’s fight-or-flight reaction, thus
giving the child a little extra time to gather himself and inhibit the rage explosion.
These medications do not address the root cause of the rage, which is the
dysphoria felt in the down phase of the mood swing and the craving for stimulus
satisfaction. Overdose of these medications can result in a worsening of the child’s
depression.
New treatments from naturopathic medicine are showing promise for the
treatment of rage associated with mood disorders. These are described in detail in
Chapter 6 and include the use of vegetable-based lithium (which does not have
the toxic side-effects of the lithium carbonate prescribed by medical doctors), and
essential fatty acids in the Omega-3 classification.
Understanding Bipolar brain chemistry is a survival factor

The more you know about how the brain works during the Bipolar mood shift,
the better will be your ability to devise solutions that help children with these
issues. You do not need the in-depth technical knowledge of a neurologist
equipped with a functional MRI (magnetic resonance imaging) brain scanner or
other technology, but you do need to know enough about brain function to make
a good science-and-art assessment of the issue and get your plan together. If you
can recognize the soft signs of seizure that precede rage, you can defend yourself
and the child better. If you know what medication does, you can get a specific idea
of what his issues are and what kind of help he needs.
Recently I spoke with the father of a very bright 13-year-old girl with Tourette
Syndrome and with a possible mood disorder on board as well. The girl had a big
problem talking out in class. She just wouldn’t be quiet and listen. My client was a
veteran of raising a neurobiologically involved child and so our conversation cut
to the chase: (a) Was inattention causing her talk-outs, was she just not following,
or was she day-dreaming? If so, perhaps talking to their doctor about a stimulant
might be in order. Stimulants had helped her in the past. (b) Maybe the problem
involved her inability to decode what the teacher was saying. This kind of auditory
processing issue is common in the Attention Different population and points to
the need for classroom accommodation. (c) Or was it her tendency to fixate on
everything? If this was the case, then maybe a medication to address her anxiety
or obsessionality (such as low-dose Prozac) might be in order. But this was prob-
lematic given the possibility that her talk-outs might indicate the presence of
hypomania. If Bipolar Disorder were part of the picture (and the girl did have Bipo-
lar-like rage episodes), then the use of antidepressant medication or stimulant
medication might not be indicated.
My client had the advantage of a good set of notes that he had kept on his
daughter’s day-to-day life. And he had a working knowledge of what was going
on for her neurologically. He could be a conscious consumer of my consultation
(or that of another counselor or physician) and know that he had control of the
situation.
Knowing that certain brain organ systems control certain reactions gives you
the ability to get a better idea of whether nature or nurture, environment or bio-
chemistry, is the problem. Given the severe issues that will confront you as the
parent of a child with BD challenges, it is important to make accurate assessments

of what you are dealing with.
As a therapist, I have seen that having a practical knowledge of brain function
helps me understand what psychotherapeutic interventions are most appropriate.
A therapist who does not understand the biochemical tie-in, at least in general
terms, might, for example, misdiagnose a client who has no demonstrated
empathy for others’ feelings as suffering from ‘attachment disorder’ when the real
cause is lack of empathy related to depression (and function of the left frontal
lobe) seen in Bipolar Disorder. The parenting and psychotherapeutic strategies
that are appropriate for a child who does not experience a sense of bonding (the
attachment issue) with his parents are vastly different from those necessary to help
a child heal from Bipolar challenges.
I give assessment of brain function equal status with assessment of the child’s
presentation in terms of his emotional life, his challenges, and the resources that
he possesses to meet the challenge. This attitude toward the psychosomatic
dimension is one that is shared by the most resourceful and successful parents.
CHAPTER 3
Martha’s Story
Understanding and Managing Rage in Children
with Early-Onset Bipolar Disorder
As long as I can remember anything, I recollect being subject to violent

paroxysms of rage, so disproportional to the cause, as to surprise me when they
were over, and this still continues. I cannot coolly view anything that excites my
feelings, and once the lurking devil in me is roused, I lose all command of myself.
George Gordon, Lord Byron, 1823
The experience of rage among children and teens with Bipolar challenges is the
most often cited reason why parents bring their children to my psychotherapy
practice. Many psychotherapists see rage as the acting out or re-enactment of
trauma, but this is not the only cause. By and large, the rage that these kids pack in
their personalities comes as a result of birth to that particular family, not as a result
of its dysfunction. Most of the children in the population of kids I serve receive
superb parenting.
A raging child can scar a family as Sherman’s march to the sea scarred the
South for years after the event. The screaming, spitting, hitting, biting, throwing
of objects, destruction of toys, slamming of doors, swearing, threatening, and
expressions of contempt can wear a family down and kill its soul. Parents come to
hate their child and hate living in fear, loathing, and stress.
Rage is the take-over of the cortex or thinking brain by the emotional brain –
the limbic system. The cortex is usually successful at holding the ‘animal’ energy
of the limbic brain in check. But during rage, the limbic system takes over,
flooding the cortex with nerve impulses. As the cortical brain shuts down, the
limbic brain consolidates its victory over the body. The screaming-laughing-
crying and frothing at the mouth of the enraged Bipolar child are dramatic
expressions of the limbic brain’s power, and it is scary!
Parents and siblings of the raging child come to relish being away from home
for any reason because absence brings relief from the great oppression of the rage.
Living with a ten-year-old with a rage problem is like living with a full-grown
tyrant. A mood of despair and depression takes over the family.
50
MARTHA’S STORY / 51
Everyone has advice for, and judgments of, parents of rageful children: be
firmer, be more lenient, pray, go to church, deal with your own anger, be more
consistent, lock her up, don’t let her run your life. But they cannot know what it is
like until they experience the pure force of parenting a child like this themselves.
You have to live with this problem to understand it.
In Bipolar Disorder rage results from the collision of the manic and depressed
phases of the disorder in the ‘mixed-state’ diagnosis. In this situation, rage
expresses the ‘despairing anxiety’ of the depressed phase in combination with the
flight of ideas and feeling of internal pressure of the manic state. I have seen this
rage emerge in children as young as four.
Bipolar rage expresses manic depression: It is not ‘meltdown’

The term ‘meltdown’ was made popular by Dr Ross Greene in his book The
Explosive Child (Greene 1998). Greene uses the term to describe an emotional
reaction which is similar to the rage seen in Bipolar Disorder but is different in
several significant ways, and different methods are needed for its management.
Meltdown is a rage-like condition in which the child explodes into a temper
tantrum driven by feelings of being overwhelmed, overstressed, and out of
control. Meltdown is seen in children with anxiety issues who may be diagnosed
with Oppositional Defiant Disorder, ADHD, Obsessive Compulsive Disorder
(OCD), or Asperger’s Syndrome. Most children with Asperger’s Syndrome suffer
greatly from anxiety and so I cover the topic of management of the meltdown in
Chapter 7 as it applies to these children.
In the meltdown, the child may scream or run from the scene or may violently
resist attempts to physically control him. He will cry violently, swear and spit, but
his temper outburst will lack the manic force of Bipolar Disorder and will
diminish sooner than the rage that is seen in early-onset BD.
In Bipolar-related rage, the child comes loaded for bear – putting the
cross-hairs of his anger on any available target. His rage expresses the pressure he
feels and may have an aggressive quality to it. Though his anger is probably not
premeditated, it has a deliberate, intentional feel to it. The child will deliberately
torment other children or move into an attack position with an authority figure as
if challenging the adult in an attempt to gain dominance in the situation.
The meltdown does not have the directed, aggressive tone of Bipolar rage but
expresses the urge to flee. It may or may not be kicked off by the ‘no’ word – a
parent’s denial of a demand – but it lacks aggressive intent. The child acts like a
cornered animal and engages in the emotional event from that position.
It is exhausting to parent the ‘anxious, oppositional, and easily frustrated’
child who is prone to meltdown (qualities noted in the subtitle of The Explosive
Child), but the stress of raising a child like this is not as severe as raising one who
suffers from Bipolar Disorder. Meltdown expresses the ‘flight’ aspect of the stress
reaction, and therefore may diminish quickly if the stress is removed or parents
handle the situation skillfully – perhaps using Ross Greene’s system of setting
parenting priorities using three ‘baskets’ for essential, negotiable, and less
important issues.
The rage seen in Bipolar Disorder is different first because it expresses the
child’s depression greatly amplified by his manic energy. Depression energizes
the ‘fight’ aspects of his character and makes his rage aggressive, demanding and
destructive. Unlike meltdown which is typically ineffectual, a big temper tantrum
or a screaming fit, Bipolar-related rage will often result in kids attacking adults
with objects, and these kids are not usually amenable to negotiation.
Rage in children with Bipolar Disorder often comes out of nowhere, like a
seizure. There is something so wild about its onset that there is no question about
negotiation by the time it hits. It is totally explosive and mindless. There may be
no real reason for its occurrence other than the build-up of stress on the child.
Children who experience meltdown hate losing control and may recover
within 15 minutes or so, but children with Bipolar challenges will often report
that the rage felt energizing and helped them focus, and the rage goes on well past
half an hour.
Eight ways to distinguish the Asperger’s meltdown from rage related to

Bipolar Disorder
It is important to know the difference between the experience of meltdown seen
in Asperger’s Syndrome and other anxious children, and the experience of rage
which is expressed by children with Bipolar challenges. The nurturing, consola-
tion, and refuge you give an anxious Asperger’s child to help him deal with his
rage may not be sufficient help for the Bipolar child. And you must make a
decision about medical treatment which will differ if anxiety, Bipolar Disorder, or
Asperger’s Syndrome are present.
1. The meltdown is avoidant. The Asperger’s child screams, holds her ears,
and runs away. Or, if she attacks the adult, she pulls her punches – she
holds back her power somewhat. Her emotions shout ‘Keep away!’
2. The child may hurl invectives but there is a frantic quality to her
swearing – it is sensed as angry frustration. She will not report that it
felt activating or pleasurable to her (as do many children with Bipolar
Disorder).
3. Meltdown is triggered by a parent’s demands, it is defensive. It is set off
by an adult’s attempt to gain compliance such as requiring the child to
complete a lesson for school. Unlike Bipolar rage, which may be
triggered by the adult saying ‘No’ to some demand the child makes,
meltdown is most often triggered by adults trying to push the child to

do something he does not want to do or cannot do.
4. In meltdown triggered by interruption of an obsession, the child will
nonverbally express great frustration but will not talk about its source.
The child may show the ‘50-yard stare’ which is signatory of her
obsessionality. She is trying to recover the obsession so that she can
complete it and is being thwarted by adults in the process. The
enormous pressure and frustration she experiences from her OCs may
drive her into meltdown.
5. Meltdown may happen when the adult tries to stop the child from
talking endlessly. This ‘pressured speech’ is a feature seen in many
neuropsychological conditions including Asperger’s Syndrome, Bipolar
Disorder, and Tourette Syndrome. Interrupting it may be experienced as
painfully as is the interruption of an obsession or compulsion.
6. Meltdown may result from the child’s oversensitivity to a particular
stimulus – a noise, an adult’s tone of voice, or a mannerism that
distresses the child that the adult does not stop.
7. Meltdown may happen when an adult tries to change the child’s
position on an issue. The child is totally stubborn, totally fixed on his
own way of looking at the situation.
8. Meltdown is usually responsive to anti-anxiety and antidepressant
medications such as fluoxotine (b. Prozac), buspirone (b. BuSpar), or
fluvoxomine (b. Luvox) or medications in the benzodiazepine class such
as clonazepam (b. Klonopin).
It is probably true that rage and meltdown exist on a spectrum of emotional
dysinhibition. This chapter contains methods directed toward the prevention of
rage, though they are useful for meltdown management as well. Please see
Chapter 7 for a more detailed look at the dynamic of meltdown and for survival
strategies for dealing with it when it occurs in the lives of children with Asperger’s
Syndrome and the other diagnoses noted above.
Ten markers of Bipolar Disorder in a child’s rage

Rage is a predominant feature of early-onset Bipolar Disorder and has ten distinc-
tive markers when seen in the behavior of elementary-school-age boys and girls.
1. The child may be fine at school during the day. The rage happens at
home, at night during rebound from medication when exhaustion from
the effort of controlling herself all day overwhelms the child’s ability to
cope. The child is most vulnerable to rage after 9 or 10 p.m.
2. The rage may erupt at the drop of a hat for no apparent reason – when
the child is denied something or some prohibition is put on behavior.
The child may deliberately provoke adults around her to get a rage
cycle going. I term this ‘stalking a reaction.’ This is the opening salvo in
her gambit to realize stimulus satisfaction in the adrenaline rush of the
chaos that ensues.
3. Once activated, the rage takes a predictable course through build-up,
explosive behavior, and diminution. The child will often report
headaches or exhaustion, or go to sleep after the rage.
4. The volume of the rage is great. Dr Charles Popper (Popper 1989, p.6)
says that Bipolar-related rage is so powerful that ‘you could not imitate
it if you tried.’ The child may rave, giggle, cry so hard tears squirt
across the room or shout obscenities. She may lose all coping skills and
emotionally regress to a younger age.
5. Gory thinking, involving the use of knives, fire, dismemberment of
loved ones, will be verbally expressed by the child during rage. Rarely
does she follow through on threats, but the intensity of the delivery can
be terrifying.
6. The child will attack and destroy objects precious to her, such as a
prized teddy bear. She will go after her parents’ things, throwing the
remote at the answering machine or chucking the pepper mill through
the dining-room window. Often the child will experience an ‘obsessive
feeling’ that she needs to attack a particular object. When the limbic
brain takes over, its energies may turn on her to destroy everything that
is precious to her in normal consciousness.
7. The child describes the rage as a build-up of heat that is sensed up the
anterior side of the body, from the stomach, the sternum, the throat, the
face, and the head. Some children report an aura before the build-up of
rage; visual fuzziness, a waking ‘bad dream,’ sensitivity to smells, or
headaches. This indicates the involvement of the limbic brain’s olfactory
tubercle and the neurotransmitter system, the catecholamine system,
which is operant when the child is sleeping.
8. Children will report rage almost as an entity that takes them over or
that is clearly localized as a presence. ‘It’s like the Donald Duck cartoon
in which the devil [rage] sits on my left shoulder and the angel on the
right.’ One of my clients reported it as ‘my brain [rage] vs. my heart
[her family].’ This girl had intuitively localized the demon in her limbic
brain and felt caught in a cross-fire between it and the rest of her
world.
9. Reward Deficiency Syndrome is present. Rage may be experienced as

pleasantly energizing. The child relishes the fight. The term ‘Reward
Deficiency Syndrome (RDS)’ describes a dysfunction in the brain’s
reward system that may be part of this Bipolar challenge. RDS is a term
coined by researchers Kenneth Blum and David Comings (Blum and
Comings 1996) to identify a phenomenon they observed in persons
with a vulnerability for alcoholism who were incapable of experiencing
a sense of satisfaction from anything.
Most people get a little shot of pleasure neurochemical (in the form
of enkaphalins or endorphins) in the frontal lobes of their brains when
they learn something. This is the way the brain marks the learning so
that it can be remembered and used as part of the person’s overall
knowledge base. In RDS, this neurochemical spurt does not happen and
so the person cannot experience satisfaction from any activity. Many
kids with Bipolar challenges also suffer from this profound anhedonia.
The Blum and Comings results showed that flaws in the brain’s
reward circuitry were contributory to alcoholism and other addictions.
People with this problem pursued substance use as self-medication from
the awful feeling of dullness and depression in their lives. Rage can also
be used to self-medicate RDS in Bipolar illness. Rage causes the child’s
brain to release a rush of adrenaline which leads to the release of a little
shot of enkaphalin or other pleasure neurotransmitter. Not only does he
feel pleasure, he also is able to experience alertness, focus, and clarity.
These positive effects exert a powerful pull on him for continual
re-experience of rage.
10. During rage, the child may show a paranoid attitude – ‘The whole
world is messed up, I’m not.’ This attitude is a natural effect of the stress
reaction. In the fight-or-flight state of consciousness good judgment
and self-awareness shut down and parents and other authority figures
are seen as the enemy.
Summary: Markers of Bipolar Disorder in a child’s rage

1. Rage most often happens at night.
2. Rage roars out of nowhere at the drop of a hat.
3. Rage takes a predictable course through build-up, explosion, and
exhaustion.
4. The volume of rage is great and ‘could not be imitated.’
5. Gory thinking occurs during rage.
6. The child will destroy precious objects.

7. The child will report the build-up of rage as a sense of heat.
8. Rage is felt as an entity which takes over the child.
9. Reward Deficiency Syndrome is present. Rage may be experienced as
pleasantly energizing.
10. During rage, the child shows a highly paranoid attitude.
Healing Bipolar Disorder-related rage: Martha’s story

Most children with Bipolar Disorder are haunted by the biological ghost of rage.
Parents of children with rage problems often find themselves isolated from
friends, family, and social events. This was the case for John and Kim, parents of
Martha, a bright 12-year-old with a major rage problem and a medical diagnosis
of Bipolar Disorder with ‘mixed symptoms.’ They talked about how lonely they
are for adult company, and how cut off from others they are as a result of Martha’s
rage.
John and Kim were happily married entrepreneurs. He was in sales, she ran her
own business out of their home. This was a convenient arrangement for the family
as Martha’s school would frequently call for someone to come and get her after an
altercation. They were resourceful parents.
In the two years of our work together, Martha, with her parents’ assistance,
made some powerful positive changes in her life. When counseling ended, Martha
had much better control of her rage, was doing well in school, and had two or
three good friends. But she was not in this position when her parents first came in
to see me.
Kim told me that when Martha became enraged, she would get a feral look on
her face and her pupils would dilate. Kim said Martha got ‘scary-looking, like a
person possessed by the devil.’
‘Martha’s rage is set off when we try to control her behavior, impose some
limit, such as a lights out at bedtime, or when we refuse her something – a new toy,
a trip to a favorite concert, or a dish of ice cream. If we say “no” we know we’re in
for it!’
As the rage began she would clench her fists, her voice would become shrill
and she would search for targets to attack. At home she ran around the house
trashing anything in view, taking scissors to her clothing, scratching a can opener
across the front of the TV set, grabbing a knife from the kitchen to butcher the
teddy bear – her only friend since she was four – into fluff and rags on the floor.
She first started having violent rages around the age of five, accompanied by
disturbingly morbid and vivid imagery – obsessional thoughts about hurting
people and pets close to her. She was fascinated and terrified by the eyes of people
in some photographs and had cut the eyes out of several pictures in her mom’s
photo album. Now, at twelve, she experienced obsessional thoughts about sex –
bizarre scenarios involving cartoon characters that were extremely distressing to
her.
Martha hadn’t really been a problem at school until the last couple of years, but
things were getting out of hand there too. When the school principal tried to calm
her she threw a book at the woman and called her a ‘fucking bitch.’ When she was
back at school after a two-day suspension, her parents were put on notice by the
principal that the school would call 911 if there were another incident.
Martha had no friends. The other kids learned that, though she could be
fiercely loyal, if she became annoyed she was verbally abusive. Several of the
children in her class were afraid of her. Their parents had put the school on notice
that they considered her a menace and that something had to be done or they
would file an official complaint with the district.
When she came in to counseling for her first session, she appeared somewhat
hyperactive, unsmiling and tense but otherwise presented as an intelligent,
normal, and attractive kid. She admitted that she had a problem losing her temper,
though she was not willing to admit that it was as bad as her parents said it was.
Her rage pattern fit the early-onset Bipolar type and like many children with these
challenges, she felt a deep suspicion of therapy, along with a need to talk with
someone who would not judge her.
Though she was well aware of what set off her rage, there were times when she
reacted normally to the requirements her parents put on her. The times that rage
emerged were always preceded by a drop in mood, into a dark, depressed,
self-critical, unable-to-think, low-energy place. It was as if a black net dropped
around her and sapped all her good feelings, making any little disappointment or
noise impossible to bear.
John and Kim were working with a local psychiatrist to find the right medica-
tion to treat her rage. Her parents and doctor had tried to calm it with a moderate
dose of quanfacine (b. Tenex), which had been partially effective. When she began
treatment with me, her psychiatrist had just finished a re-evaluation for the use of
valproate (b. Depakote) and she had begun a prescription of that drug with good
results.
To begin the healing process, Martha had to accept the problem

In treating children with complex behavioral issues, the starting point must be to
work with the child to own the problem – to accept the fact that there are different
ways to respond to stress, even to the stress of biochemically caused depression.
Martha was similar to many children who experience Bipolar-related rage in that
she initially did not take responsibility for initiating the rage event. Her first
reaction to her parents’ statement of the problem was an angry denial of her role
and the accusation that her parents were to blame for all the rage incidents that
had occurred.
It makes sense that children with rage issues carry powerful denial of the
situation because at the time of rage their consciousness is functionally incapable
of ‘seeing the big picture.’ At this moment everyone else is the enemy. Research
shows that at the time of rage, ‘executive function’ areas of the frontal lobes shut
down. These are the areas tasked to complex thought, decision-making, and for
giving us perspective on our actions. In this state of consciousness the child cannot
see her own part in the problem.
The mood disorder itself tends to create a style of perception in which denial is
the operant defense mechanism. In the elated and euphoric stage, the person with
Bipolar Disorder can see no reason to take medication or do anything that
decreases the frankly pleasurable state of consciousness. Depressed, she becomes
combative and antagonizes everyone around her, thus making it more difficult to
get the help she needs.
The moment of truth: Martha’s parents call 911

A child like Martha can terrorize her family for years before the situation is finally
brought to a head. This usually requires the involvement of other caregivers and,
in some cases, the authorities. Most parents can’t stand the idea of calling 911 and
will not do so even when their Bipolar child becomes physically abusive. But
there are some cases in which calling the police is the best thing to do.
The evening that Martha’s parents called 911 started off fairly normally. But
Martha was in a bad mood. She had been playing Nintendo for a couple of hours
and was getting cranky as a result of it. She decided that she needed her parents to
buy her a particular Nintendo game that one of her friends had shown her. She
presented her demand and when her parents rebuffed the idea, she began to pester
them noisily. Though Kim and John did a good job of deflecting her, she eventu-
ally ended up screaming in her father’s face at the top of her voice that she
‘Wanted That Fucking Game And Wanted Him To Go Out And Buy It Right Now
Is That Clear?’
John said ‘No game tonight,’ and Martha decided that if she couldn’t have
what she wanted, her parents would suffer. She picked up the phone and threw it
hard against the hearth, splitting it into several pieces. When her father tried to
restrain her she spit a mouthful of slobber at point-blank range into his face and
punched him savagely in the nose, causing a profuse nose bleed. After a hasty
consult, Kim called 911.
The police came and seemed to be familiar with this kind of situation. With the
parents’ permission, they took Martha to the emergency room (ER) of a local
hospital, where she waited for over an hour before being interviewed by the local
county mental health professional (MHP). She knew that the job of the MHP was
to decide if she needed to be admitted to a psychiatric hospital. By the time

Martha got to the ER, she was calmed down considerably. And she was awestruck
and intimidated by the level of suffering she saw around her. She did not want to
go through this again.
Martha did not go ‘inpatient’ that night and she came back home solemn and
anxious about the violence that had happened in her home and where it had led.
Eventually the local court allowed her to use a legal process termed ‘deferred adju-
dication’ that resulted in her getting directed to perform 20 hours of community
service without having to suffer the consequences of being formally charged with
assault in court. Community service was an appropriate sentence for her attack on
her parents because it gave her the knowledge that she had taken something from
the community (her family) in being violent and that she had to give something
back. Doing community service also gave her a way to atone and let go of the
shame she had around the incident, especially for her savage attack on her father.
I asked Martha to draw me a picture that conveyed her feelings about the
events that led to the call to 911. She drew a picture of ‘the night from hell’ as she
called it, for me, working quietly on the little table in my office. She drew herself
standing in front of a burning house – her mother was on one side with tears
coming down, the devil and his pitchfork on the other. I asked her what the worst
thing was that the devil part had done. She told me that it was when it told her to
hit her dad in the face.
When I asked her what she was thinking about when she did this, she said she
didn’t remember thinking about anything but simply had a ‘feeling’ which
directed her to let him have it. Other kids with rage issues have described the
presence of this kind of obsessive feeling which commands them to do something
destructive in the midst of a rage. The obsessive feeling may be a primitive
emotional command from the limbic system that said simply ‘attack and destroy!’
She told me that the devil was more powerful than her mother or father at the
time when rage occurred. At these times Martha felt like she was in a ‘bad dream’
and that the rage would ‘jump out of her.’ It was clear that she was dissociating
from the rage. It made sense that she needed to get more on top of the reaction, to
slow it down.
We talked seriously about the issue for an hour. This was an important session
in our consultation – she got the opportunity to talk full out about her rage and
bipolarity with someone who understood what she was experiencing. I listened
and told her that she was not alone, that many kids have this experience. This
comment seemed to lift a weight off her shoulders. And I could tell she was finally
beginning to take some ownership of the problem.
Kids get so much conditioning on the destructive power of anger. This is
appropriate to some extent: we live in violent times and there is risk to children
who do not know how to keep from insulting or angering others, who have poor
self-control. But this injunction blocks ownership of rage in kids like Martha, who
come to see themselves as bad, defective, or broken because they carry so much
rage and cannot admit it.
Martha would not have been able to turn the corner and take more ownership
of her Bipolar Disorder if her parents had not called 911. As we talked about the
night several weeks later, John and Kim shared how embarrassing it was to have
two police cars pull up outside their house. But they decided that things had
gotten so bad that necessity overcame pride and they asked for help. Their action
got Martha’s attention long enough for her to agree on the vigorous pursuit of
medication and to work hard in psychotherapy.
The escalation of the rage reaction

Children with Bipolar Disorder challenges move through a sequence of four
phases in the escalating expression of rage: dysphoric affect, provocation,
explosion, and exhaustion. To effectively manage the situation, parents must be
able to reduce stress and redirect the child so as to reverse the process.
1. THE DYSPHORIC PHASE

Rage will often begin with the child’s expression of bitter irritation. Everything
annoys her and nothing comforts her. Behaviors characteristic of this phase
include:
Escalation
Explosion
Provocation
Exhaustion
Dysphoric affect
Figure 3.1 The escalation of the rage reaction

• angry nonverbal facial expressions

• raised voice
• hyperactivity
• pestering and whining
• tormenting her parents with rude remarks, poking at her sister
• remarks to the effect that she feels bad or ‘doesn’t feel like herself.’
2. THE PROVOCATIVE PHASE

As her dysphoria deepens, she begins to look around for a fight. The following
behaviors are seen as she enters the provocative phase:
• a silly devilish facial expression
• swearing and insults directed at other family members
• interruption of parents’ phone calls
• threatening parents with making a scene
• clenching fists and approaching parents using threatening nonverbals
• slamming doors.
3. THE EXPLOSIVE PHASE

At this point, the frontal lobes of the brain become functionally inoperative and
the limbic brain takes over the child’s behavior, catapulting her into total
dysinhibition. The following behaviors occur:
• screaming and crying, sometimes at the same time, sometimes with
sufficient force to break facial blood vessels
• foaming at the mouth, dilation of the pupils
• clinically paranoid ideation – the child darts around the house furtively
trying to avoid adults or accusing them of trying to do her harm
• death threats against parents and siblings, suicide threats
• threatening with knives, electrical appliances, and heavy objects
• behaving violently toward pets – usually short of doing serious harm
• wild evasive behavior, running into the street, attempting to jump out
of a moving car.
This is the acute stage of the reaction. At this stage, the child is functionally unable
to listen or follow corrective action.
4. THE EXHAUSTED PHASE

Children with rage related to early-onset Bipolar Disorder demonstrate several
characteristic behaviors when the rage subsides:
• The child often collapses and appears dazed and ‘out of it.’
• She complains of a bad headache.
• She falls asleep for a period of time.
• She does not remember what happened during the rage.
• Upon waking, many children will express genuine remorse for their
actions or may refuse to talk about what happened. The child’s denial
is fueled by her terror that she is stark-raving mad, incurable, and
shameful.
Nine survival strategies for managing rage

1. Use the ‘Tension Feedback Scale’
Designed to communicate with your child about the build-up of tension. Escala-
tion into rage is preventable in the dysphoric phase. Parents may use the following
strategies to reverse the dysphoria so the child may experience a sense of relaxed,
pleasant focus and a happy state of mind.
Parents, teachers, and other caregivers must have a way to communicate with
the child on the build-up of dysphoria and rage. The first step is to agree on a scale
to measure build-up when the child is in a problem-solving mood. Here is one
possibility:
Table 3.1 Tension Feedback Scale
Mild dysphoria Mood darkening Intense depression/physical discomfort
1 2 3 4 5 6 7
Discuss with the child examples of the rage-related behavior that occurs at each
point on the scale. Tell her that a 1 is like mild medication withdrawal. A 4 is a
painful drop in mood but may be reversed with some activity like exercise or a
pleasant experience. A score of 6 or 7 describes full-on misery: aggressive depres-
sion that will soon be expressed as verbal attacks on those around her. Use an
informal, non-shaming tone of voice. For young children, use a color range. White
means calm, yellow means heating to rage, orange means rage at the early-onset
stage, red means fully involved in rage.
‘You know, Martha, we can all get heated up around here and lose our tempers
and I hate it when that happens. We need to be able to tell each other quickly how
we’re feeling so things don’t get worse. I’d like to use a little code so that we can
check things out without a lot of talk, OK?’
Introducing the use of this scale makes the situation a communication problem
and takes the pressure off the child. The Tension Feedback Scale is a vehicle for
her to stay more aware of her experience and not get lost in a blaming attack on
everyone around her.
2. Reduce stress and redirect the limbic energy

Resolution of Bipolar-related rage involves redirection of the child’s limbic
energy. This is an alternative option that gives her time to de-escalate from her
excitation, and meets her need for stimulation in a positive, non-destructive way.
Redirection needs to happen early in the build-up of excitement because once the
limbic wave kicks in, the energy of the limbic brain comes into the battle and takes
over.
(a) First, separate the child from stressful social situations. If you see that your
child is warming up to a hassle with a friend, gently intervene and
suggest separate activities. If possible, negotiate a resolution to the issue
without being too obtrusive. Send the friend home if you have to. Most
Attention Different children are upset by transitions and this can
precipitate a change in mood.
(b) Distract her toward a positive, enjoyable pastime involving exercise. Exercise is
an important way to discharge stress and the muscular dysphoria that
contributes to rage. Exercise calms us down. It upregulates adrenaline,
dopamine, and serotonin in the brain, and helps create a calm and
focused awareness. Join the local Y [YMCA/YWCA in Britain] and
make ‘going to the gym’ part of your child’s routine. You are building
in a natural antidepressant activity. Provide a punching bag for your
child. This should be the kind of ‘body bag’ that is used to train
football players, the big, hanging, duffel-sized bag that does not
bounce back when punched hard. Rage is stored in the body’s
musculature as tension, and a good work-out on the punching bag
allows the child to discharge this energy at the muscular level, while
letting go of destructive mental energy.
(c) Invite the child to have something to eat. Food may calm her mood. Make
sure that she has a good balance of carbohydrates and proteins. Make
sure that she drinks eight glasses of water a day. Dietary research shows
that water is essential to the body’s detoxification, and the build-up of
toxins is positively correlated with depression and dysphoric mood.
Avoid sugar and caffeine as these can contribute to depressive affect and
make a child more vulnerable to Bipolar rage.
(d) Call the game. If the child seems to be following you around looking for
a fight, say ‘I have the feeling that you are trying to get a rise out of me
for the fun of it. But I don’t want to play that game. What can we come
up with that would be more interesting for both of us?’ Take the child’s
provocative behavior as her way of telling you that she is approaching
her wits’ end and needs some inspiration to keep from crashing into
dysphoria and rage.
3. Have a battle plan

Rage may come out of nowhere. You may not have time to discuss the right thing
to do. It is a good idea to have your response planned ahead of time. Pick your
battles. The most successful parents view their child’s rage as their main opponent,
in much the same way as a virus that had infected her.
They know that she is energized by straight-on argument. These parents do
not argue. They enforce the rules that are important, and negotiate the rest. If they
have to call 911, they call 911. They do things according to a plan which
specifies:
(a) Which of the parents is in charge in the situation. When rage erupts, one
parent should be in charge and the other in back-up. If both parents
engage in the encounter, the child will feel ganged up on, and the
opportunity to use the second parent as a mediator will be lost. You
keep in close communication. After the encounter, the back-up parent
should be tasked to handle the next one. Too often parents get stuck
into patterns that leave both parents exhausted and resentful. True
teamwork and sharing of the burden is required!
(b) Protection of non-combatants (siblings). It is up to parents to make sure that
everyone is safe. This should be part of the family’s emergency plan.
Non-AD siblings of children with rage issues often show signs of Post
Traumatic Stress Disorder such as hypervigilant reactions, nervousness
and nightmares. These symptoms are caused by living under the
continual stress of the threat of violence in the home. ‘Non-combatant’
PTSD may be markedly reduced by coordinated action on the parents’
parts in which other children in the house go to a safe place, put on
earphones and wait out the storm.
(c) If physical restraint is to be applied, when and how it will be used. If a child is
endangering herself or others, or if she is destroying property, physical
restraint may be necessary. Many parents will decide not to resort to
physical restraint, but will call in professional help (such as the police or
psychiatric-medical assistance) or will attempt to isolate the child until
rage subsides. Other parents see no problem with restraint. Work out
your operating philosophy before you need to exercise the decision.
Having to physically restrain a child may push a parent to lose
self-control. Getting yelled at is one thing, but getting punched, bitten,
or spit on repeatedly, full in the face, can drive the most restrained
parent over the edge. These assaults often occur when the parent tries to
physically restrain the child. Be prepared for the worst.
If restraint is necessary, most parents prefer the stand-behind
position. They hold the child’s wrists, her arms crossed over her front.
They stay clear of her thrashing head. These parents have a fine-tuned
awareness of their own stress reaction, and remove themselves from the
situation if they experience an urge to be rough or otherwise hurt the
child.
(d) The circumstances that will result in a call to 911. If you lose control of the
situation and your child is in danger to herself or others, you may have
to call 911. There should be no argument between parents when the
call is made.
Implement the plan and don’t let hot emotionality rule the day. Parents must
know when to insist that their child comply with some demand and when to back
off. Above all, they must know that they are in charge of the situation and the
child is not.
4. Keep communications clear, positive, and short

Here are three linguistic techniques for helping your child to understand you
when she is seized with rage:
(a) Because depression makes a child reflexively oppositional, it is
important to use language which describes a positive outcome and does
not contain prohibition on behavior. The general rule is that the child
will do everything that comes after the word ‘Stop’: for instance, your
statement, ‘Stop teasing the dog,’ will result in an increase in this
behavior. Use positive language syntax. Do not say ‘Pay attention!’
Instead, say ‘I’ll start again when you let me know that you want to talk
and listen.’
(b) Because a child can lose awareness of her behavior in the heat of her
provocation, the use of ‘reminder’ language may be helpful. Say ‘When
you show me that you are with me by no longer swearing at me, but are
talking politely, we can continue.’
(c) Use short words and short sentences. When the stress reaction begins, a
shut-down of the thinking process occurs in the frontal lobes of the
brain. Complex verbal messages will not be understood at this time.

‘Telegraph’ your directives to her and don’t argue:
‘Please go to your room now.’
‘Sit down and breathe slowly a couple of times.’
‘You are swearing at me. I will talk to you when the swearing stops.’
5. Keep your cool to prevent mood contagion

Know that the child is visually and auditorily cued to your words and behavior. If
you are upset, she will be upset. If you are calm, she will be calm. It is important to
choose the images and sounds that you put in front of her as she may not ‘edit’ her
behavior but will follow what she hears and sees. Children in the heat of
emotional upheaval may ‘catch’ their parents’ reaction.
If you feel yourself beginning to lose it, tell the child ‘I’m getting angry. I’m
putting myself in a five-minute time-out.’ Go to a place where you are no longer in
contact with the child for five minutes and breathe down to your abdomen.
Return to the encounter when you have your perspective back.
6. If you begin to lose control, call for back-up from supportive adults, the police,
or your doctor
It is important that parents commit to nonviolence in their dealings with their
child. They may need to restrain her or call 911, but they must not hit her.
Once the rage has begun it is most important to create physical safety for the
family and the child.
Though the raging child may not attack others with homicidal intention, she
may mount a crazy flailing assault, punching, biting, and scratching those around
her. If she possesses a weapon, such as a knife or heavy object, she is much more
dangerous and may behave like an angry drunk. At these times isolate the rest of
the family, call 911, and let the police handle the situation. It is best to keep guns
out of the house. If you have to call the police, let them know your child’s
diagnosis right away and tell her that if she is holding a knife when the police
come in she is in danger of being shot. This grim reality will calm most children
enough to put any weapon down that they are holding.
7. Use the exhaustion phase as an opportunity for healing

To help the child learn from her experience, do not confront her or blame her, but
take a reflective stance. Simply mirror back any statements she might make about
her feelings around the event. Briefly relate events from your own life that may be
comparable to her experience. Let her talk. It is more important that she talk to
you than it is for her to listen to your suggestions for change. If conversation
proceeds naturally, you may get the opportunity to introduce and process the
event. Use these questions to frame that discussion:
• What behavior did she believe was problematic?
• What was her concern or need?
• What set things off?
• What could we all do if this situation comes up again?
This is an opportunity for reflection, bridge-building, and corrective action
planning. It should result in the affirmation of the child’s intention to have more
control in the future and build the feeling of ‘live and learn,’ of planning for a
better future.
8. Teach the child the Six-Step Rage Freeze

When a child becomes enraged, her thought processes speed up and assume the
fight-or-flight mode seen in the stress reaction. She stops thinking rationally and
starts seeing everyone around her as her mortal enemy. This internal mental
doom-saying drives the rage and makes it worse. In order for a child to interrupt
the process and calm down, she needs to be able to have greater control over her
thought processes at times when she becomes frustrated or dysphoric. I have seen
that kids can have this control if they can remember a time when they ‘kept their
cool’ despite some stressor, and associate the mental imagery and feelings they
had then with a current stressful situation.
THE SIX STEPS OF THE RAGE FREEZE

This is an exercise drawn from the tool bag of therapists who use a therapy system
called Neuro Linguistic Programming (NLP) to help people change self-defeating
inner dialogue and imagery. In the following exercise, the therapist or parent finds
what NLP practitioners call a ‘resource state’ – a memory of a time when the
person behaved effectively in a situation – to wire in more effective (resourceful)
ways of behaving in the problem situation. The problem for the child with
early-onset Bipolar Disorder is rage, so the exercise starts there. But it moves
quickly after that point to helping her see that there is a better way of dealing with
the situation.
The Rage Freeze draws its effectiveness from the child’s motivation to change
and the presence of a supportive adult who is available to gently cue her to use the
technique in the early dysphoric state when she is best able to relax and redirect
the build-up of tension that could lead to rage.
It should be taught to the child by a supportive adult (her ‘rage coach’) during a
period of mood stability when she is feeling confident enough to learn new skills
to deal with her rage.
1. Ask the child to remember a time when she had a bad rage attack.
Because recall is difficult, you (her rage coach) may need to help the
child recall a particular episode. Once she has brought the scene to
mind ask her to describe her mental picture of the incident in detail and
recall as much as she can about the feelings that she experienced as if
she were describing a dream.
• In her memory of the incident, does she see herself in color or black
and white?
• If there are other people in the image, are they bigger or smaller than
her?
• If she can describe her feelings as a color that surrounds the image in
her mind, what color does she give these feelings?
• Finally ask her where, in her internal imagery, does she see the image?
If she were to look at the memory as a picture floating above a flat
landscape in her mind, is the picture on her right or left or in the
middle? Is it high or low on the horizon? When she has done this, ask
her to set the image in place ‘just a bit to the left in your mind picture,
around the place where the nine or ten o’clock would be on a clock
face.’
2. Next, ask her to recall another incident in which she was stressed to the
point of rage but was able to hold her temper. What is her mental
imagery of this successful experience? Using the same questions noted
above, get her to describe the incident. When she has done this, ask her
to set that image just a bit to the right in her mind picture, at about the
‘two o’clock position’ over her internal landscape.
3. Now ask her to imagine a ‘light bridge’ between this image and that of
her rage incident. The light bridge would be represented as a band of
light or energy or a feeling of connection between the two images.
Across this light bridge, ask her to transport all the details from the
image in which she behaved successfully to the image of her losing it to
the rage. Ask her to change the negative image gradually, as all the
details come across, to look like the positive image. If the positive image
had a blue light around it, the negative image should now have that
light. If, in the positive image, she saw herself as the same size as
others, the negative image should also show her as the same size. Check
with her after 30 seconds or so to see if she has done this. If she has
difficulty letting her internal imagery form, tell her it’s OK to just
imagine the scene.
4. Once she has completed the light bridge, ask her to take the negative
image and move it down left in her mind’s eye, putting it at about the
nine o’clock position and making it smaller and dimmer, about the size
of a postage stamp. When she has done this, she should see the positive
image vividly in the upper right-hand corner of her mind’s eye. Ask her
to ‘just look at the positive image’ and let it set itself naturally in that
position.
5. Once her internal imagery has been adjusted, she will need a way to
remind herself to remember this internal positive image when she starts
heating up to a rage. This is called an ‘anchor.’ If she can bring it to
mind quickly, it will have a powerful calmative effect on her. Ask her
what she notices in her body when she starts moving into rage. Some
kids will say that their temples throb or their eyes feel squinty, or the
head feels like it’s on fire. Choose one of these somatic signals and ask
her to put a couple of her fingers together and touch her temple or
forehead – wherever she first notices the rage – as she thinks about the
positive image.
6. Practice this cross-association with her by asking her to briefly pull up
a memory of getting enraged and ‘short-circuiting’ it with a positive
image and anchor. She will probably report that the exercise results in a
very rapid decrease in her angry thoughts.
9. Use the RBG method (refuge, breathe, ground)

This will help the child gain greater control over rage.
If you have been successful in helping your child develop awareness of her rage
reaction (the Tension Feedback Scale, p.62), and built a sense of inner resourceful-
ness (the Six-Step Rage Freeze, p.67), you are in a position to begin handing off
other techniques for self-calming in the moment of rage. The RBG method is a
three-step exercise used to restore an inner state of confidence and connection – in
effect, to turn up the functionality of the frontal lobes of the brain and turn down
the limbic reaction.
The RBG method is useful because it can be automatically activated when the
child senses that a rage build-up is occurring. This personal ‘rage ritual’ must be
age- and intelligence-appropriate and the child must be motivated to use it. Some
children like to have a reward system built in to encourage them to initiate and
complete the exercise. As is the case with the Six-Step Rage Freeze, this method
requires the participation of a rage coach. These three steps to the RBG are:
Step 1: When the child enters the dysphoric stage of the rage reaction, say ‘Please
go to your refuge.’
A refuge is a place the child associates with calm and relaxation. It may be her
room or a place outside in the back yard such as a tree house or fort, or anywhere
that has a positive, non-punitive connotation for her.
Step 2: Teach the child to say to herself (once she is in her refuge) ‘Breathe to a
count of three.’
Before using this exercise, teach the child to breathe deeply. The calming
breath is a deep, slow intake of air to the lower abdomen, which results in the
expansion of the diaphragm. She should breathe to a slow count of three in, three
out, ‘as if filling up a bottle with air from the bottom up.’ It is physically impossible
to be anxious when doing this kind of breathing. Children with rage issues should
practice deep breathing every day by incorporating it into their daily routine
before or after school on a regular basis. I suggest ‘book breathing,’ an exercise in
which the child lies on the floor with a book on her lower abdomen and slowly
raises and lowers the book with the breath, in and out, for twenty breaths or so.
Step 3: Teach the child to say to herself (once in her refuge) ‘Ground yourself.’
The request to ‘ground’ is a reminder to the child to feel her feet on the
ground, to feel supported, to feel herself in her body. The nature of the rage reaction
is to blast consciousness upward to the head and out of the body so that the child
becomes breathless, dizzy, and feels ‘ungrounded’ or ‘out of it.’ This experience of
dissociation contributes to panic and a worsening of rage.
To ground herself, the child first stands with knees relaxed, and breathes down
to the diaphragm, while rocking very gently on the heels and balls of her feet.
The second part of grounding is the ‘droop,’ an ancient Chinese grounding
exercise in which the child bends over from the waist, letting her head, neck and
arms hang down loosely (‘like a sack of potatoes’) for a minute or so. After doing
this, she should slowly rise back up to standing, one vertebra at a time. Once she is
back in the upright standing position, I suggest the use of another position
borrowed from yoga called ‘the Bow,’ a position in which she thrusts her chest out
with her hands on her hips, elbows back, bringing her shoulders back so that they
are roughly in line with her heels. Have the child take a breath in with her chest
bowed out in this position, letting the air go through her all the way from her feet
to her head. Then ask her to gently bring herself up to an erect standing position.
As a result of these exercises she feels ‘heavier’ on her feet, more relaxed, and more
in touch with her body and her surroundings.
This variation of the RBG command set uses a specific body feeling as an anchor.
Here is a variation of the RBG delivered in the sentence syntax of an
11-year-old. If the child is able to self-calm using the Rage Freeze or other
methods, you may be able to teach her to use a specific body feeling that accompa-
nies the emergence of limbic brain tension such as a tightening of the jaws, a
queasy feeling in the stomach, or shortness of breath to cue the relaxation
response. Practice the following syntax to help her self-calm:
Child begins: My ears feel hot, Mom, and my jaws are getting tight.
(Silly giggle.)
Mother: Thanks for telling me this, Linda. Do you need a reminder of
what to do?
Linda: Yes.
Mother: OK. I want you to breathe to the count of three. OK? (Linda
complies.)
Mother: Now can I get you to spend five minutes in your refuge until you
feel calm? I’ll set the timer and let you know when time’s up.
OK?
Linda: I’m on my way, Mom.
Use of the RBG method with very young children with early-onset
Bipolar rage problems
Very young children need a little more guidance to activate this method but can be
very receptive to it, and responsive when rewarded with simple praise from
parents or teachers. Here is an example of a work-through of the RBG method
with a seven-year-old. This method requires that you have taught the child a
calming image beforehand such as going with her dad fishing, sitting by the lake,
quietly talking, and that you have taught her to use the Tension Feedback Scale:
Mother: I notice that you seem pretty angry. What number are you at?
(Or for a very young child ‘What color are you at?’)
Child: ‘I think I’m at about four, Mom. I feel funny.’
Mother: OK. Please breathe down to your tummy and let it out to my
count of three. (The parent leads the child through this exercise
five times slowly.)
Mother: Please bring your calming image to mind. Are you seeing the
calming image? If not, say ‘Hold [specify the image] in your
mind and tell me when you can see it and feel it.’ Once the child
has focused on the image, say ‘Would you like to go to your ref-
uge space to calm?’ Guide the child to her refuge, or disengage if
she is self-calming.)
Once the child completes the process, finish with a compliment.
Mother: You did a good job of calming yourself that time. I’m real proud
of you!
Conclusion: Keeping quiet in the center of the storm

For families with kids like Martha, rage is their greatest stressor. It is a two-headed
dragon that expresses both the manic (the wild, pressured irritability) and the
depressed (the anguished, miserable mood) aspect of Bipolar Disorder. When this
dragon’s temper cools, powerful energy is released for management of other
symptoms. Once appropriate medication is in place and the child stabilizes, the
call is for dialogue within the family to rebuild trust and for therapy with the child
to build her resourcefulness.
The outcome of personal therapy must be to help the child build awareness of
the rage within herself, to accept it and to learn ways to direct it productively.
Anger is a human emotion. Sometimes the most therapeutic, wise thing to do is to
get angry at someone, but the child with BD must realize that she has a vulnerabil-
ity to excessive expression of this particular emotion, just as a person might have a
vulnerability to substance abuse.
And once the child is able to tame this dragon, she will be able to deal with any
challenge posed by the Bipolar aspect of her personality. This is the crucible expe-
rience for her family and herself – the expression of great ‘fire’ that requires that
the child be able to go inside herself and find ‘water,’ in the form of coolness, and
self-acceptance to soothe her spirit and do what she needs to do to keep the
dragon at bay.
It is her parents’ coolness – their quietude and love for her in the midst of the
hell that she is creating all around her – that she needs to find for her own
resources. She needs her parents’ example as much as a builder needs a blueprint
for a house. She cannot do this by herself. Their example of cool action and caring
gives her the ability to see herself as a successful person who can control the
dragon inside her and build a future for herself, one behavior at a time, one
awareness at a time, one step at a time.
CHAPTER 4
Tom’s Story
Charting a Change Strategy for
a Teen with Bipolar Disorder
It’s the soul afraid of dying who never learns to live.

Bette Midler, The Rose
Tom was a bright eighth-grade boy who came into counseling diagnosed with
ADHD and Oppositional Defiant Disorder. Both diagnoses are shorthand for ‘He
refuses to follow the rules, and is engaged in dangerous and self-destructive
behavior that we [the caregivers] don’t know how to handle.’ Tom was capable of
brilliant achievement in school and athletics. He had powerful gifts as a writer and
actor in local theater productions. But he also had a wild and moody side that was
straining the resources of his parents and teachers.
He had a history of taking dangerous risks with drugs, and law-breaking, such
as damaging the property of another teenager at school who had incurred his
wrath in an argument over a girl. He experienced periodic mood swings in which
he raged and swore at his parents, refusing to go to school, spending days holed
up in his room in a mindless funk, depressed and inconsolable.
He was diagnosed with ADHD when he was seven as a result of his marked
impulsivity and inattention at school. With the help of a well-written Individual
Education Plan (IEP) and a good school district, he had been moderately success-
ful until he hit middle school. But in the larger classrooms of the sixth and seventh
grade he began to fail and had not been able to raise his grades past a low C
average since.
Now his sleep habits were disrupted (his usual drop-off time was about 1.30
a.m.), and he often got into pressured speech, fixating on things he thought he
needed and pestering his parents until they were ready to scream.
He was fortunate that his parents, Linda and Craig, were paying attention to
him and not ignoring his behavior or shaming him for it. In fact, like most of the
parents that I work with, they spent about 80 percent of their available time
helping their child succeed at the projects he was involved in and helping him
stave off the debilitating discouragement that would come over him from time to
time.
73
Craig was diagnosed with ADD himself, and was taking medication for it.
Though Linda did not have a diagnosis for any attention difference, she described
herself as ‘moody, high-energy, high-strung, and perfectionist’ with a tendency to
get pretty depressed every few months or so for a couple of weeks. She was in
marketing and her high energy paid off in terms of career success but she admitted
that there were times when she felt decidedly depressed about her life, to the point
that she had a difficult time getting out of bed in the morning.
Linda told me that her mother had been diagnosed with manic-depressive
illness in her twenties and had been in and out of depressions that could last for
months her whole life. Linda told me that she could track these same qualities
back into her family history along with a strong predilection for alcohol abuse on
both her mother’s and father’s sides. Her narrative did not surprise me. People
with mood disorders often come from family lines in which substance abuse and
mood disorders are present, and transmission along the maternal side is often sig-
nificant. Drs Frederick Goodwin and Kay Redfield Jamison maintain in their
landmark book Manic-Depressive Illness (Goodwin and Jamison 1990) that Bipolar
Disorder is one of the most inheritable human conditions – if one parent is
diagnosed with the disorder, they say that there is a high probability that any
children of this parent will also meet diagnostic criteria for it.
Tom’s family physician had diagnosed him with ADHD but stimulant medica-
tion made him more hyper and irritable. They had also tried the antidepressant
class of medications including Prozac and Zoloft, which made him more agitated,
weepy, or oversensitive to all kinds of stimuli. They were fed up and discouraged,
thinking that they had an ADHD kid who could not be treated with the kinds of
medications that were supposed to help kids like him.
I suspected that his primary attention difference might be a mood disorder, but
one not described accurately by the classic definition of Bipolar Disorder. Though
he met the central diagnostic criteria for extremes in mood swing seen in
manic-depressive illness, he did not really experience the ‘manic’ or hypomanic
highs of that disorder but instead experienced pressured, anxious normalcy punc-
tuated by descent into dark and foreboding mood states. His presentation
indicated that he probably suffered from early-onset Bipolar Disorder that had
become more florid as he approached puberty but had probably always been with
him and been misdiagnosed as ADHD. A review of his history showed that as a
child he had experienced night terrors, rage, very wild behavior, such as running
into busy streets as if there were no traffic present, and pressured speech – all indi-
cations that something other than pure ADHD was going on.
I asked him to give me specific examples of what he experienced when he got
into self-destructiveness or fought with his parents. He told me that though he
always felt a little blue, there was a lot of difference between feeling blue and what
happened when his mood dropped. He would be going about his life, going to
TOM’S STORY / 75
school perhaps, and then suddenly look up and a weird mood would descend on
him and pull him down. He said it was ‘like a spider growing out of my forehead
and taking over my body.’ He drew a picture of what this felt like and as he did I
could see that his mood swing followed a predictable sequence somewhat like the
experience of a migraine headache. He would first sense the arrival of his mood
change by awareness of particular smells that he could not quite identify. He
would then become hypersensitive to light and feel mildly nauseated. These sen-
sations would be replaced by a feeling of internal agitation, of unpleasant ner-
vousness. Soon after this feeling the spider image would emerge. At this time if
any demand were put on him he would explode in curses or withdraw deeply into
himself. If he suppressed the impulse to scream out his anger, he would become
depressed and sometimes developed migraine headaches.
I hypothesized that his mood shift was heralded by the limbic wave phenome-
non described in Chapter 2, and that hypersensitivities, nausea, and peculiar
effects were related to the onset of the wave.
Tom appeared fairly ordinary on the outside, but he told me that he felt
numbed out on the inside, and that it took extreme action to get any sensation or
feeling – like sneaking out into the night and puffing on a cigarette butt he found
on the street. And once the spider mood, the dark funk, came to stay, any demand
put on him was intolerable – even the requirement to get out of bed and go to
school. He would meet these ordinary demands with ferocious push-back – thus
the diagnosis of oppositional defiance.
And once he fell into a funk, his ability to succeed at anything was severely
curtailed, and made worse by the stress he experienced when people accused him
of being lazy, defiant, or unmotivated.
Tom first resists, then accepts medication

After my first interview with Tom and his parents I recommended to them that
they have his ADHD diagnosis revisited by a well-known pediatric neurologist in
their area. This doctor diagnosed Tom as having a non-specific Bipolar Disorder
and recommended that he begin taking the anticonvulsant medication divalproex
sodium (b. Depakote).
Tom at first resisted the doctor’s recommendation. He did not like the idea that
he would be taking a drug that could be very dangerous in overdose. He com-
plained about having to take yet another medication – he had hoped to beat his
bipolarity by himself. But despite his willingness to work on his issues in therapy,
his mood shifts continued to happen with a vengeance and were having major
effects on his ability to concentrate and complete his school work.
Once a child enters the teenage years, I advise parents not to try to force him to
take medication by severe disciplinary measures, withholding of privileges, etc.,
but to use the child’s resistance as an opportunity to get the message across that he
is responsible for his own life and has the right to make decisions regarding what
kinds of medications or drugs he will accept. Many Bipolar children are suscepti-
ble to illegal drug abuse because of their biochemical craving for high stimulation
and relief of the depressing numbness of the condition. Forcing a child to take a
medication gives him the message that his body is not his own, that he is not in
charge of his life, and that drugs are the only help you can find. He needs to hear
another message: that as difficult as it may be, he has to walk the lonely road to
self-care himself and that important people in his life support his self-strength-
ening in this regard.
Heartened by the possibility that change was possible and that the initial
negative side-effects of Depakote, the headaches, dullness, and stomach upsets,
would usually fade in a week or two, Tom decided to start taking the medication
and quite soon experienced excellent results from it. His grades went from failing
to As and Bs. His mood shift improved markedly. Though he still experienced
mood swing, he was now able to identify and talk about the mood swing in
process and take action to help himself. The Depakote greatly enabled his change
in therapy and was a powerful force for building the stress-positive lifestyle that
he had made his primary goal as we worked together into the early recovery
phase.
Planning psychotherapy using the force field technique

I used a model borrowed from pioneering social scientist Dr Kurt Lewin (Lewin
1997) to describe Tom’s problem behavior and to plan changes. Lewin said that
any state of being, any status quo, is a result of forces that drive for it and forces
that resist it – a state of balance in which these opposing forces are at a dynamic
standstill.
Change is a result of the resolution of competing forces
Forces driving toward the status quo
The status quo
Forces resisting the status quo
Figure 4.1
TOM’S STORY / 77
We talked about Tom’s mood swings in these terms, drawing together the forces
that were driving toward a status quo of failure, oppositionality, and misery, and
those that were resisting it.
Forces driving and resisting Tom’s failure

‘A life of failure and misery.’
Forces driving toward this outcome:

(a) possible inherited brain tendencies for a mood disorder
(b) denial of his condition when he was in the midst of it
(c) poor stress-management skills.
Forces resisting this outcome:
(a) supportive friends and loving parents who believed in him
(b) powerful intelligence and determination to survive
(c) a commitment to personal wellness.
It was important that Tom and I were able to talk about the forces that maintained
the misery in his life because in so doing he could begin to get an idea of what
change was possible. This was an interactive assessment in which how I developed
my concept of Tom’s problem became part of the solution. After working with
many teenagers I have learned that change requires dialogue and that teens will
push back with great ferocity toward any professional who assumes a know-it-all
position of detachment in the interaction.
In order to change you have to be able to see the state of change you want and
be able to define it. The next step was for Tom to describe his desired new state:
‘To graduate from high school in one piece and go to community college to study
some aspect of the healing arts.’ He had not decided what field he wanted to enter,
but he was able to identify his long-term objectives and mobilize a positive feeling
around the outcome. This is a very important step for him as a person suffering
from depression, because the depression itself can sit on the energy needed for
movement toward a more resourceful way of dealing with the situation. In permit-
ting himself to have the thought of a positive future he was beginning to climb out
of his hole.
We drew a new force field diagram putting this new objective on our status line
and reversing the driving and resisting forces pushing toward this outcome.
Forces driving and resisting Tom’s success

‘To graduate from high school and pursue my career.’
Forces driving toward this outcome:

(a) supportive friends and loving parents who believed in him
(b) powerful intelligence and determination to survive
(c) a commitment to personal wellness.
Forces resisting this outcome:
(a) inherited brain tendencies for a mood disorder
(b) denial of his condition when he was in the midst of it
(c) poor stress-management skills.
Five survival strategies to help kids like Tom deal with Bipolar Disorder
Once we had diagrammed the desired status quo we began to plan actions that he
could take to weaken the forces that resisted this outcome and strengthen those
that drove for it. Change requires that both sides of the line be addressed, or there
will be an imbalance in which noble plans flounder on unacknowledged resis-
tance. Each of the lines of the diagram became starting points for informal brain-
storming and psychotherapeutic techniques for the next six or eight of our
sessions together.
1. Build acceptance/overcome denial

Tom admitted that once his mood shift happened, he was captivated by it and lost
the power to think clearly about anything, be it to take his parents’ guidance or
deal objectively with even minor hassles from his friends. When you’re depressed,
it’s like you’re walking around on the inside of a bubble and all you see is the
reflection of your own thoughts coming back at you.
To decrease the power of denial, we discussed how the condition stepped on
his freedom to do what he wanted to do in his life (a powerful motivator for
self-centered and freedom-loving teenagers). I made sure that when we talked
TOM’S STORY / 79
about the challenges that he faced from his bipolarity, we also talked about his
gifts, strengths, and aspirations. It’s easier for a kid to discuss his ‘brokeness’ if he does
so from the psychological position of basically being OK, though challenged!
The biggest hurdle for Tom, as it is for other teens with a Bipolar challenge,
was to accept that he has a biochemically caused brain condition that makes him
different from other kids and that he will have to deal with possibly all his life. But
as we discussed the positive aspects of his personality, he saw that he was a pretty
neat kid apart from the great surface disturbances, the wild waves of his hyperac-
tivity, and mood shifts. As things came more into perspective, I could see him
begin to visibly shift to a state of greater calm, self-confidence and more effective
self-management.
I downplayed the gloom and doom aspects of the term ‘Bipolar Disorder,’
saying that he ‘probably fit the diagnosis pretty well’ because of his mood shift but
that it was important to understand that he was not crazy or ‘mental,’ to use
teenager jargon, but had a problem managing his highs and lows that he shared
with millions of other people.
I told Tom that I understood the stress he had gone through his whole life,
trying to hide his moody and dysphoric side, to make nice all the time, when there
was a fire-fight going on inside between the self-critical aspects of himself. I asked
him if he would give up trying to be nice for a week and tell people around him as
honestly as he could what was going on. He agreed, giving me that look teenagers
give adults that says ‘You’re crazy but maybe crazy-good in some way that is
useful to me.’ I chose this suggestion carefully to build on his natural sense of
honesty. His mother reported a lessening of his dysphoria immediately after our
session – saying that the overall pressure of his mood shift had lessened from
about a daily average of –3 (on a 1 to –7 scale – see below) to about –1.5. This was
a signal that we were on the right track.
When he came in the next time, I used the technique outlined in the box on
p.80 to help him integrate and accept different ‘parts’ of himself involved in his
bipolarity. He had defined his Bipolar, depressed, side as his ‘head’ or ‘brain’
aspect and the part that opposed this aspect as his ‘heart’ or ‘love’ side. I knew that
the power of denial is decreased by the integration of conflicting voices in oneself.
Once competing voices are integrated, considerable energy is freed for the
healing process.
Children react differently to exercises like this. If the time is right for the
exercise, the child will often look relaxed after completing it. Some kids will just
act differently in subtle ways in the days that follow to clue you that they are ‘more
together.’ A shy child becomes more assertive. An angry one can decide that she’s
going to drop her grudge with a schoolmate.
Parents and therapists can use this technique if a child has the interest and
cognitive/emotional acceptance of the process. It is important to give him time to
complete and process the experience on his own terms. If he encounters resis-
tance, you may want to halt the exercise and let him speak his resistance. Do not
Two-hand mood-integration method

This exercise is useful for older children or teens.
First, tell the child that everyone has different ‘parts’ in them-
selves that tend to behave in fairly consistent ways. ‘When you’re
feeling good about yourself, you can take a lot of flak from your
teachers and parents and roll with it. This is your confident, high
self-esteem part. But in your worst class you might feel dull as mud,
like you’ll never get through the day and never get the lesson. These
are all subparts of your personality. This exercise helps you get the
“depressed” part of you together with the more normal part of you.’
Second, ask the child to have one hand represent the ‘depressed’
aspect of himself and the other hand the ‘normal’ aspect. Talk up the
separate ‘personalities’ the child assigns to each hand, going a bit
into the characteristics of each. ‘On your left hand is your “normal”
part. He’s great to have around and gets things done but he is sad and
unmotivated,’ or ‘On your right hand you have the “angry” aspect of
yourself. He is no fun to be with but he protects you.’ Etc.
Third, ask the child to hold his hands with palms facing each
other and bring them slowly together ‘Only as fast as you need to
fully bring these aspects together in yourself so that you feel a sense
of peacefulness.’ If he is benefitting from the exercise, you will
probably see him visibly relax. In doing so he is learning an impor-
tant ‘resource state’ – a place of calm that is created by ‘getting
himself together’ and that he can come back to.
rush through this kind of integrative approach but give opportunity for all aspects
of the self that are involved to have a voice in the integrative process. The child
might say, for example, ‘I can’t do this. My angry and normal parts don’t get along
well enough yet.’ Respect this resistance. Change happens at its own pace.
2. Strengthen communication with important caregivers

To strengthen Tom’s ability to gain support from adults and friends in his life, we
brainstormed ways for him to take the initiative to communicate when he was
approaching his mood shift so that he did not become isolated once it fully
descended into his psyche.
TOM’S STORY / 81
An essential step in giving Tom more control was to establish better communi-
cation between himself and his parents – to decrease the desperation they felt
when he became unresponsive or hostile. Early on he told me about the ‘spider.’ I
asked him to calibrate his drop in mood on a – 4 to +4 scale in which 1 means
‘normal consciousness’ and – 4 means ‘fully depressed’ or ‘out of it,’ and a +4
means that he feels ‘rushy,’ ‘pressured,’ ‘agitated,’ or ‘manic.’
Table 4.1 Mood Feedback Scale
Deeply depressed lethargic normal agitated hypomanic
– 4______________________________+1_____________________________+4
Tom had mentioned to me that he used to have rage fits quite frequently when his
mom or dad wanted him to do something when his mood was dropping. We
practiced assigning different numbers to specific feelings during his mood shift
until he could clearly link a number with a point on the cycle. Once he was able to
calibrate his change in feeling this way, he could tell his parents what was going
on. Now he had more perspective on what his brain was doing and thus more
control over that reaction, so that he could simply withdraw psychologically,
sitting and staring into space, or go to his room, lock the door, play video games,
or try to sleep.
Linda and Craig also had a valuable resource to head off Tom’s mood shift.
They had a way of knowing when he was most vulnerable to it and could help him
relax and relieve stress at the time. A mood state of –3 would not be a good time to
put demands on him for homework, chores, or any task that required effort, espe-
cially cognitive effort.
Once a child and his family have a way of communicating about the child’s
inner experience of Bipolar Disorder, acceptance of the physiological basis for the
child’s behavior is possible – that he is not doing what he does just to make his
parents’ lives miserable. The paradox is that a depressed child will use strategies to
try to get the upper hand in power struggles and will project the horrible feelings
he experiences on everyone else so as to get a sense of relief from these feelings.
But he rarely does so out of genuine malevolence or manipulativeness – he does so
because he is miserable and Bipolar misery loves company! The way to short-
circuit the depression–misery cycle is to talk about it up front, when it starts,
before it gets a grip on the emotional lives of everyone in the home.
Opening communication relieves parents of the terror that they are raising a
deranged child – the part brain chemistry plays becomes clear. If they are able to
see Bipolar Disorder as something like a seizure condition, they do not feel
stalked by the malevolence of it, and can give the child help with self-manage-
ment and stress management.
If rage is part of the picture, the rage may continue, but it will not be nourished
by the terror of the parents. And parents will be able to let the child know that
violence will not be tolerated. They know what they are facing and where to get
help.
As we continued to work in therapy, Tom gained greater awareness of how his
drop in mood impacted his cognitive and emotional functions. This was a big step
and a big part of his acceptance of medication because he wanted to succeed at
school. Once the Mood Feedback Scale technique was communicated to his
teachers, they had a way of understanding how Tom’s affective disorder impacted
his school performance and were able to devise ways to help him compensate for it
in class, such as finding a refuge for him in the school building where he could
turn down the lights, and do some breathing and relaxation exercises which
would sometimes head off the drop into depression.
3. Develop awareness of how mood shift is triggered

In Survival Strategies for Parenting Your ADD Child (Lynn 1996), I noted how
important the quality of feeling in control of life events is to personal stress manage-
ment. If you feel in control, you are able to take things one at a time, maintain
serenity and so are strengthened for the next challenge. Dr Hans Selye called this
positive attitude ‘eustress’ (Selye 1956), using the Latin prefix eu to mean ‘good’
stress. There is abundant research to substantiate the connection between stress
and the onset of Bipolar symptomology. To avoid the experience of symptoms
and strengthen himself for the next bout of mood shift, Tom needed to exercise a
eustress-type reaction to events in his life.
You gain more control and more long-term hardiness by developing the ability
to anticipate the situations that set off mood swings. I asked Tom to think back
over several of his depressed episodes and list the changes that his body went
through at the outset and the kinds of external triggers that seemed to prompt the
drop in mood. It was very important for Tom to track his mood shift carefully so
that he could take action to calm himself, be it by turning down the lights, taking
a short nap, going for a walk, doing some breathing exercises, or taking a relaxing
bath.
Some children report that their mood shift feels like an animal stalking them.
Tom had his own version of this in his spider metaphor. And his mood shift would
powerfully influence his perception. If he felt down, he would angrily push back
from any help and would resist taking his medication. If he felt up, he believed he
no longer needed medication or help from anyone else.
I taught Tom the following technique to track the build-up of pressure before
his mood shift so that he could take action to head it off, or change his daily
TOM’S STORY / 83
routine before it began to influence his perception. I asked him to post this infor-
mation over his desk at home as an awareness reminder.
Developing awareness of when his mood was shifting was a powerful move in the
right direction because it gave him a sense of control. He would need his parents’
help and medication (see below) to pull through, but making this list gave him a
sense that there was something that he could do to keep a little bit of control over
Tom’s mood-shift warning list

To: Tom Samples
From: Tom Samples
Pay Attention to These Warning Signs that the Spider Is Stalking
You!
When my mood is shifting:

I wake up feeling tired
I lose my appetite
I start having strange thoughts about sex
I start listening to my crazy friends’ advice to do stupid things.
As my mood darkens:
I feel like I am carrying around a heavy wet blanket
I wake up worrying about everything
I forget to keep myself clean
I can’t keep my mouth shut and talk too much.
When I’m really into it:
I can’t stand the sound of my mom’s voice
I can’t stand to be told to do my chores and get real angry
I feel like I’m dragging around a hundred-pound weight.
his mood. Every bit of confidence is important for a kid with early-onset Bipolar
Disorder challenges.
After we had better specification of the feelings, thoughts, and behavior that
he experienced during the mood shift, we put together a second list which would
also be posted in a conspicuous place in his bedroom as a reminder of situations to
avoid to keep a healthy head space. These ‘trigger’ situations included:
4. Ensure that the child has a regular sleep schedule to prevent worsening of mania
Many research studies have shown that lack of sleep can worsen hypomania. It is
important to make sure that your child’s sleep cycle is stable. Use of stimulant
medication or antidepressant medication may contribute to the onset of mania as
Tom’s trigger-situation warning list

To: Tom Samples
From: Tom Samples
Know that in these situations you are vulnerable to the Spider:

staying up all night
sneaking out with Micky at school for a cigarette or puff of pot
drinking beer
getting up too fast in the morning
drinking coffee at night and staying up late
eating sugar
any kind of change that I don’t feel good about
letting homework pile up – too much homework
being verbally abused by Sara (his girlfriend at school)
staying in the sun too long or riding my bike without a break.
an indirect result of its ability to cause insomnia in some children.

Stabilize sleep patterns by noting the amount of sleep your child needs and
limiting late-night distractions and stimulation that may keep him awake.
Consider this factor to be a safety and health issue and require the child to comply
with your sleep schedule for him as a condition of remaining in your home.
Consult with your medical or naturopathic physician for the prescription of medi-
cation to help your child sleep. Know that the worst mania, the worst rage, the
worst grief for your family may follow one night of sleeplessness of the child with
Bipolar challenges.
5. To help a child build a sense of self, help him identify Bipolar Disorder
as part of Big Story
Dr Jean Houston (Houston 1987), preeminent educator and philosopher, says
that the goal of psychotherapy, education, and philosophy is to enable people to
see the pain and drama in their lives as what she calls Big Story. She believes that
TOM’S STORY / 85
suffering will always be with us and we each have our own variation of it. It is very
important to see the perfection in the kind of suffering that is in our lives and how
we can use it to make ourselves stronger. Houston talks about how ‘being
wounded’ as a requirement for ‘being healed’ is found in stories and myths from
around the world. The feeling of being grace-full and the desire to be blessed are
central motifs in every religion. The word ‘blessed’ is derived from an Old English
word meaning ‘to sanctify by wounding.’ It is through the wound that grace,
change, and growth are said to come. Being born with Bipolar Disorder is such a
wound.
It is a condition that requires a child to live in extremes whether he’d like to or
not. It is also one that carries powerful energy for genius, especially in the arts. It is
important that sooner or later Bipolar children become aware of their connection
to Big Story in this way. They inhabit the archetype of the Warrior and they must
choose how to direct the energy they command with this temperament.
The invitation to raise the issue to Big Story does not express Pollyannaish
sentiment. Bipolar Disorder is a great stressor and it has inflicted excruciating pain
on many children and their families. But once it is accepted, as one would accept
the existence of any other disorder or illness, it becomes clear that it gives the
child a depth of knowledge about the human condition and about the reality of
suffering in the world that his non-Bipolar friends could never approach.
I have worked thousands of hours with children with a variety of attention dif-
ferences and in that time have learned one thing very clearly: healing does not
occur until the child can see his condition in terms of the big picture of his life, or
his Big Story. What is required of me as a psychotherapist is that I listen carefully
to help him identify his strengths, his resources, and to tie these in with his
uniqueness as a child with Bipolar Disorder.
Tom was a skilled actor in school and local little theater productions and was a
decent poet for his age and sophistication. He enjoyed my talking about the lives
of eminent people who were diagnosed with Bipolar Disorder or may have been
Bipolar. Some of his favorites were writers Edgar Allan Poe, Ernest Hemingway
and actress Patty Duke. In Tom’s acting personas and his writing, he seemed able
to assume the archetypes of the characters, to know quickly their central themes
of suffering and joy. He could do this because of his familiarity with emotional
extremes. As we talked, he recognized that acting was therapeutic for him (as he
put it, ‘good for my head’) because it required him to pull together aspects of
himself (his dysphoric, angry, normal, and good-kid aspects) that could spill out
of him at the wrong time if the pressure was not released through acting.
Every session gave me the opportunity to note strengths in Tom’s character –
his honesty, his courage, his intelligence, and his compassion. With every one, I
could see his energy lighten a bit – tip a bit more toward better management of his
Bipolar-related challenges. He needed to feel strong about himself, and the adults
around him were helping him with firm limits and lots of praise even for small
successes. Tom was excruciatingly pained by being made the ‘identified patient.’
His mother and father knew this and had used humor, straight talk, even anger to
express their acceptance of him, Bipolar and all. As is the case with a lot of the
families I have worked with who have Bipolar children, this family had the grit to
survive!
CHAPTER 5
Compassion Makes a Big Difference

The Empathy Factor
in Children with Bipolar Disorder
Children with Bipolar Disorder and the other Attention Different conditions
discussed in this book may be very self-centered. This is a problem that accompa-
nies the inner feeling of being out of control, of experiencing reality as a chaotic
blur. This state of consciousness moves a child to want to simplify things, reduce
novelty, and do things his way. This quality is seen in all children with BD chal-
lenges.
If the quality of empathy is present, self-centeredness will be less problematic.
Empathy is the ability to sense the feeling of others and understand the connec-
tion between one’s behavior and its impact on others. If empathy is not present to
balance the natural selfishness of the Bipolar presentation, a child is in double
trouble. Many, though not all, children with Bipolar Disorder show a lack of
empathy in their dealings with others (Kovacs and Pollock 1995), and so it is
essential to get a good idea of what is going on in order to help them. I term the
inability to experience empathy ‘anempathy,’ using the Latin prefix to mean ‘not,’
or ‘not able to,’ in the same sense as the prefix an is used in ‘anhedonia’ – the
inability to experience pleasure.
Anempathy and the Golden Rule

Empathy is the feeling behind the Golden Rule. If I can see your pain and feel it,
and see your joy and be moved by it, I am motivated to be careful in my relation-
ship with you. I feel connected to you in my awareness of you as a human being. If
you can feel my pain and joy, you connect with me. You may be less apt to attack
me and more interested in seeking a peaceful solution to some argument we have.
We are aware of our connection and our interdependence.
‘Do unto others as you would have them do unto you,’ is an affirmation of the
empathy in human behavior. It is a prescription for survival. In today’s world we
are all interdependent; we are only as strong as our connection with others.
Empathy, when functioning as part of our overall psyche, allows us to see the
big picture: to see ourselves and others at the same time, as if we were above
87
ourselves looking down. Without empathy, we may behave as if we were the only
beings alive on the planet and this can have disastrous results. Without empathy
the monkey-feel-monkey-do reflex of the limbic system rules.
Many children with ADHD, Bipolar Disorder, Asperger’s Syndrome, and
Tourette Syndrome feel every emotion to the extreme. These Attention Different
kids are in a dangerous situation if empathy is not on board to apply the brakes to
their emotional states. In this situation, there is no reason not to go all the way. The
lack of empathy may cause the child to develop endless rationalizations to defend
his self-destructive behavior. And it cuts him off from experiencing at any depth
the harm he may do to his community, and his family.
Accurate assessment of a child’s ability to experience empathy is crucial. A
child who has a sense of social conscience is motivated to change his behavior
because he feels ashamed for hurting others. A child who does not have a sense of
social conscience needs a particular kind of parenting and psychotherapy; one in
which firm boundaries and discipline share an equal status with parental love. And
one in which loving mistrust and tough love must be the operant principles.
A child may manifest anempathy as a result of any of five factors: (1) frontal-
lobe dysfunction, (2) a developmental disorder termed ‘Alexithymia’ (described
below), (3) psychosis, (4) Post Traumatic Stress, or (5) Asperger’s Syndrome. The
purpose of this chapter is to help parents understand which of these factors might
be contributing to their child’s anempathy so that they can give him the help he
needs.
1. Frontal-lobe dysfunction
This presents a severe challenge to the experience of empathy, and is seen in
dangerous impulsivity.
The frontal lobes of a child’s brain, the part of the cortical brain which sits
behind the forehead, gives him ‘observer perspective’ – the ability to see his
actions in the context of their impact on others. They contain the brain’s ‘editor’
function, which enables the child to evaluate action and moderate emotion
(Comings 1990). The frontal cortex is the locus of the ability to pay attention and
organize one’s activity. This vital brain structure balances the excitatory response
of the limbic brain, enabling the child to pull back, to think for a moment about
what he is doing, to focus on appropriate action and make the right decision.
Brain research shows that misguided, dysinhibited behavior may be caused by
underfunction of a frontal-lobe structure found right over and behind the right
eye called the ‘orbitofrontal cortex.’ The OFC is the structure responsible for
‘executive function’ in the child’s mental processes; his ability to observe his
actions in the context of their consequences, to pay attention, and to edit his
thoughts and impulses (Mate 1999).
COMPASSION MAKES A BIG DIFFERENCE / 89
Underfunction of the OFC results in a child’s inability to control impulsive

action. The term ‘dysinhibition’ is used to denote this predilection for self-
destructive and risky behavior that may have an extremely adverse impact on the
child and his family. The axiom of ‘teen-see-teen-do’ is operant with these
impulsive youngsters. Examples of the trouble they get into include:
• stealing parents’ credit cards and money
• taking passwords or going on the Net to download pornography
• sexual impulsivity
• abuse of drugs
• law-breaking.
These behaviors may surprise many parents who know in their hearts that their
kids are decent, loving human beings. They know their children are not predatory
criminals. Parents find it hard to believe that their kids could be guilty of wrong-
doing. But the child’s lack of ability to inhibit his action, to ask himself ‘Is this a
good idea?’ when confronted with a potentially dangerous action, is the heart of
the problem. The common understanding of the meaning of the word ‘impulsive’
is that the word equates with ‘spontaneous,’ but in fact many children demonstrate
quite a bit of prior planning in the commission of destructive behavior. The term
‘impulsive’ is better defined to mean ‘mindless’ or ‘acting on impulse without
clear thinking,’ and this kind of activity may be carried out over hours or days.
Younger children with an underfunctioning OFC may not be as challenging as
teenagers because there are so many more people controlling their lives – teachers,
counselors, and mentors – as well as their parents.
Impulsive action is driven by distorted thinking. Parents of dysinhibited teens,
and many teens with Bipolar challenges are in the group, report that their kids do
not seem to connect their behavior with its consequences. This is an accurate
assessment of the issue in that the teen does not hold a personal timeline: he does
not carry an idea of his future in his head. He is a captive of the present moment
and disabled in his ability to defer his gratification or to be aware of what
problems his behavior could cause. The teen does not automatically have this
sense of time and consequence. Lacking this sense, he behaves anempathetically
and becomes a danger to himself and others.
Puberty complicates the problem. At this time, the child undergoes a massive
growth spurt in his limbic brain. The predilection for wildness and impulsivity
brought on by the development of the limbic brain comes at a time when the teen
has a lot more freedom and opportunity for risky action. The frontal lobe is the
civilizing force in his life and if it is underfunctioning, the teenager is doubly vul-
nerable.
The good news is that towards the end of adolescence, the teen’s brain goes
through a final growth spurt. This time it is the frontal lobes that develop to
maturity. Getting an impulsive teen to this point requires that his parents have the
endurance of marathon runners. The prize for this extraordinary effort is the
knowledge that they have done all that they can to give their son or daughter a
foundation for being successful in life despite the challenge of dysinhibition.
Anempathy in a child may also relate to Reward Deficiency Syndrome (RDS). I
pointed out in Chapter 2 that people normally get a little shot of pleasure
neurochemical (in the form of enkaphalins or endorphins) in the frontal lobes of
their brains when they learn something. This is the way the brain marks the
learning so that it can be remembered and used as part of the person’s overall
learning process. In RDS, this neurochemical spurt does not happen and so the
person cannot experience satisfaction from any activity.
Researchers Kenneth Blum and David Comings (Blum and Comings 1996)
refined the RDS hypothesis in their work on the genetics of alcoholism. Their
results showed that flaws in the brain’s reward circuitry were contributory to alco-
holism and other addictions. People with this problem pursued substance use as
self-medication from the awful feeling of dullness and depression in their lives.
Teenagers who show vulnerability to addiction may do so as a result of the
low-level chronic depression caused by RDS.
RDS causes a lack of empathy because the child lacks the energy to focus
outside himself long enough to see the suffering of others. His attention is riveted
on relieving the pain he experiences from his inability to get any enjoyment from
his life. In a real sense, RDS deprives the child of the ability to laugh, to be happy
for even a few moments, and so to rise above his situation and see his life in
context. Life becomes a grim struggle in which getting through the day is all that
counts and there is very little emotional energy left over for anything.
Markers of frontal-lobe dysfunction as a causative in anempathy

Use the following checklist to analyze the possibility that frontal-lobe dysfunc-
tion may be contributing to your child’s anempathetic reaction.
1. The child cannot foresee the consequences of his behavior – he does
not easily relate effects to causes.
2. Very concrete thinking is evidenced. The child has a difficult time
generalizing one experience to other situations.
3. He has very poor behavior planning skills, and rarely asks ‘Is this a
good idea?’ before initiating behavior.
4. Motivation is poor. He is not able to delay gratification.
5. He may show a short attention span and be distractible.
6. Lying may be a problem not because of fabrication but because he

cannot tell the difference between what is real and what is not.
7. Perseverance is present: he repeats words, sounds, behaviors, or
automatically imitates others.
8. Severe rage may be seen in which the child does not seem to
understand the destruction that he causes and does not show remorse
after the event.
9. Problems with sexual discontrol may be in evidence. The child or teen
makes unwelcome sexual advances or inappropriately touches others
and does not show remorse or understanding of why this behavior is
prohibited.
10. There is evidence of the presence of Reward Deficiency Syndrome as
seen in the child’s predilection for compulsive or addictive behavior and
pestering.
2. Anempathy and Alexithymia

Anempathy may also be caused by a learning disorder called ‘Alexithymia,’
defined by Mosby’s [Medical] Dictionary as the ‘inability to experience or commu-
nicate emotion.’ The disorder is caused by a person’s inability to label or name her
own emotions. Not being able to label them, she can’t reference them as a
standard of comparison with others. Alexithymia is a learning disorder, not a
moral defect.
Research on Alexithymics shows that their overall ability to experience
emotional reaction is considerably less than that of the neurotypical population.
And they pay less attention to the emotional expressions of others. Their
anempathy is driven by a greatly downregulated emotional response overall.
The Alexithymic also experiences great difficulty knowing what she is feeling.
Studies suggest that the cause of this lack of awareness is related to her brain
structure (Roedema and Simons 1999). The amygdala and thalamus in the limbic
brain are important structures in terms of our ability to experience empathy. We
can sense what others are feeling only to the degree that we can sense and name
our own emotional states. In Alexithymia the neural pathways between the
amygdala and thalamus and the verbal and visual centers of the cortex are
defective, resulting in a person’s inability to name what she is feeling and under-
stand the signs of emotion that others display. This causes her to experience
continual confusion and miscommunication with people because she has no way
of comparing and contrasting their expression of emotion with her own.
Psychotherapy can be useful to help the Alexithymic child generalize her
emotional reactions from situations in which she does experience feelings of being
mad, glad, sad, or scared to situations in which these feelings are not present. This
is a process of constructing fluency in emotional labeling and empathy, one step at
a time, in the same way one would learn a foreign language.
John: A brief portrait of an Alexithymic teen

John, a 13-year-old, came into counseling with his father to help him deal with a
chronic depression that he had experienced as long as his parents could
remember. He was not overtly sad all the time, but just didn’t seem to enjoy life
much. John seemed perfectly happy to go to school, come home, do his
homework, and go to bed. He had one friend who was a lot like him whom he
hung out with from time to time. His dad said that John and his buddy were never
a problem to anyone because they never made waves about anything. In fact the
two were so unassuming, sedentary, quiet, and cooperative that adults around
them became uncomfortable.
As I talked with John privately, I wondered if he were Alexithymic. We
discussed the movie Private Ryan and I asked him if he was emotionally affected by
it. He said that far from being moved by the film, he found it boring. We talked
about the epidemic of killing-spree-type shootings happening in American high
schools. John was nonchalant about the stories of the suffering of the victims of
the school shootings. He told me that when things happened at school that
provoked emotional reactions in the other kids, such as one of their classmates
dying in an automobile accident, or their high school basketball team making the
state finals, he would not experience any emotional arousal at all. He was annoyed
that everyone else made a big deal about it. John did not relate at all to his friends’
consternation with him when he did something that annoyed them. He would
often seem profoundly self-centered or self-absorbed, as if no one else in the
world existed.
John told me that he was lonely for the company of others, but he had decided
he was so different that he probably would never have good friends. He told me
that unlike other kids, he rarely had feelings, but instead had thoughts. If someone
got angry at him, he would rarely react to the anger but would be confused by it
and simply think about what he needed to do to get away from the person or say
to calm him down.
John was not a problem to anyone, but his lack of ability to experience
emotional arousal and to relate to the emotions of others cut him off from support
and threatened to bedevil his success as he grew up. We live in a culture that
demands a great deal of human interaction, and without the ability to communi-
cate at the affective level, a person is greatly limited. No one is going to give you a
job if you come off as a robot in the job interview.
Therapy for John began with my acceptance of him as a person who may have
Alexithymia. I talked with him about the condition. He seemed greatly relieved
that he was not the only one in the world who functioned with such low
emotional arousal. I asked him if he wanted to try medication to deal with some of
the anxiety that he experienced from the Alexithymia. He thought that was a
good idea and so I discussed the possibility with his parents of talking to a psychi-
atrist about starting low-dosage antidepressant therapy with him.
I taught John several strategies that he could use to bridge communications
with other kids and his teachers (see a description of these techniques as survival
strategy numbers 11 and 12 below). I revisited these strategies every time he came
in to counseling for the next several months, so that he could use them fluently in a
particular situation. Psychotherapy with John was not directed to making him
more emotionally responsive. It was directed to helping him learn ways to make
his perceptual style less of a problem so that he could engage in social interaction.
Markers of Alexithymia as a causative in anempathy

1. One experiences a sense of boredom talking with the child. There is a
lack of emotional flavor in the interaction.
2. The child cannot say what emotions people display in TV or movie
dramas.
3. He shows evidence that he has a difficult time decoding the emotional
meanings in what he reads, sees, or hears. There is a failure to
comprehend the meaning of emotional information.
4. Other family members show evidence of low emotional arousal and
enjoy activities that are highly cerebral, such as playing chess or bridge.
Family members are somewhat phobic about risk taking, and displays
of emotion are not OK.
5. The child displays an inappropriately low-key reaction to any
emotional situation, as if he is depressed, but a mood disorder is not
present. He is emotionally underaroused.
6. He does not meet diagnostic criteria for other conditions which may
also be marked by anempathy, such as Frontal Lobe Syndrome,
Asperger’s Syndrome, Post Traumatic Stress, or psychopathology.
3. Anempathy, psychopathology, and The X Files

The media has done a lot to create confusion about children who lack empathy.
Many parents are loath to admit that a child has Bipolar Disorder because of the
popular misconception that the children with this condition are ‘bad seed.’ The
popular TV series The X Files has contributed to this misinformation by mislabel-
ing its psychotic and amoral characters (serial killer types) as having ‘Bipolar
Disorder.’
Traditionally, affective and interpersonal traits such as egocentricity, deceit,
shallow affect, manipulativeness, selfishness, and lack of empathy have been con-
sidered evidence that a person may be psychopathic. In 1980 this tradition was
broken with the publication of the third edition of the Diagnostic and Statistical
Manual, the template used by psychiatrists to diagnose mental illness. The
DSM-III renamed ‘Psychopathy’ as ‘Antisocial Personality Disorder’ (APD),
which it defined as persistent violations of social norms, including lying, stealing,
truancy, inconsistent work behavior and traffic arrests. These types of behavior are
also seen frequently in teenagers and adults with Bipolar Disorder (BD). The
result is to confuse the line between psychopathology and BD, so that children
with Bipolar challenges may be mislabeled as psychopaths.
Children and adults with Bipolar Disorder may experience psychotic thinking
from time to time but their delusional thought patterns tend to wax and wane with
their mood swings. Lack of empathy is seen in both psychopathology and Bipolar
Disorder. In psychopathology it expresses the deep hatreds resident in the person-
ality of the child. The child with Bipolar Disorder, on the other hand, lacks
empathy because of his inability to escape focus on his own depression and misery
long enough to see the misery of others. The psychopath’s coldness to the
suffering of others expresses his destructive desires and mental illness. Some
persons experience a sense of calm when committing violent acts. This disturbing
phenomenon is noted by Dr Daniel Goleman (Goleman 1995, p.97) to be present
in some spouse batterers and child abusers.
Obviously it is extremely important to understand the cause of a child’s
anempathetic behavior. If a child is psychopathic, his behavior must be monitored
closely to prevent harm to himself or others. Inpatient psychiatric hospitalization
is a first-order choice, not a last resort as it is in the case of the child with Bipolar
Disorder. A careful clinical assessment must be made to administer medication.
Typically the antipsychotic class of medication is not a first choice for treatment of
Bipolar Disorder, but it is for treatment of psychosis.
It is crucial to understand the different factors that cause anempathy because a
decision on this factor is central to making the right diagnosis. Misdiagnosing the
child’s Bipolar Disorder as psychopathology may cost the child his freedom.
Misdiagnosis may result in prescription of the wrong medication and wrong
psychotherapeutic approach. It is also dangerous (for the community) to
misdiagnose a psychotic child with the milder label of Bipolar Disorder, thus
leaving people in his life unguarded from the destructive effects of his psychotic
behavior.
Markers of psychosis as a causative in anempathy

1. The child reports pleasure and a feeling of calmed focus during
commission of conduct-disordered behaviors such as lying, stealing,
fire-setting, or attacking others.
2. Anempathetic response is shown in the act of injuring other people or
animals. The child does not consider lack of empathy to be a problem
(as is the case with non-psychotic children).
3. He makes statements which indicate satisfaction for hurtful actions: ‘She
had it coming to her. She deserved what she got.’
4. Assessment of the child’s anempathetic behavior shows that it was
premeditated.
5. The child attempts to manipulate others, setting them up for injurious
acts.
6. He displays shallow affect along with deceitfulness.
7. The child is sadistic, and experiences sexual pleasure from injuring
others.
8. The child experiences other symptoms of psychosis, to include
hallucinations and paranoid thinking.
4. Anempathy and lack of nurturing or Post Traumatic Stress

The conventional psychological explanation is that criminals are made not born.
Cruel and destructive behavior is most often seen as a symptom of a violent or
neglectful childhood. Violent behavior is believed to express the child’s pent-up
rage at her parents for their abuse of her.
If a child was raised in a ‘good enough’ home environment and she shows a
lack of empathy, there is reason to suspect brain chemistry is involved. If the child
developed violent, impulsive, or perseverant actions after a head injury and does
not show empathy, there is a good reason to suspect that her issues are not caused
by family-of-origin factors. Nature may be more causative than nurture in these
cases.
If a child or adult is surrounded by dysfunction, alcoholism, emotional
poverty, deprivation, or violence (such as is the case in many inner cities in the US),
there is a good chance that environment is the cause of her lack of empathy. People
learn violent ways of behaving from their parents and culture when they are
young. The master therapist Salvador Minuchin (Minuchin 1986) has written that
homicide may be committed out of a son’s loyalty to a violent father. This is the
murderer’s statement, ‘Am I good enough, Father? Did I live up to your teaching?’
A young drug gangster may mercilessly kill others in a drive-by shooting out of
allegiance to his peer group. Lacking any nurturing in his life he gives himself over
to other disturbed souls for his education. His merciless violence is part of his ini-
tiation into his violent peer group and his only concern is their acceptance and
that he not get caught. Though he must be held responsible for his actions, he has
also been formed by the abuses that surrounded him as he grew into adulthood.
This must be taken into account as a factor in his anempathetic behavior.
Persons with combat stress also show a lack of empathy. ‘Kill them all and let
God sort them out,’ was the chillingly anempathetic motto of many US soldiers in
Vietnam. The exceptional cruelty of war in places like Vietnam, Bosnia, Rwanda,
and Chechnya has burned the empathy out of hundreds of thousands of soldiers
and civilians who have essentially given up hope that there is any justice in the
universe. Persons suffering from this type of Post Traumatic Stress Disorder
(PTSD) may not be so much a risk to others as they are to themselves (Orsillo et al.
1995). Over one hundred thousand returning American servicemen have taken
their own lives since the war in Vietnam ended in 1975. This is a good example of
the anempathetic response turned against oneself when all hope is lost.
Diagnostically, if there is evidence of this kind of extreme violence in a child’s
life, then there is a good case to be made for PTSD being to blame for his lack of
ability to experience empathy.
Indications of the presence of PTSD as a causative in anempathy

1. Lack of empathy is accompanied by other symptoms of Post Traumatic
Stress Disorder, which include:
2. Experience of a traumatic event or traumatic upbringing.
3. The traumatic event was terrifying and the child felt helpless to protect
himself.
4. The child experiences recurrent recollections of the event and these
themes are also seen in his play behavior.
5. Nightmares and flashbacks (reliving the experience) are present.
6. The child experiences intense stress when reminded of the event.
7. He avoids thoughts, feelings or conversations associated with the event.
8. He cannot recall parts of the event.
9. He has a feeling of detachment from others.
10. He has difficulty falling or staying asleep.
11. Rage, hypervigilance, and an exaggerated startle response are present.
12. He has difficulty concentrating.
5. Anempathy and Asperger’s Syndrome

One of the most powerful features of Asperger’s Syndrome (AS) is the inability to
experience complex emotional states. The Asperger’s child’s lack of response does
not so much indicate a lack of empathy as it does a global emotional flatness that
colors every aspect of his attention. This is a developmental delay that is unlike the
anempathy caused by other factors described here.
The Asperger’s tendency for anempathy rarely causes the child to have conduct
problems or hurt other people. Asperger’s kids tend to be honest and very
law-abiding and are rarely involved in violent, destructive, or conduct-disordered
behavior. But the inability to understand the feelings of others can bedevil his
social relationships and (as he grows into adulthood) can trash his intimate rela-
tionships.
The anempathetic Asperger’s child may react to seeing another child at school
fall down and cry by laughing at her. The AS kid does not understand his class-
mates’ verbal and nonverbal displays of distress (Attwood 1998). To him it’s like
watching an episode of The Three Stooges. The child is struck by the slapstick
imagery of the incident and needs to be specifically told what to do in the
situation: ‘When you see another child fall down or cry, you should either watch
silently, or go to the child and ask “Can I help you?”’
Adults with Asperger’s Syndrome may get in deep trouble with their spouses
because they do not understand how their behavior stresses, frustrates, and angers
their partners. The Asperger’s adult may be continually inattentive, indecisive, and
unorganized. Procrastination and inattention drive his spouse crazy but he just
does not understand her strong feelings about the issue. He may suggest that she
needs to take Prozac to calm herself down and may promise to do better next time.
Deep within his own consciousness he has no empathy for her. Empathy is a
requirement for survival in any social situation and unless he learns to behave in a
different way, his relationship is doomed.
Indications of the presence of Asperger’s Syndrome as a causative in anempathy

1. The primary indication that AS is a causative in anempathy is the
presence of symptoms of Asperger’s Syndrome. These are listed in
Chapter 7 and are summarized here.
2. There is an impairment of social interaction: the child has a limited
ability to express herself verbally and nonverbally. She doesn’t have
many friends and cannot participate in a two-way conversation.
3. She shows restricted patterns of behavior, to include the presence of a
special interest that is abnormal in terms of intensity and focus.
4. She is inflexible and adheres to nonfunctional routines or rituals

compulsively.
5. She experiences continual high anxiety and has profound sensitivities
to stimulation.
Know the five possible causes for anempathy

1. Frontal Lobe Syndrome
2. Alexithymia
3. Psychopathology
4. Post Traumatic Stress Disorder
5. Asperger’s Syndrome
Ten survival strategies for managing anempathy in children and teens

with impulsive, dangerous, and destructive behavior
Though not all anempathetic children demonstrate dangerous or destructive
behavior, lack of empathy may become a serious problem when these behaviors
are related to it. Here are ten important parenting strategies to reduce the destruc-
tive impact of anempathy and begin to turn things around (two more strategies
follow on from this in the next section – when violence is not a problem).
1. Make a good assessment of the causes for your child’s anempathy

The first step is to carefully assess factors which contribute to anempathy. Use the
checklists above to explore the issue and listen attentively to understand his
feelings and perceptions about the issue. Understanding the origins of a child’s
anempathy requires good psychological detective work. You must listen carefully
to understand the phenomena that he experiences, and suspend your judgments
and theories about what causes a lack of conscience. This is a vitally important
task. A child without a sense of conscience will at least have a difficult time
relating to others and at most be a danger to himself or others. You must bring all
of your analytical and intuitive ability to understand what is going on with the
child so that you can give him the help that he needs.
2. Allow your own grief process

To survive emotionally as the parent of an anempathetic child you must come to
terms with the reality that your child has a severe impairment in her ability to
exercise good judgment and understand the consequences of her behavior on

others. Because of this impairment she may hurt you, steal from you, hurt others,
or hurt herself. You must let go of your belief that good, loving, firm, and moral
parenting practices will get your child through. Face the fact that the legal system
doesn’t care if she has a psychiatric diagnosis if she breaks the law. The idea that
criminals are created by child abuse and neglect has governed the way we look at
moral wrongdoing for fifty years, but this paradigm is flawed. Sometimes heredity
can set up a dangerous predilection for law-breaking. Being anempathetic is very
similar to having a life-threatening disease. Parents of kids like this must look
straight at the reality of it without cursing God or themselves for being so ineffec-
tive. Tears are in order. Mourning is in order. And the determination not to let
anempathy and all the problems that go with it destroy your child or your own life
is in order. Once you see what is going on you are in a position to take positive
action.
3. Treat the primary neuropsychological condition

Many violently anempathetic children are also diagnosed with Bipolar Disorder
or Unipolar Depression. Some percentage of these kids will also show symptoms
of severe ADHD or may demonstrate psychotic ideation or behavior. These
disorders create a state of emotional chaos for a child that makes his life totally
unpredictable.
The child with Bipolar challenges does not experience empathy because when
hypomanic, he is so captured by ideas and stimulation that he cannot pay
attention to anyone else. He does not experience empathy in his depressed state
because when depressed, he is mired in anger and cynicism. A child who does not
have control over his own mood swing is a poor candidate for learning to be
empathetic and emotionally responsive to others. Whether the method be psy-
chotherapy or pharmacology, the target of change must be in alleviating the
primary symptoms first. This may result in an increase in empathy.
A Bipolar eight-year-old may experience some remorse for killing his brother’s
pet frog, but, lost in his aggressive depression, it will not occur to him that he
needs to express his remorse. The twelve-year-old boy who steals his parents’
credit cards and racks up hundreds of dollars’ worth of calls to sexually oriented
1-900 lines may express regret for what he has done, but he will do the same
thing again because his hypomania is calling the shots.
4. Get the right medical intervention in place

Appropriate use of medication for the Bipolar challenge is the first step in healing.
Medication gives the child a sense of refuge from his mood swing and internal
chaos and permits him to develop a sense of self and so know who is ‘me’ and who
is ‘the other.’ Psychotropic medication also treats the impulsivity, and the destruc-
tive behavior that is a core aspect of anempathy. The overall intended impact is to
upregulate the inhibitory ability of the frontal lobes and moderate the wildness of
the limbic system. Physicians will usually begin treatment with the most benign
medication (with the least side-effects) and add other medications as needed.
Here are some typical medication approaches (Wilens 1998):
• Stimulant medication to strengthen the brain’s ability to inhibit the
excitatory response and improve attention and focus may be prescribed.
Stimulants such as dextroamphetamine (b. Dexedrine) or
metaphenyldate (b. Ritalin), which are used to treat ADHD, may also
be useful in treating the more serious brain condition evidenced by
frontal-lobe problems. Careful assessment needs to be made to make
sure that stimulants do not cause the exacerbation of tics, agitation, or
obsessive-compulsive behavior.
• Atypical antidepressants that have the ability to energize focus while
raising brain serotonin levels such as buspirone (b. Wellbutrin) or
venlafaxine (b. Effexor) may strengthen the editor function of the
frontal lobes while decreasing dysinhibition of the limbic brain. As I
have noted elsewhere in this book, there is a caution about the use of
these drugs, which may agitate the child if Bipolar Disorder is present.
• Selective Serotonin Reuptake Inhibitors (SSRIs) such as fluoxotine (b.
Prozac) or setraline (b. Zoloft) may also be in order to raise brain
serotonin levels and thus help the child put a brake on impulsivity.
• Medications which downregulate the body’s use of adrenaline may be
in order. Clonidine (b. Catepres) or quanfacine (b. Tenex) permits the
child to have a more relaxed response to stress and improve his ability
to inhibit his reflex to anger or rage.
• Mood stabilizers in the anticonvulsant class such as carbamazepine (b.
Tegretol), valproate (b. Depakote), or lamotrigine (b. Lamictal) may
also help modulate the limbic brain’s contribution to unregulated wild
and extreme behavior. These are primary medications for early-onset
Bipolar Disorder, and given the fact that anempathetic behavior is
likely to occur, either when a child is hypomanic or is experiencing the
mixed state of aggressive depression, any medication that stabilizes his
mood will give him more control over his dangerous, destructive, risky,
and anempathetic behavior. The novel anticonvulsant topiramate (b.
Topamax) shows promise for relieving many of the flashback
symptoms associated with PTSD (Sherman 1999).
• Lithium carbonate is a powerful mood-stabilizing agent and may be
used in combination with an anticonvulsant. Lithium may be indicated
if a teenager has a clear split between his depressed and hypomanic

states.
• Medication in the antipsychotic class such as olanzapine (b. Zyprexa) or
risperidone (b. Risperdal) may be prescribed. This type of medication
would probably be used only in the most severe cases because of its
impact in lowering brain dopamine, which may cause cognitive
blunting in the child – the half-asleep, ‘backward’ look that some
children get with the antipsychotics. There is also a tiny (3 percent of
cases) chance that the child may develop the permanent disfiguring
facial tics called Tardive Dyskinesia (see p.46), which is a side-effect of
taking antipsychotic medication.
5. Make your expectations clear and reasonable and enforce them

You help your child behave more empathetically by providing clear, short, and
reasonable consequences and by enforcing those consequences consistently. The
child’s frontal lobes may be incapable of hearing or processing messages that are
complex, and lectures about morality go way over her head. To get her attention
you keep things simple. If she steals money from you, you ground her for a day
and require that she pay the money back out of her allowance or that she work it
off. You do not make the mistake of imposing a massive consequence (such as
grounding the kid for a month), because you are probably not able to enforce this
penalty and without enforcement your authority is undermined in your child’s
eyes.
Your child must know that you will not shield her from the community’s
response if she breaks the law and that you will not hesitate to call 911 if she is
violent. Having a neurological disorder is an explanation, but it is not an excuse.
Acceptance of this basic fact may require that the child experience the pain of
isolation from her parents if she breaks the law. Part of your grief process involves
letting go of the urge to defend her whatever she does. It is important for you to
understand that her long-term best interests are served by having to face the con-
sequences of her actions.
6. Assert your moral authority and take control

Many impulsive children and teens have confided to me in counseling that their
parents must be in charge or they will take over and run the family themselves. But
many of these same children do not give their parents what is termed ‘moral
authority’ over their lives. They do not subscribe to the view that there is any
reason to obey their parents or take parental guidance.
Parents must be willing to assert their control even when their anempathetic
child shows contempt, profanity, or deliberate defiance. Assertion of control is
seen in the parents’ willingness to let the teen know that his room is not off limits
to search and that they may search him when he comes in the door if they suspect
he is carrying contraband or drugs. It means that they give up the illusion that
they can continue to parent democratically. They must become firm, fair, and
authoritarian. Some impulsive and anempathetic teens will respect these limits,
others will push back or run away. Whatever happens as a result, the parents really
have no choice in the matter but to require adherence to the controls they put on
the teen’s behavior and to the rules of the family. It may be heart- wrenching to
call the police if a teen gets out of hand and hits his parents, but it is something
that must be done for the sake of the teen and the emotional survival of his parents
and siblings.
7. Trust but verify

Parents of anempathetic children learn quickly that it is sound policy to ‘expect
the best but prepare for the worst.’ This means that you do not let down your
guard. You do not indulge in the illusion that your child can be trusted. You lock
things up. You maintain a shredder to dispose of documents that the child might
use to run up charges on your credit cards. You put a steering-wheel lock on the
car. You watch for tell-tale signs of substance abuse such as a rapid change in
grades or loss of motivation. To monitor the important dimension of school, you
set up a system with your child’s teacher to check for compliance around
homework assignments and to keep you posted on potential problems. You trust
your teenager conditionally. You do not browbeat him or threaten him with loss of
privileges. But you realize that the distorted thinking that drives him may cause
him to lie. If he is not restrained by the forces of his own conscience, you must
provide behavioral restraint with external controls.
8. Make discipline affirm the Golden Rule

Long-term research on the lives of children with Conduct Disorder challenges
related to Bipolar Disorder shows that the ones who turned out to be successful as
adults had a sense of discipline in their teen years. There was someone there who
made them toe the line, as difficult and daunting a task as this may have been. One
severely conduct-disordered 14-year-old flabbergasted his father and me during a
family therapy session with his indignant comment that we were lucky because
we had ‘very strict fathers and the military’ to ‘give us discipline’ when we were
kids. This little rebel was telling us what the research on Bipolar Disorder had
proven: that the fiery impulsivity of the child’s attention difference will burn up
everything around him if it is not contained with a powerful will by the parents
and the community.
There are no cut-and-dried formulas for being a good parental disciplinarian.

Probably the derivation of the word itself gives us the best clue to right action.
The word discipline is related to the word ‘disciple,’ to denote the presence of a
teaching relationship. A good teacher knows how to get his student’s attention
and he knows how to draw out the student’s resourcefulness to develop his own
knowledge.
Once you get the child’s attention, you are in a position to help him under-
stand and take responsibility for what he did. This may be extremely difficult for
children with affective disorders, but it is crucially important. Once the child
accepts responsibility he sees his interconnection with others.
Begin this process by using discipline that affirms the Golden Rule. Conse-
quences for an action should affirm the fact that when the child takes something from
the community he must give something back.
• If he kicks a hole in the wall, he repairs the hole or pays for the repair.
If he doesn’t have enough money to pay for the repair, parents
subsidize the job beforehand but he pays for the job later, personally,
with his money.
• If he steals from someone, he makes personal restitution to them on
their terms.
• If he recklessly damages his own property, he earns money to replace it
or does without it.
• If he destroys something for which monetary payback is not feasible,
he gives back to the community by doing community service.
It may be difficult for parents to stand aside and let the child experience the conse-
quences of his actions. They may instinctively focus on the fact that he is really a
good kid underneath it all. But the child has to learn, as difficult as it is, that the
community will not tolerate violent or illegal behavior. He has to know that crazy
people, tyrants, and thieves do not run the world!
9. Consider a residential school

Though some anempathetic teens may not be impulsive, some need 24-hours-a-
day supervision. The best way for some teens to get through the dangerous years
from 14 to 18 is to attend a residential school. In some cases, school districts may
pay for these placements if it is shown that after-school behavioral issues prevent
progress at school during the day. Parents considering this option and seeking to
get their local school district to pay for it will need to retain an educational
attorney who will advise them how to make their case for a paid residential
placement. Usually it will be important to get a letter of recommendation from the
child’s psychiatrist.
Three basic types of residential schools are: (a) those which use strict, mili-
tary-style control methods; (b) those which may have a strong disciplinary
structure but also see personal emotional growth to be a part of the program; and
(c) those which do not have a strong disciplinary approach and depend on the
attractiveness of the program to keep children in attendance. Two good Internet
sites to learn more about boarding schools are seen at:
www.bridgetounderstanding.com or www.petersonsguide.com
The teen may thrive in the residential environment if she gets psychological coun-
seling, has a healthy peer group, and benefits from a very predictable schedule.
There is little opportunity for wrongdoing and a lot of real-time feedback and
sanction when it occurs.
Impulsivity and anempathy can make a teen a loner. No other kids want to
associate with her because she has a reputation for being a hothead or a loser. In a
residential placement, many impulsive children will find friends with the same
type of problems they have. This is an opportunity to develop awareness of the
challenges that they face and acquire tools to deal with these challenges.
10. The drink drinks the drinker

Use this exercise to build a sense of consequence for risky behavior.
This intervention for helping the anempathetic child construct a sense of con-
science is based on a technique used by Alcoholics Anonymous in which a person
tempted to fall off the wagon is encouraged to deliberately envision the eventual
consequences of taking just one drink.
1. Gain ownership of the problem. Set the stage by discussing a problem
the child is having with impulsive behavior. Relate this to her lack of a
sense of future – it is hard for her to see the future, to plan back and
organize herself, or to see consequences of her present behavior. Ask
her if she would like to experiment with a visualization exercise to help
her deal with the issue, to get better organized, to be less impulsive, etc.
If you get buy-in for this, proceed to the next step.
2. Ask her to close her eyes, breathe down to her abdomen and let an
image come to mind which shows her involved in the impulsive or
dangerous behavior. She does not have to tell you what it is. Have her
place a ‘bar chart’ or ‘download bar’ on the bottom of the image to rate
its attractiveness in terms of stimulus satisfaction; a 1 indicates ‘low
stimulus return’ and a 7 indicates ‘very satisfying.’
3. After a moment, ask her to speed up the image and play it to the point
past the thrill to the cost: when the innate destructiveness of the
behavior becomes apparent. Examples of cost visualization include:
• Drug use might lead to more drug use, depression, rage at home,
failure at school, and jail.
• Driving crazy might lead to ending up in a wheelchair, or death.
• Stealing from her parents might lead to a permanent state of distrust in
her most important relationship.
4. Ask her to imagine a range meter at the bottom of this visualization
which rates the negative effects in her life and the losses she suffers as a
result of the behavior. Use a rating of 1 to indicate that there is very
little loss or negative cost to the action. A rating of 7 indicates a major
cost in terms of damage to her relationships or the potential
involvement of the penal system.
5. When she has a sense of the feeling of this experience, ask her to let it
fade and replace the internal frame with a picture of something positive
that she is looking forward to.
6. Give her a way to remember to act appropriately, an anchor for positive
behavior. Ask her to bring the negative consequence to mind while
asking her to lightly pinch herself on the hand or arm. She can do this
when her intuition tells her that she may be approaching a dangerous
situation, in order to remember what can happen if she gets into
impulsive behavior. Cross-check her reaction by asking her to lightly
pinch herself and see if this brings the image of the negative behavior
to mind.
7. Finish the exercise with an affirmation of her intention to take good
care of herself and those she loves, and that a way to do this is to let
herself react appropriately when she approaches a situation that could
lead to destructive impulsive action. When dealing with teens with
these issues, understatement is key to their acceptance of a new way of
looking at a situation. Don’t ever lecture them (you are talking only to
yourself ), but wait until the misery that they experience opens them to
ask for new ways of behaving.
When violence is not a problem: Two more survival strategies for helping
Asperger’s Syndrome children and Alexithymics develop empathy
Unlike children and teens with Bipolar Disorder, frontal-lobe problems, or
psychosis, the Asperger’s child or the Alexithymic may also demonstrate
anempathy, but he or she will not be violent. Once again, accurate assessment of
the issue is vitally important. Though both Alexithymics and AS children may
demonstrate anempathy, the patterns of these disorders are dramatically different.
Alexithymia is a learning disorder that may exist within the context of a person’s
life that is otherwise marked by success and personal happiness. The Alexithymic
needs help decoding others’ emotional nonverbal messages. The Asperger’s child,
on the other hand, carries profound differences in his ability to adjust to novelty,
to generalize learning from his experience, and to relate to others in the world.
Children with Asperger’s challenges or Alexithymia are no more likely to par-
ticipate in conduct-disordered-type behavior than other children. But their
inflexibility and inability to respond to others can be very isolating and contribute
to their depression. If they are to have friends, they will need help in learning the
basics of reading others’ nonverbals and responding appropriately. The following
two strategies help build their skill for empathetic response:
11. Teach the child to subvocalize empathetic statements

Children with AS and Alexithymia have a difficult time making sense of the
nonverbal behaviors of others because there is an interruption in the way that
their brains receive visual information, compare it with previous experience, code
it into language, and react. The child cannot instantaneously and ‘intuitively’ gen-
eralize the meaning of another person’s nonverbal behavior to understand the
other’s emotional states. Such children cannot put all the details together to come
up with the whole picture. Though they may notice discrete details of the other
person’s face – her mouth is turned down, her eyes are squinting, her face is
turning red – they do not instantaneously generalize to the meaning ‘she’s angry.’
But they do notice the details. Build on this ability to pick out the ‘trees in the
forest’ by helping the child notice nonverbal behavior and memorize what it
means in terms of the other’s emotional expression. Ask the child to memorize a
statement to be used as a cue to what the other is feeling:
• When someone’s face turns red while he is yelling, it means that he is
angry.
• When someone tightens her fists, it also means that she is angry.
• When a person cries, it means that he feels sad and has to let it out in
tears.
Then teach the child to use specific verbalizations in response to the nonverbal
behavior he sees:
• In response to noticing that another child’s face is turning red and she
is clenching her fists, say: ‘You look angry. I’m sorry. I didn’t mean to
make you angry.’
• In response to observing a child crying in the playground after a fall,
say: ‘Can I help you?’
• In response to observing his mother’s voice go way up and her eyes
narrow, say: ‘I don’t mean to bug you, Mom.’
This technique helps the child appear ordinary enough that he is not scolded by
other adults or criticized by potential friends for being unfeeling. It does not
change his personality, or make him more of a social gadfly, but it does help him
overcome his isolation and be more successful. Asperger’s children may have the
most difficulty using this technique because they do not remember the appropri-
ate response in the appropriate situation; so they will need a lot of prompting from
teachers, parents, and other adults with whom they interact on a day-to-day basis.
12. Teach the child to label his feelings from emotional memories
The only experience of sadness that Jeremy, a ten-year-old Alexithymic, could
remember was the death of his dog, Ralph. Ralph’s passing put Jeremy into a
crying funk for a week. His mother helped him come to terms with the loss and
made a special area in Jeremy’s room where he could put things he associated with
Ralph. I helped him develop more empathetic reactions to other kids by first
exploring with him the body sensations he organized around his sadness from
losing Ralph. His feelings of sadness were sensed as tension and tears in his eyes, a
red face he could notice in the mirror, a hot feeling in his chest, and the lump in his
throat which made talk about his feelings difficult. Once he could identify these
sensations and the look of sadness in his own face and body, he had a template for
evaluating the sadness (and anger) in the nonverbal behavior of other people. I
helped him compare what he felt with the physical referents of sadness and anger
he observed in others (crying, yelling, tightened mouth, and looking down). To
complete the loop, I tied in specific empathetic statements that Jeremy could make
when he noticed others’ sadness or anger. This three-step emotional training
process is summarized as follows:
1. Help the child remember an experience of a specific emotion.
2. Help him analyze and identify the sensations and physical nonverbal
behaviors associated with this emotion.
3. Help him compose a scripted response when he sees these nonverbal
behaviors in others.
How to use incidental learning to help an Asperger’s child develop

empathetic response
Asperger’s children do not relate easily to the emotional domain, so when a child
does mention an event that evoked an emotional reaction, parents and therapists
are well advised to pay attention and explore his experience of the event so that
they can help him remember what it feels like. Explore the full range of the child’s
experience and mark off sensory referents that indicated the presence of a particu-
lar emotion.
• If the child shows an emotional response to something he sees on TV,

mark it for future use and talk with him right after the event:
‘Watching Schindler’s List seemed to make you sad and angry, Tony.
What kinds of sensations in your body did you notice as you were
watching it?’
• ‘Jack, you complain a lot when you see an overweight person on the
street. Your face gets red and your eyes squint. Does that mean you are
angry?’
• ‘Steven, I’m pleased you got a good belly laugh out of my joke. I don’t
often see you laugh. What kinds of feelings do you have in your body
when your are amused by something? What kinds of behavior do other
kids show when they’re having a good time?’
Use every opportunity to build the child’s data base of emotions. If he is curious
about what someone’s nonverbal behavior means, don’t give him an answer right
away; say ‘Well, Jeremy, what do you think she is feeling when she cries like that?’
Or ‘What do you think the old man is feeling when he is yelling and crying at the
same time?’ Make this kind of logical analysis part of your normal family life.
Conclusion: Coming to terms with the challenge of parenting

an anempathetic child
It is very important to know what causes your child’s anempathy. If he has
anempathy as a result of frontal-lobe dysfunction, stimulant medication that
increases his focus and inhibits his behavior may be in order. If he becomes
anempathetic in the hypomanic phase of his Bipolar Disorder, a different medica-
tion is indicated. Stabilizing his mood swing is the first order of business. You have
to know what’s causing the problem to come up with the correct solution.
If a child comes from a violent home and demonstrates anempathy as a result
of PTSD, long-term supportive therapy is indicated. If the child is psychotic,
antipsychotic medication, close supervision, and long-term psychotherapeutic
help will be necessary. In complex cases, a variety of different interventions may
be appropriate.
Raising this child with anempathetic challenges is an excruciating experience
for you as his parent because you are caught between managing the child’s
dangerous and destructive behavior at the same time that you are dealing with the
consequences of his behavior in the community. This struggle may be a source of
strength if you are able to let go of the illusion that you are guilty for having a child
with wild, extreme, and destructive behavior and focus your attention on the
process of change, one step at a time.
A child or teen without a built-in sense of conscience and consequence needs
to have adults around him who will provide the structures he needs to participate
in civilized society. His predilection for anempathy will be a continual source of

trouble and grief in your lives, and these troubles will not be over until he is
through his teens and out on his own. Learn to anticipate the trouble, roll with it as
a challenge, and don’t blame yourself for the mistakes you make along the way.
Prepare for the worst and expect the best. Don’t be afraid to get on the phone and
involve all the authorities in your community who deal with kids with this kind of
issue. Know that you can only do so much for your child and your most important
gifts to him will be your love, strength, and honesty. If you provide these qualities
in good measure, you are doing the best that you can. The rest is up to him.
CHAPTER 6
Innovative Non-Pharmacological
Treatment Approaches for
Bipolar Disorder, ADD,
and Depression in Children
Medication may not be a feasible alternative for treating children with wild and
extreme behavior, for several reasons.
Bipolar Disorder In the manic phase of Bipolar Disorder, the child does not
want to dampen his sense of euphoria with medication, and spits out pills given to
him. In the depressed phase, he is angry, hypercritical, and pessimistic about
anything helping him and he pushes back at medication. Other BD children may
see no symptom relief from medication, or side-effects may be intolerable.
Tourette Syndrome Children with TS are notoriously hypersensitive to medica-
tion and may react to anything but the lowest therapeutic dosage. This is probably
an effect of the greatly overcharged systems of these kids on emotional, physical,
and cognitive levels. Medication that increases the brain’s use of dopamine in the
frontal lobes may make it easier for the child to pay attention, but because the
medication also increases dopamine in his base brain, it may give him worse tics or
obsessions.
Asperger’s Syndrome Asperger’s children show intense anxiety and may also
experience the tics which are diagnostic of Tourette. Any medication which
upregulates the brain’s use of dopamine and serotonin may cause AS children to
experience intense agitation. Research on the issue of medication and AS shows
that many of these kids are helped more by naturopathic remedies than by
pharmacologics.
Attention Deficit Disorder Most ADD kids are greatly assisted by stimulant medi-
cation, but if depression is on board this may be made worse by stimulants. And if
there is a question of a comorbid Bipolar Disorder or Tourette Syndrome, medica-
tions in the antidepressant class are counterindicated.
110
INNOVATIVE NON-PHARMACOLOGICAL TREATMENT APPROACHES… / 111
Naturopathic remedies
(With contributions from Walter Crinnion, ND.)
Research on the efficacy of naturopathic remedies for wild and extreme behavior
is not well established but I have seen that the following types of herbal, vitamin
and mineral supplementation can have a significant impact in reducing symptoms. A
good general rule is to check with your physician before using any over-the-
counter supplement.
Dr Walter Crinnion, a naturopathic physician from Kirkland, Washington,
who wrote a chapter on diet and ADD in Survival Strategies for Parenting Your ADD
Child (Lynn 1996), has contributed the following comments (in italics) about each
of these supplements and vitamins. Dr Crinnion may be contacted at
[email protected] (Walter also does a radio show in Seattle on naturo-
pathic medicine).
Brain chemical balancing in droplet form

Dr Crinnion states that ‘Elimination of food allergies is important in the control of
affective disorders.’ He does not use supplements as a primary treatment but does an
overall evaluation of brain chemistry first. He treats his patients with naturopathic
remedies indicated by this screening and uses supplementation if indicated. He
also refers them for craniosacral therapy (see below, page 115), which he has
found to be highly efficacious for treating depression.
Dr Crinnion comments: ‘To treat Bipolar Disorder, I do brain chemical balancing [see
below]. These folks are often “off ” in GABA.’ (Author’s note: GABA, y-aminobutyric
acid, is a neurotransmitter that is found throughout the body and plays an
important role in inhibiting the nervous system.)
Dr Crinnion continues: ‘Irregularities in GABA are seen in persons with an affective
disorder. I will also use a vegetable-based lithium (li-zyme, from Biotics Research) and have
found it efficacious for stabilizing mood without the bad side-effects of pharmaceutical
lithium. There is no detectable blood level toxicity (a potential side-effect of lithium
carbonate).’
Dr Crinnion reports:
Brain chemical balancing is a procedure I use that is an offshoot of Dr Robert Gardener’s
work in alleviating food allergy reactions using minute doses of certain aromatic chemicals
naturally occurring in foods. Dr Abram Ber (MD in homeopathy in Phoenix, Arizona)
began to use this concept with certain neurotransmitter chemicals (acetylcholine, dopamine,
GABA, norepinephrine, serotonin, and others) and found that using ‘neutralizing’ doses of
the brain chemicals that the person tested ‘bad’ on (using electrodermal testing) resulted in
some phenomenal reversal of neurologic problems. Treatment involves prescription of ‘drops’
containing these neurochemicals which the patient takes three times daily for 8 weeks, then
twice daily for 8 weeks, and finally once daily for 8 weeks. I test again at each of the 8-week
intervals to be sure that the reduction in dosage is appropriate. For most persons 6 months is
sufficient time to produce a therapeutic change. I have seen these drops work successfully with
anger outbursts, ADD/ADHD, depression, anxiety, and schizophrenia. Some of my patients
have referred to them as their ‘miracle drops.’
Ten naturopathic supplements that help Attention Different children

deal with extremes in mood, inattention, and other challenges
1. OMEGA-3 FATTY ACIDS

Research has provided evidence that Omega–3 polyunsaturated fatty acids found
in fish, fish oil and flax seed may ameliorate symptoms in Bipolar Disorder,
schizophrenia and other psychiatric disorders. Dr Crinnion’s research has shown
that this supplement may be an excellent mood stabilizer for many people with
rapid-cycling Bipolar Disorder. Daily dosage for research purposes was 6.2 grams
of eicosapentanoic acid (EPA) and 3.4 grams of docosabexaenoic acid (DHA).
Consult your naturopathic or medical doctor before initiating this treatment.
2. VITAMIN B-6 (ADJUNCTED WITH A GOOD MIXED B VITAMIN)

This vitamin is mentioned by researchers and parents alike as important to the
brain’s production of serotonin and should be taken with a good mixed B vitamin.
The mixed B contains niacin, a vitamin which boosts B-6’s tonic effect on
serotonin. B-6 helps stabilize mood swing, dysphoria, and obsessionality. It has
also been shown to help reduce brain seizure incidence. And preliminary reports
show that B-6 may also be useful in reducing Tardive Dyskinesia, the crippling
facial tics associated with use of antipsychotic medication. B-6 is depleted by
stress. For this reason it makes sense to use the vitamin on an ongoing basis to
boost the child’s biochemical stress resistance. B-6, as Dr Crinnion points out
below, does have the potential to create a state of overexcitation in a child, which is
especially problematic for children with problems involving hypomania and
hyperactivity. It is important not to overuse this vitamin.
I strongly recommend a high-potency B complex. B-6 should not be used by itself. If taken
in the evening this vitamin will keep you up. If too much B-6 is taken for a period of 1 or more
years it can cause peripheral neuropathy (too much is defined as 500–2000 mg daily).
Peripheral neuropathy is a disorder of the peripheral nervous system: numbness,
feelings of tingling or needles and pins.
3. VITAMINS E AND C WITH BETA CAROTENE

These vitamins aid short-term memory, a problem for many children with
attention differences, and they are antioxidants: they cleanse the body of ‘free
radicals’ – oxygen molecules which are not absorbed by the body and which block
digestion, metabolism, and amino acid production. The combined effect of these
two vitamins is to act as a tonic for focus and mood control of children with a wide
range of attentional differences. Therapeutic dosage of vitamin E is 200 to 400
mg a day. Vitamin E should be balanced with an increase in the daily dose of
vitamin C, recommended at 250 to 1000 mg of C daily and supplemented with
10 to 30 mg a day of beta carotene. Studies show that a combination of these
vitamins is important for the prevention of overproduction of free radicals, which
can occur if vitamin E is taken on its own.
4. MAGNESIUM, CALCIUM, AND ZINC

These minerals all enhance serotonin production and help people to calm and to
focus. Magnesium is ‘nature’s tranquilizer’ and is found in green vegetables such as
broccoli. Calcium helps the body absorb the magnesium. These vitamins help
Bipolar and ADD children manage ‘the giddies’ – the mild hypomania seen in
their dysinhibited, silly, confrontive behavior – and they help them get to sleep at
night. They also reduce the anxiety that Asperger’s kids experience and so
improve their interpersonal communication ability.
Of these magnesium is the best. It is a natural relaxant to the muscles and nerves. If the
child is constipated and has hard, dry stools (rabbit pellets) then he is certain to be magne-
sium-deficient. Other magnesium deficiency signs are muscle cramps, chocolate cravings, body
odor, and insomnia.
5. MELATONIN
Many parents use melatonin (some cut the 3-mg tab in half ) to help their
Attention Different kids get to sleep. Insomnia may be a medication side-effect or
a natural expression of the child’s cognitive hyperactivity. Give the child the
melatonin (on an empty stomach) an hour before bedtime. Melatonin stimulates
the body’s waking-to-sleeping cycle, making a person more apt to get sleepy
when it gets dark. A small percentage of children and adults report unpleasant
feelings, obsessions, or mild hallucinations just before falling off to sleep after
taking melatonin. Melatonin may also lengthen the time the child is in the deep
sleep stage of sleep. This may cause bedwetting because the child’s arousal switch is
turned to the ‘off ’ position. Watch carefully for these effects, and discontinue use
if you observe them. It is possible that children with early-onset Bipolar Disorder
are more susceptible to melatonin-induced hallucinations, just as they may be
more likely to be adversely affected by the SSRIs. Some children respond well to
as little as 1 mg of it a day. Check with your physician before using melatonin.
Some children do not produce enough melatonin in their systems. If this is the case, they
will definitely have trouble sleeping. I will often do a salivary test for melatonin production.
Otherwise I do a trial of melatonin supplementation. If you take more than your body wants
you will feel drugged or groggy the next day. If this occurs you should reduce your dosage.
Take the amount your body is happy with. Melatonin is also a very potent antioxidant (one of
the most potent).
6. CHOLINE AND CHOLINE INOSITOL

Choline is a derivative of phosphaidyl choline (PC). It is naturally found in soy beans,
liver, oatmeal, cabbage, and cauliflower. It is also a component of the neurotrans-
mitter acetylcholine and so has an impact on neurological conditions such as
Bipolar Disorder which have shown to involve the cholinergic system. Inositol
has been shown to reduce panic and depression in Bipolar Disorder.
Inositol is a B vitamin that performs a function in the body similar to choline of transport-
ing and metabolizing fat and facilitating communication between cells. It is naturally found
in nuts, beans, wheat, wheat bran, cantaloupe, and oranges. It has been shown to be effective in
reducing obsessionality in children with autism, though a fairly high dose is required (1 to 3
grams a day).
For some people with depression or Bipolar Disorder, the dietary supplements
with choline and Inositol alleviate depression as effectively as Prozac. Suggested
dosage is 250 mg of the combined supplement twice a day. If you are considering
using choline and Inositol to treat your child’s affective disorder, check with her
physician.
7. CHROMIUM PICOLINATE
Many children with affective disorders, ADD, and Tourette who show aggressive
depression in their behavior have a chronic sugar-craving. A probable cause for
sugar’s impact on mood is its ability to downregulate serotonin and blood sugar,
especially when consumed in high doses. Just one tablet (200 mg) of chromium
picolinate a day may greatly reduce your child’s craving for refined sugar and the
products that contain it.
8. VEGETABLE-BASED LITHIUM
Biotics Research in Houston, Texas, came up with a unique way to produce mineral supple-
ments some years back. They grow medicinal plants that are then made into tablets. If they
want the tablet to have iron or lithium or another mineral they ‘feed’ the plants water with a
high content of that mineral. The plants incorporate the mineral from their water supply.
Since the tablets are made out of plant material, they are cellulose-based tablets. Cellu-
lose-based tablets are the most absorbable nutrient supplements (according to a study at the
Linus Pauling Institute in Menlo Park, California, done a decade ago).
9. SECRETIN
It has long been thought that the challenges of autism and Asperger’s Syndrome
are related to neurochemical imbalance in the body or to adverse reactions to
certain types of food. Research indicates that secretin, a natural hormone
produced by all mammals, alleviates the most challenging symptoms of autism

including improvement of eye contact, awareness, sociability, speech, and sleep
habits.
While it is not a drug, and it is not harmful, the FDA nevertheless requires that it be sold
only by prescription. Secretin is usually given by slow injection (infusion), but there are other
methods of administration which are being considered.
10. SAM-E (S-ADENOSYLMETHIONINE)

In early clinical trial this supplement has been shown to dramatically reduce
depression without the side-effects of other antidepressant medications. SAM-e
should be used carefully in children with Bipolar Disorder. Research indicates
that about a third of these kids will experience hypomania after taking the supple-
ment. For this reason it is a good idea to have a mood stabilizer in the picture
before taking it. That being said, SAM-e has been shown to have marvelous anti-
depressant effects if a treatment plan involves the use of an antidepressant remedy.
Some researchers believe it may also minimize the pain of fibromyalgia (achiness
in the muscles and soft tissue) that is often comorbid with mood disorders. It is
fast-acting, and may ease depression within a week of taking it. SAM-e is
produced naturally in the body from a substance called adenosine triphosphate, or
ATP, and the amino acid methionine, which is found in protein-rich foods and is
long thought to have properties that affect mood and mental functions. SAM-e’s
major role in the body is to release an essential substance called a ‘methyl group,’
which fuels dozens of biochemical reactions and accounts for SAM-e’s purported
benefits. Though it is a promising and potent supplement, it has not been exten-
sively tested for children. For these reasons, it is a good idea to use it under the
supervision of a medical or naturopathic doctor.
Craniosacral therapy (CST)

Craniosacral therapy is administered by a craniosacral therapist or osteopath who
manipulates the bones of the skull so as to enable the flow of cerebrospinal fluid. It
has been shown to be effective for relieving the symptoms of depression in some
children.
Craniosacral therapy focuses on the craniosacral system, the three layers of
membranes and fluid that surround and protect the brain and spinal cord. This
system extends from the bones of the skull, face, and mouth (cranium) down to the
sacrum, or tailbone. Its purpose is to produce, circulate, and reabsorb
cerebrospinal fluid. During this process, a continuous rise and fall of fluid pressure
in the tissue around the spinal column produces a pulse all its own. By tuning in to
the rhythm of this fluid, CST therapists identify areas of blockage and provide
relief for a wide variety of ailments.
In the CST procedure, the client is fully clothed and lies on a padded table. A
session lasts 45 minutes to an hour. CST may be intensely relaxing as well as ther-
apeutic.
CST is not advised for people who have had a recent stroke, cerebral
aneurysm, brain-stem tumor, head injury, or bleeding within the head.
Electroconvulsive therapy (ECT)

Though ECT ‘shock treatment’ has been portrayed as psychiatric torture in the
popular media, its use continues to be therapeutic for persons suffering from
depression that is not remedied with medication (APA Online 1996). Exactly how
it helps is unknown, but it does induce brain seizures in specific areas that seem to
function as a ‘fire break’ against the development of major depression. And it may
stimulate the growth of brain cells that are destroyed by depression, thus contrib-
uting to long-term healing. Modern ECT procedures no longer involve the elec-
trification of the entire brain, but pinpoint the electrification of specific areas
while the patient is under anesthesia. This stimulus causes a seizure within the
brain which lasts for approximately a minute.
ECT will usually be administered in a hospital by medical staff. In a small per-
centage of the cases, it is accessed by patients on an outpatient status. A course of
treatment with ECT usually consists of six to twelve treatments given three times a
week for a month or less. The patient is given general anesthesia and a muscle
relaxant. When these have taken full effect, the patient’s brain is stimulated, using
electrodes placed at precise locations on her head, with a brief controlled series of
electrical pulses. Because of the muscle relaxants and anesthesia, the patient’s
body does not convulse and she feels no pain. She awakens after five to ten
minutes, much as she would from minor surgery.
Electroconvulsive therapy is generally used with severely depressed patients
when other forms of therapy – such as medication or psychotherapy – have not
been effective, cannot be tolerated, or (in life-threatening cases) will not help the
patient quickly enough. ECT also helps patients who suffer with most forms of
mania, some forms of schizophrenia, and a few other mental and neurological
disorders.
Numerous studies since the 1940s have demonstrated ECT’s effectiveness.
Clinical evidence indicates that for uncomplicated cases of severe major depres-
sion, ECT will produce a substantial improvement in at least 80 percent of
patients.
The most significant risk from ECT is posed by the need to use a general anes-
thetic during the process. In a tiny percentage of cases, people given general anes-
thetics prior to a surgical process experience dangerous cardiovascular irregulari-
ties. Still, the decision to use a general anesthetic must be made in balance against
the danger to the person of unregulated depression.
Immediate side-effects from ECT are rare except for headaches, muscle ache or
soreness, nausea and confusion, usually occurring during the first few hours
following the procedure. Over the course of ECT, it may be more difficult for
patients to remember newly learned information, though this difficulty disap-
pears over the days and weeks following completion of the ECT course. Some
patients also report a partial loss of memory for events that occurred during the
days, weeks, and months preceding ECT. While most of these memories typically
return over a period of days to months following ECT, some patients have
reported longer-lasting problems with recall of such memories.
USE OF ECT WITH CHILDREN

Recent use of electroconvulsive therapy in adolescents has shown that ECT is
highly effective for treating depression in teens when no other therapy or medica-
tion has helped. It is used less with pre-adolescent children, but follow-up studies
show that it has been effective with this group also. Severe Bipolar Disorder or
depression can cripple a child psychologically. Parents are justified in being
cautious about any medical procedure and when a particular procedure has the
kind of impact that ECT does, it is wise to proceed carefully. This being said, this
technology holds great promise for the future and may become one of the treat-
ments of choice for affective illness in the twenty-first century.
Repeated transcranial magnetic stimulation (rTMS)

Repeated transcranial magnetic stimulation of the brain (rTMS) is a new technol-
ogy for the treatment of depression and Bipolar Disorder in which a therapist
places an electromagnet on the scalp of the patient and by rapidly turning it on
and off, stimulates underlying cortical neurons. rTMS delivered to the frontal
lobes of the brain results in the alleviation of depression in some patients and
seems to do so without side-effects. It is less troublesome than ECT in that the
patient is awake and communicating with the therapist during the procedure.
Frequencies in 20-cycles-per-second stimulation create antidepressant effects
in some patients. Many patients who have not responded to antidepressant medi-
cation are helped by rTMS. Though not currently widely available, rTMS is being
researched vigorously at the National Institute of Mental Health.
Conclusion: The importance of a holistic approach to the treatment

of affective illness
In Survival Strategies for Parenting Your ADD Child (Lynn 1996) I discussed how
important parents’ attitude is to effective management of the challenges of
Attention Different children. I have observed that there is a certain philosophy of
life that characterizes the strongest, least stressful, most healthy styles of
parenting. As a statement it is: ‘We accept the challenge of our child’s attention
difference. We will not let it destroy us! And we will leave no stone unturned to
help him heal.’
Typically these parents are willing to try a variety of interventions to help their
child: they know the situation is complex and they are skeptical about ‘one size
fits all’ solutions. They use psychotherapy, medication, stress management, and
alternative therapies to gradually change the field of biochemical and environ-
mental factors that influence their child so as to promote his overall psychoso-
matic healing.
Part Two
Asperger’s Syndrome and

Bipolar Disorder in Teens
Managing inertia, school resistance,
stimulus-craving, and lack of common sense
CHAPTER 7
The Hermit
Asperger’s Syndrome – Helping the Brilliant,
Anxious and Oppositional Child Find
His Way and Express His Gifts
If Asperger’s Syndrome had somehow been stamped out of the human genetic
code, we’d all still be in caves making pleasant social chit-chat.
Temple Grandin (as told by Dr Tony Attwood 1998b)
The archetype: The Hermit

The hermit is a solitary, contemplative character who has been a feature of
cross-cultural myths for tens of thousands of years. He or she is said to have
learned powerful secrets about magic and mysticism from solitary and intense
study. This archetype befits the solitary and sometimes brilliant character of the
child with the diagnosis of Asperger’s Syndrome (AS). This is a child who learns
about something by putting a white-hot focus on it until he knows the subject to
its very core.
THE GIFTS
People who were Asperger’s probably include Albert Einstein, the great Bach
interpreter Glenn Gould, Madame Curie, and many other luminaries in the arts
and sciences. Their contributions are original and fundamentally creative and
come from a penetrating, obsessive attention to a problem within their subject
area.
THE CHALLENGES
The ability of the Asperger’s child to explore the depth of his subject is matched
by his inability to explore its width: he may get so stuck in his specialization that
he cannot generalize learning to other activities. He may have great difficulty
switching from one thing to another. The Asperger’s Hermit predilection for
solitude is matched by his inability to understand the behavior of others. He lacks
a ‘theory of other’s mind,’ which means he lacks the ability to look at the verbal
120
THE HERMIT: ASPERGER’S SYNDROME / 121
and nonverbal expressions of others and guess what they are experiencing. He is a
social ignoramus.
Asperger’s children are not biochemically suited for the rapid change of
attention that is required in human society and in highly dynamic learning envi-
ronments such as the modern classroom. Because they cannot shift focus quickly,
they become extremely anxious, frustrated, and angry.
Richard’s story
Richard was a 15-year-old referred to me by his family physician for treatment of
anxiety and low self-esteem. He came in with his mother Pam and father Howard.
Richard carried a medical diagnosis of Asperger’s Syndrome. I felt fortunate to be
working with him because he did not have symptoms of other disorders seen with
AS, such as depression, Bipolar Disorder, Tourette Syndrome, or obsessionality. In
short, Richard gave me a clear and perfect picture of his temperament as a child
with Asperger’s Syndrome.
The first thing that struck me about him was the difference between the way
he looked and acted and his mother’s statement that he had no friends. He was a
good-looking kid and though his manner of speaking was a bit odd, he could
easily have gotten away with people thinking this was just another version of teen
speak. I have noticed that good looks and popularity generally go together for
teens, but Richard seemed to be an anomaly to this rule.
‘I’m amazed that you don’t have girls falling all over themselves for your phone
number, Richard. What’s the deal?’
‘Girls? No thanks.’ He looked at me like I was just a bit out of line. ‘They just
get in the way of my work.’
Richard’s passion was the martial art of aikido and he was very good at it. He
practiced every evening. But his excellence in this area meant nothing to his PE
teacher, who had a tendency to deliver loud, shaming comments to the kids who
were not good team players. Richard was not a good team player. Just thinking
about PE filled him with dread.
His lack of interest in girls and social events generally was also right on
Asperger’s. Many AS teens simply don’t care about sex and they do not get a sense
of enjoyment out of social events. The ideal social relationship for an AS kid is one
other kid, who is either AS himself or has the ability to bridge from the way most
people see things to the logical and unemotional way that Asperger’s kids relate to
the world.
‘And those pep rallies. I hate those pep rallies. All the yelling just really stresses
me. I mean what’s the point? Gawd! I don’t know what’s worse. Having to go to
the pep rallies or having to go to PE!’
For Richard, social interaction did not seem to deliver the little shot of
endorphin, of pleasure neurotransmitter, that it gives other kids. Participation in a
team was especially painful because of his slowed processing ability. Non-AS
people take it for granted, but human social interaction, including the exchange of
nonverbal cues, happens very fast, and children with AS cannot follow at this
speed. They get left behind in confusion and embarrassment.
Richard’s single-minded enjoyment of aikido and his disdain for PE also fit
the picture. Asperger’s children tend to excel in one thing – this is the area of their
gift. They go very deep in this area. Aikido was Richard’s special interest but PE
was a nightmare of social interactions, bullying, and screaming from his teacher
that left him a wreck.
Did he feel lonely? ‘Yeah’ – he copped to sometimes feeling lonely but he was
resigned that he was so odd that no one could like him.
‘But it’s so much work talking to people. I guess I just prefer to do my own
thing.’ He made another distinction that I first read in Donna Williams’ book
Nobody Nowhere: The Extraordinary Autobiography of an Autistic (Williams 1992). He
said he knew that he was different, living in his own world and that there was
another world out there. But he didn’t know quite how to join it. This comment
cued me to the work that we had to do on Richard’s self-esteem. Being ‘a stranger
in a strange land’ was taking its toll on this kid. As it has for millions of other
Asperger’s children.
The hassles Richard was having in class following the teacher’s lecture, despite
his high intelligence, hinted at the presence of auditory processing issues which are
so common in Asperger’s children they are close to diagnostic (Karen Williams
1995). An ideal learning environment for these children is more visual, with much
more time for the explanation of operations and sequences than is available in
mainstream classrooms.
In a typical mainstream classroom, long verbal strings are delivered by the
teacher and multisequenced tasks are set up to teach the kids everything from dia-
gramming a sentence to completion of an experiment in biology. Richard’s mind
processed too slowly to complete these tasks. He ended up bluffing his way
through class and taking everything home to complete. Usually this meant that he
and his parents had to slug through five hours of homework or more a night.
I could help Richard recover a better sense of himself, but the way it turned
out, I ended up being more of assistance consulting with his parents about their
child’s civil rights (that Richard receive educational services appropriate to his
disability) and by participating in meetings at his school to change things in his
learning environment. It took several meetings, but the school district eventually
placed Richard in a class for gifted teens who had learning styles similar to his
own. The program utilized small class size, was very structured, and had a chal-
lenging curriculum. A lot of attention was given to the reduction of extraneous
stressors. Because children like Richard often have short-term memory problems,
the program took its time teaching concepts and made sure that the kids knew
how to apply them before moving on.
A ‘guiding hand,’ a staff member at school who liked Richard and wanted to
work with him, was appointed. She helped him organize his material daily, sort
out what he didn’t need to take home, and make sure that he got his assignments
home on time. Richard’s homework dropped to less than one hour a night. And
his school agreed to let him do his aikido during PE and get credit for it. He did
not have to participate in the team sports that he dreaded.
Summary of Richard’s Asperger’s Syndrome-related challenges

• He processed information slower than other children, though once he
learned an operation he could repeat it flawlessly.
• He sometimes did not understand information presented to him verbally in
class; he was like a high-performance computer matched up with an
inept programmer (his teacher).
• He had few social skills and very little interest in socializing.
• He had a favorite subject (aikido and the martial arts) that he fixated on
and about which he learned everything he could. He could be a
compelling conversationalist in his subject area. He could not tolerate
small-talk.
• He became highly anxious around a lot of other people.
• He was not a team player but could be a splendid solo performer, i.e. at
aikido. He needed a lot of structure in his social interactions.
Putting Richard in context: An overview of Asperger’s Syndrome

In his 1942 doctoral thesis, Dr Hans Asperger identified a subset of autistic
patients who did not show the cognitive delays or delays in the use of speech seen
in autism but who fit the diagnosis in terms of delays in social development
(Asperger 1944).
In addition, Asperger’s population subset showed another common denomi-
nator, and that was the presence of the ‘special interest’ or obsessive fixation in a
particular topic. These kids also had peculiarities in the way they talked (odd
speech inflexion or pronunciation or monotone), and an odd, uncoordinated
physical gait. These criteria have since been refined by other diagnosticians, who
named the subtype ‘Asperger’s Syndrome.’ Asperger’s Syndrome is the term used in
common parlance and more accurately reflects the fact that Asperger’s is not a
disorder that has been linked definitively to some defect in brain structure. It is
rather, like a syndrome, a constellation of traits that form an identifiable pattern.
The DSM-IV diagnosis contains the following diagnostic criteria:
DSM-IV diagnosis: Asperger’s Disorder (299.80)

Impairment of social interaction (must have at least two of items (a) through (d)):
(a) impairment in the use of nonverbal behaviors such as eye contact, facial
expression, body postures, and gestures
(b) failure to develop peer relationships
(c) lack of spontaneous seeking to share enjoyments and interests
(d) lack of social or emotional reciprocity.
Restricted patterns of behavior (must have at least one of items (e) though (h)):
(e) presence of a special interest that is abnormal in intensity and focus
(f ) inflexible adherence to nonfunctional routines or rituals
(g) stereotypical and repetitive motor mannerisms (hand flapping, finger
twisting)
(h) preoccupation with parts of objects.
These other features must be present:
(i) no clinically significant delays in language – single words used by age
two
(j) no clinically significant delay in cognitive development
(k) criteria not met for another disorder.
Richard’s parents kept their priorities straight

Richard had a special interest in a solo sport, aikido. As is the case for many
Asperger’s children, he chose a special interest that did not require a lot of interac-
tion with others. Many children with the AS diagnosis center their lives around
computers, science fiction, some species of animal, or some type of machinery.
Richard could talk up a storm on his favorite topic, and there was no stopping
him once he got started. He’d pace around the office looking at me intently to
make some point important to him about aikido. He was similar to many other AS
kids and to children with the Bipolar diathesis in his use of this kind of ‘pressured
speech.’
Most Asperger’s children are inherently likable once you accept their oddness.
They are sure of themselves, are skillful at getting the conversation on the track
they want, and are breathtakingly honest. Many seem well compensated for their
lack of social ease with the presence of one or two close friends that share their
special interest.
The most successful parents of children with Asperger’s have their priorities in
order – they accept the child’s lack of interest in social reciprocity, his oddness, and
physical problems, and focus on keeping his spirits up and anxiety at bay so that
his genius can shine through.
Richard’s early life held clues to his Asperger’s temperament

Richard’s parents told me that his behavior as a pre-schooler and elementary
school student had caused them to experience a huge amount of stress. He had
always been very hyperactive, but unlike children with ADHD, he was not helped
much by stimulant medication. And whatever assistance it did give him was
antidoted by social stress; his hyperactivity went up as a function of increases in
the number of other kids in the room. His low response to even high doses of
Ritalin was their first clue that something more than ADHD was on board.
Richard had other problems as a younger child. He had horrible social skills
and really never got out of the ‘playing in parallel’ mode. He could not do any
kind of team sport. He didn’t show much emotion except a kind of wild glee when
he became hyperactive. He would push other kids, or touch them to bug them,
and he wasn’t afraid of anyone. On one occasion his dad had told him to stay away
from the back of the car as he was pulling out of the driveway. Richard did a quar-
ter-turn and then ran behind the car as his father pulled out. Howard was able to
stop in time but he was badly shaken.
Pam and Howard had taken Richard through several different medications in
an attempt to get his inability to attend under control. Since the age of twelve or
so, he had been taking a daily low dose of Dexedrine (10 mg) and Prozac (5 mg)
and this had helped him somewhat. Richard’s powerful intelligence and the
superb parenting he was getting had seen him through to this point. He needed all
of that support to negotiate the tricky water of adolescence. The nature of the ado-
lescent is to bond with other adolescents. Richard inhabited the archetype of the
Hermit and bonding with other kids was not easy for him.
Physicians will sometimes diagnose younger children with these issues with a
condition listed in the DSM-IV as ‘Pervasive Developmental Disorder’ or ‘PDD.’
This is a catch-all phrase that includes pediatric Asperger’s Syndrome and autism
and is used in cases in which symptoms are not serious enough or evident enough
for a full diagnosis but in which the issues of inattention, anxiety, hyperactivity,
and lack of emotional development are prominent.
As is the case in pediatric Bipolar Disorder, the understanding of how
Asperger’s shows up in young children is limited. This picture is changing with
the growth and dissemination of research on the Internet pushed by parent

interest.
Summary of characteristics of Asperger’s Syndrome/Pervasive

Developmental Disorder in younger children
The child demonstrates:
• Very poor social skills, and plays ‘in parallel’ well past the time when
other children are more interactive. She is incapable of team sports
play.
• Inability to read others’ nonverbal cues. He may aggravate other
children and not be responsive to attempts to educate him on more
appropriate social behavior.
• Inability to express complex emotion; his main emotional expressions
are anxiety and anger.
• Extreme hyperactivity and inattention. These issues are somewhat
responsive to stimulant medication but stimulants do not help the child
control her behavior the way they help ADHD children control their
impulsivity.
Mild variations of Asperger’s are common

Many clinicians would not consider Richard to have Asperger’s Syndrome at all.
They would say that he did not show three characteristics that must be present to
include him in the diagnosis: he had good eye contact, he had a sense of humor,
and he had decent conversational skills. Many of my Asperger’s clients are quite
capable in all three areas. Those with more severe auditory processing issues
(understanding what is said to them) are those who have the most difficulty
making eye contact. They cannot look at you and understand what you say at the
same time. This peculiarity is more a learning disability than a characterological
issue, though it is amazing how many counselors think that forcing an Asperger’s
child to make eye contact improves communication with him.
Richard did have an auditory processing deficit, but in the low-stress environ-
ment of my counseling room it did not interfere with our communication or his
ability to make eye contact. In a noisy, crowded classroom, his eye contact would
be very limited, as was his ability to understand much of what the teacher was
saying to him.
And he did have a sense of humor. He enjoyed making jokes and could get a
chuckle out of things, though his jokes did seem to be age-delayed, more the kind
of potty humor that is seen in ten-year-olds.
He was not very interactive in conversation and definitely enjoyed speaking on

his own topic more than listening. But he could follow what was being said to him
and could respond appropriately. His issues went deeper than the inability to
make eye contact, or interact socially.
The description of mild autism that is contained in Dr John Ratey and
Catherine Johnson’s book Shadow Syndromes (Ratey and Johnson 1997, p.254) fit
Richard. As they point out, the fact that a person has a milder version of the
condition does not mean that life is easy for him. In fact, they say, people with less
severe symptoms stand a greater chance of being misunderstood. Very
high-functioning teens with AS know the truth of this assertion.
The four major challenges of Asperger’s children

Richard fit the Asperger’s diagnosis because despite his strengths, his personality
showed four challenges, four powerful core features of the Asperger’s child. He
had:
1. a powerful predisposition for anxiety and stimulus sensitivity
2. auditory processing issues
3. inertia or terror when stressed
4. impaired ability to be practical about things.
1. Asperger’s children have a powerful predisposition for anxiety and stimulus sensitivity.
Anxiety is a dread of something unnamed, a feeling that something bad, which
cannot be identified, is going to happen. Teens with Asperger’s Syndrome experi-
ence anxiety when they are pushed beyond their capability to perform tasks by
adults, and when they are overstimulated or understimulated.
Asperger’s children show powerful preferences and aversions to all kinds of
stimulation. Younger children become hyperenergized and highly anxious when
put around more than a few other people. A vicious cycle occurs as the close
proximity of others shuts down the child’s ability to interact. Parents of AS
children often habituate themselves to solitary activities with their children that
put no demands on the child for social interaction. In one-to-one situations the
child may have no difficulty communicating and can focus on things normally
and effectively.
Many Asperger’s and autistic children will demonstrate peculiar cravings for
stimulation and aversions to other stimuli. Stimulus-seeking behavior includes such
activities as self-delivered low-voltage electrical shock, self-compression (such as
the piling of cushions on oneself or wrapping things around oneself ), cutting
oneself, self-choking, enjoyment of painfully cold or hot water, tasting extremely
sour or spiced foodstuffs, or extreme physical activity. Younger Asperger’s
children may absent-mindedly fondle themselves as an anxiety reaction or a way

to deal with boredom.
Asperger’s children may experience extreme stimulus aversions (exposure to
stimulus prompts screaming or meltdown) to mechanical noise, the noise people
make when they eat, people’s voices, bright lights including sunlight, certain
smells, being touched on their limbs or back, or the feel of certain types of
clothing. Noises that many Asperger’s kids report as near-intolerable include
barking dogs, high-pitched sounds (though some enjoy sound at these decibel
levels), noisy cars, and background electronic noises and telephones.
Many Asperger’s children feel caught between feeling intensely overstimu-
lated and intensely understimulated. This results in them feeling numb inside
much of the time, and they may attempt to relieve this feeling of numbness with
intense self-stimulation including abuse of drugs.
2. The Asperger’s child may have severe auditory processing issues. Richard, as is the case
with very many children with Asperger’s Syndrome, had intensely sensitive
hearing. He had great difficulty separating one noise from another. All sounds
came through too loud so that he felt surrounded by a field of noise and was
unable to pick out and decode communications from his teacher. He could hear
another kid’s pencil scratching on paper thirty feet away and he was deafened by
the sound of the air conditioner in his classroom. Amidst these distractions, his
teacher’s words were not meaningful communications, but just part of the noise.
These features go together to make up what is known as a ‘central auditory pro-
cessing’ (CAP) disability.
One way of understanding the AS child’s attentional problems is to think of
how an automatic light-adjusting camera works. With more light, the photosensi-
tive cell closes the lens louver. With less light, it opens the lens. The Asperger’s
child is typically ‘stuck open’ to stimulation and cannot easily and smoothly open
and close his attentional ‘lens’ when he moves from one situation to another.
Different centers in the brain are involved in processing information and in AS,
these centers do not always function properly or communicate with each other:
• The center that performs the function of seeing does not communicate
with the center specialized for comparing the stimulation to previous
experience and assigning a meaning to it. The Asperger’s child may get
lost or highly anxious going from one class to another. Even though
he’s done this hundreds of times, it is still a new experience for him.
• The center that remembers experience does not communicate with the
center tasked to assigning emotional flavor to it. The child meets a
friend in the hall who is happily excited over some academic triumph
the two have shared, and the Asperger’s child looks at him impassively,
grunts, and continues to walk.
• He has auditory processing problems. Confused by his friend’s

interruption of his focus on his next destination, he does not
understand his teacher who calls out to him as he walks past the
classroom that is supposed to be his destination.
This inability to understand words is signatory of AS. An adult with an
Asperger’s-related auditory processing issue is quoted by Tony Attwood in
Asperger’s Syndrome: ‘I was sometimes able to hear a word or two at the start and
understand it and then the next lot of words sort of merged into one another and I
could not make head or tail of it’ (Attwood 1998a, p.84).
Asperger’s children tend to process stimulation slowly and assign logical but
not emotional meanings to things. These qualities may make them very successful
later in life when they may become luminaries in the sciences. But in school a child
is expected to be on the receiving end of education and process quickly. This is not
the AS child’s cup of tea.
3. The Asperger’s child may have a powerful predisposition to inertia when stressed. Richard
had a very difficult time telling his teachers what he needed and he tended to be
passive in the face of their criticism or (as in the case of the PE teacher) denuncia-
tion. This tendency for inertia is a characteristic that is seen across the board in AS
kids; they have a difficult time taking the initiative in any human activity. They are
rarely the first to initiate a social contact or task and need to see someone else
doing it first.
Inertia may occur in the performance of ordinary tasks. One of my teenage AS
clients has a great enjoyment of cooking, but he has difficulty maintaining the
sense of flow and sequences required to put together a recipe and often totally
‘spaces out.’ At these times, he told me, his body will slow almost to stopping and
he will stare at the recipe as if he is waiting for it to somehow come to him. I have
alerted his parents to this predilection for loss of focus and inertia, and now they
help him keep on track by touching him firmly while suggesting the next step.
One Asperger’s boy I worked with was badly beaten up by several teenage
muggers at a bus stop at night because, though he was proficient in karate, he was
not able to initiate the attack and carry it through in a setting different from where
he was trained. ‘Go ahead. You initiate,’ he said to one of his muggers, who
proceeded to beat the stuffing out of him. It did not occur to him that the only
way he could prevail in the situation was to close in and attack aggressively, once it
was clear that he was gravely threatened.
This lack of ability to initialize activity probably relates to the fact that
Asperger’s kids may be deeply apraxic when it comes to affective, cognitive, and
behavioral tasks. That is, they do not automatically visualize how movements will
look, what conversation with others might sound like, or generally what will
happen in the future. If you have no way of seeing the potential future, you have
no way to calibrate present action and so you do nothing. Non-AS people contin-
ually feed themselves flashes of images of the next movement a split second before
the movement happens. Without this feed, the Asperger’s child is profoundly
slowed in movement to the point of oftentimes not moving at all.
This predilection for inertia is not a sentence of permanent institutionalization
for the child but is an indication that his learning curve is different from most
children. For example, Asperger’s children may become fine athletes, but they
usually have to be shown every move that is possible on the playing field and have
to physically rehearse every move. To learn how to play baseball, for example, the
child has to be taken physically through each position on the field and be coached
through the movements of the player of that position in much the way you would
coach someone who is learning a dance. Once the child learns the feel of a
movement, he may become splendid at its enactment, but the training process can
take a long time.
4. The Asperger’s child has an impaired ability to learn from his experience: he is low on
common sense. Learning is a process of focusing on something, taking it in, assimi-
lating it (putting it in long-term memory) and then shifting to the next focal
object. Rapid shifts in focus are necessary if learning is to be efficient. The
Asperger’s child has a difficult time making these shifts and so has a difficult time
learning from his experience at home and in school. This leaves him short of
common sense, which is a term used to describe the practical wisdom people use
to guide their everyday lives. He is the proverbial ‘absent-minded professor’; pow-
erfully knowledgeable about some esoteric subject but woefully short on practical
know-how.
Whereas a neurotypical child will know better than to walk past a group of
bullies who hang out in a certain part of the playground, the Asperger’s boy will
blithely walk into their midst. And the child may be a target of other children who
take advantage of his gullibility to talk him into perpetrating mischief while they
make a getaway. Lacking common sense, the Asperger’s child will not display suf-
ficient guile to get away with the mischief and will be easily caught.
Lack of pragmatics also impairs the child’s ability to be successful in ordinary
social situations. One bright Asperger’s boy told me that people call him impolite
because he cannot do more than one thing at a time. He could only greet the first
person in the door for his birthday party, and ignored the four or five other kids
who followed. This behavior is called ‘social apraxia’ – the inability to plan social
behavior. Most people put social niceties on baseline – automatic reaction – but
the Asperger’s child cannot divide his focus this way and will become disoriented
if required to do so.
The child will also show a lack of pragmatics in his understanding of language.
He does not understand figures of speech and may detest their use. ‘What do you
mean “You’re tied up and can’t talk?”’ or ‘What do you mean when you say you
have a hunch? Show it to me.’ Or yelling indignantly, ‘I did not go ballistic. I did
not turn into a bullet!’ (now showing real distress, holding his head) ‘I have to
know what you meant by that remark!’ The child needs help understanding the
complexity of speech if he is to be successful.
Asperger’s challenges may result in the terrified frenzy of meltdown

As a result of the four challenges described above, many children with Asperger’s
Syndrome experience extreme frustration and a resultant explosive reaction that
author Ross Greene terms ‘meltdown’ in his book The Explosive Child (Greene
1998). I introduced the term in Chapter 3 and pointed out eight essential differ-
ences between the meltdown phenomenon which is seen in Asperger’s, ADHD,
Obsessive Compulsive Disorder (OCD), and the rage seen in BD and would refer
the reader to that discussion.
Greene describes the meltdown as an emotional reaction of the extremely
oppositional, easily frustrated child who reacts to frustration by devolving into
terrified, oppositional frenzy. Lacking the skill to solve his problems or express
them, the child’s frustration explodes out of him in the meltdown.
Meltdowns usually occur if an adult tries to gain compliance with a demand –
such as ‘Do your homework’ – or the child is denied something that he perceives
to be essential to his well-being – such as the adult’s compliance with an obses-
sional dinner-time ritual to place the silverware in a certain way. The child’s
internal experience of the meltdown is ‘I’m totally out of control and terrified by
the chaos I am experiencing.’ The meltdown is different from rage which is caused
by Bipolar depression in that it expresses the flight aspect of the fight-or-flight
stress reaction.
Meltdown may be kicked off by the parent’s displeasure at the child who, in an
attempt to get the parent’s attention, makes aggravating noises, acts silly or
obnoxious. Extremely poor social skills and inability to read nonverbal cues from
another go hand in hand with the hypersensitivity to all stimulation that is seen in
children with anxiety issues and Asperger’s Syndrome. As the meltdown begins,
the child’s personality seems to regress to a much earlier age. He may knock over
furniture or break things in his frantic rush to escape the powerful feelings that he
experiences. He may attack himself, hitting, biting, or scolding himself out loud.
Or he may run from the scene in a panic.
In Asperger’s Syndrome, the meltdown may also be related to undiagnosed
obsessionality. The child explodes when his obsessional thought loops are inter-
rupted. Obsessional thoughts originate in primitive areas of the brain concerned
with self-protection. The obsessional thought pushes the performance of a com-
pulsion by saying ‘Do this in order to stay safe.’ Children with obsessions experi-
ence interruption as excruciating, for they must go back to the beginning of the
obsessive loop and start all over again.
The language-processing issues of the Asperger’s child or the anxious ADD

child make meltdown worse. She cannot understand what others are saying and
so is unable to cooperate with them even to help herself.
In some children the meltdown and rage related to Bipolar Disorder may exist
side by side, and one type of rage can provoke the other. A Bipolar child, for
example, may be interrupted in the performance of her hand-washing compul-
sion by her mother. The child’s anxiety is elevated by her mother’s prohibition.
She reacts to the mother’s actions by ‘catching’ this reaction herself (see my book
Survival Strategies for Parenting Your ADD Child (Lynn 1996) for in-depth discussion
of how Attention Different children ‘catch’ the emotional states of their parents)
and begins escalating into rage. Now her affect has a quality of attack to it.
Flight turns to fight as the Bipolar Disorder-related rage emerges. No longer is
she screaming at her mother to ‘Shut up!’ about her obsessionality. Now she goes
on the attack and begins throwing things, pursuing her mother and trying to hit
her, or breaks precious things in the house.
Seven survival strategies for managing meltdown

In most cases of meltdown, skilled management of the issue by adult caregivers
can lead to the reduction or elimination of the issue. Here are seven ways to shape
the context of the child’s life and your reaction to him that will make him more
resourceful in dealing with his frustrations and less vulnerable to meltdown.
1. Build the relationship to decrease meltdown

In Survival Strategies for Parenting Your ADD Child, I advanced the idea that
oppositionality in a child expresses his feeling that he lacks control of his own life
(Lynn 1996). The child’s inner experience of being out of control pushes the
strong ‘No!’ he shouts at an adult who demands something from him. At least this
much he can control. Meltdown may be seen as an extreme expression of this kind
of self-protective pushback in which a child goes so far into the reaction that he
loses control temporarily. This reaction is often seen in children with Asperger’s-
related challenges and in children with other neuropsychological conditions.
In Survival Strategies, I suggested that the way out of this dilemma is for parents
to avoid taking the child’s resistance head-on. Instead, deliberately build the rela-
tionship with the child to provide the context for him to say ‘Yes!’
Research cited by Dr Gabor Mate, a Vancouver physician and author of the
book Scattered Minds, suggests that building the relationship with the child may
result not only in an improvement in his ability to control himself, but it also may
result in actual brain growth which contributes to greater social intelligence and
awareness (Mate 1999). The confusing thing for many parents is that they have
always tried to have a good relationship with their child. They do not realize that
the child’s brain is delayed in its ability to allow him to be emotionally autono-
mous and that there is a need for him to keep attached to them through his
emotional ‘umbilical cord’ so as to develop parts of his brain required for
autonomy.
Paradoxically, the child may be extremely angry at his parents because he is so
dependent on them. The solution is for parents to have the patience and the
firmness to keep nurturing him while they are teaching him to be more independ-
ent and responsible.
The child with AS-related challenges is good at aggravating his parents to the
point that the adults devolve into screaming out orders or threatening the child’s
well-being. It may be difficult for parents to relate to their child’s suffering when
he confronts them angrily at every turn. But this appears to be the surest way to
begin turning around the chronic oppositionality that leads to meltdown.
Though the child’s anxiety may bring great trouble, crisis, and uproar to his
family, the family’s sense of connection and love must remain intact if the child is
to get through and grow to adulthood. What builds the relationship increases the
child’s sense of self-confidence, decreases his anxiety, and militates against
meltdown.
2. Evaluate the causes for the meltdown

Use the checklist in Chapter 3 to analyze the causes of the meltdown. It is very
important to know if the meltdown expresses Bipolar Disorder, depression,
anxiety, frustration or all of these feelings. If you are dealing with Bipolar
Disorder the first order of business is containment of rage and personal safety; the
second is mood stabilization. If meltdown is the issue, the reduction of stress, the
introduction of negotiation, and appropriate medication to treat anxiety and
improve attention and mood may be in order.
3. Get on the issue early

If you see a look of distress on his face, see him attempting to hide or avoid stimu-
lation, or notice the emergence of whining or ‘silly talk,’ he may be signaling that
he is getting anxious and overstressed. This is not the time to put any demand on
him. Help him get through stressful events and do not ignore his nonverbal cues
of stress and overload. Talk to him about the changes he will be going through in
terms of what you will be doing. Give him time and give him a mental picture so
that he can gradually adjust:
I’m setting the timer now. When it goes off, put your shoes on. Then I’ll check in
with you for next steps.
After you finish watching your program on TV, sit down and do some homework.
I will help you with it and give you a five-minute warning to help you prepare.
4. Ask yourself what is the best thing to do to reduce his anxiety, and do that thing
If he is frustrated at not being able to complete a task, try to gently redirect him to
something else for a few moments. If he is carrying stress from a hard day at
school, give him the chance to decompress. One Asperger’s boy told me that he
needed time to cry and scream for a few minutes when he came home after school,
because the experience of holding himself together in the highly stimulating
school environment built up pressure for discharge. His parents helped him by
giving him private space and time to discharge this energy without scolding him.
5. Use ‘I statements’ that invoke positive outcomes

Children with Asperger’s Syndrome and anxiety issues are reflexively
oppositional. Make a ‘big tree’ out of this tendency and go around it by painting a
picture with positive language of where you want them to go. They will get stuck
on anything negative and give you a run for your money! For example, do not say
‘Stop yelling at me this minute!’ but say ‘I’ll start again when the yelling stops and
I know that you can hear me.’ Or (using a language prompt to overcome
short-term memory problems) ‘When you can show me you are ready by looking
at me without swearing, we can continue.’
6. Know that the anxious child is visually and auditorily cued to your behavior
If you are upset, the child will be upset. If you are calm, she is calm. It is important
to choose the images and sounds you put in front of her, as she may not ‘edit’ her
behavior but will follow what is put before her. If you are not calm yourself, expect
that your child will be just as uptight as you.
7. Teach him to verbalize his anxiety

A violent behavior such as throwing over a desk or attacking an adult may be a
substitute for the inability to verbalize frustration. Encourage verbalization and
teach the child to use a shorthand if he has problems putting out his anger
verbally. Agree on a range that expresses his sense of angry tension, in which 1 is a
state of calm, and 7 is equivalent to totally losing control. Ask the child where he
is on the range. When you get a number higher than 3 consult with him to
discover ways to make things a little better – to move his internal state to a 2.
Consider the fact that anxiety is often caused by things that have happened to him
that you are not aware of. The explosion in math class may have been caused by
the humiliation he suffered in PE two hours before. Work with him to draw out
these stressors and get him to talk about them.
Nine survival strategies for managing inertia, anxiety,

auditory processing problems and lack of pragmatics
1. Four ways to help him overcome inertia
Inertia may prevent the AS child from being able to get out the door to school,
take care of practical business such as getting his driver’s license, work at a job, or
participate in social activities.
Getting ready to go to the State Licensing Office to take his driver’s test, he
‘freezes up’ in a position of head cocked to the side, staring straight ahead. He
cries or yells if this near-catatonic posture is interrupted. Or, at school, when he
has to make social contact with other kids sitting at a table in the lunch room, he
freezes up. He is stuck in the corner and has to be gently guided out by a teacher.
Feeling totally overwhelmed at his job at the local McDonald’s, he ends up staring
straight ahead and cannot remember what he’s supposed to do next. When his
supervisor addresses him he grunts out a reply but does not return to his work.
He does not know why he cannot accomplish things in his life and will seem
bewildered when you ask him about it. Because of his learning differences every-
thing in his life is frustrating to him and he is getting nothing but failure experi-
ence. Anxiety results and he reacts with inertia and defiance. Here are four general
principles that you can apply to help him overcome inertia:
(a) Consult with him Find ways to reduce the stress that he experiences. Talk to him
about what is going on at school or on the job. Asperger’s children tend to be very
proud. If they cannot follow along in a class (because of the wrong teaching
methods), they may attempt to resolve the issue by refusing to get on the bus in the
morning. It’s easier to say ‘Hell no I won’t go’ than to say ‘I feel stupid not being
able to do the work. Help me!’ If they cannot keep up the pace in a job that
requires tight teamwork, they are apt to throw down their apron and leave in a fit
of anger and frustration.
(b) Lead from behind To reduce inertia you have to get in the habit of following
behind the child somewhat. You go at his speed. If he stops, you stop and get into a
consulting role with him. ‘Jeremy, you’re doing great work getting out the door.
You looking for something right now?’ Curb your own anger, take a breath, and
bridge to his issue. Give him the time that he needs.
(c) Help him calm by pacing his breathing If he freezes up and can’t get out the door to
take the bus over to his friend’s house for a birthday party, ask him what you can
do to help. If he does not answer, assume that he is experiencing anxiety, and that
though he seems serene and very still on the outside, his mind is racing at
break-neck speed on the inside. Just sit next to him calmly and let your relaxed
pace of breathing relax his. Tell him whatever you think he needs to hear to be
more relaxed, and then get back to helping him get to the next step when he is in a
better position to hear.
(d) Teach him binary decision-making One of the most powerful causes for inertia is
the feeling of the Asperger’s child that some task is so vast and complex that he
can’t possibly accomplish it. To overcome this barrier, teach him how to factor any
problem into two decisions. He makes one of those decisions, and then factors the
next part of the issue into two more decisions, and makes one of these decisions
until the job is done.
To help him clean up his room, have him first make two piles. One pile is for things
that stay. One pile is for throwaways. When he’s down to the pile for things that
stay, divide it into one pile for clothes and one pile for electronic parts. When this
is done, take each pile in turn. In the electronic parts pile, put all parts that pertain
to current projects on one shelf and all parts from past projects on another, and so
forth. Then have him put clean clothes in one pile, and dirty clothes in another.
He needs a very concrete way to work from the whole to the parts. It’s easier to
get going on things if he deliberately uses the ‘yes/no,’ ‘zero/one’ language of
binary code to break the problem into manageable chunks.
2. Teach him to write a script to give himself confidence

The script-writing intervention I describe here is based on the work of Carol Gray,
originator of the ‘social stories’ method (Gray and Stacy 1994). Her method
builds on the strengths of Asperger’s children – to remember things as ‘whole
pictures’ or ‘complete Gestalts.’ A script is a set of behavioral instructions that the
child memorizes to guide him through difficult social situations. It helps
overcome short-term memory problems and so get past the anxiety that may
freeze him up.
To write a script for overcoming inertia, first define the situation that is prob-
lematic and do it from the first person as if told by the Asperger’s child himself.
Describe the facts of the situation and put in a sentence or two that expresses the
child’s intention to do something different, such as taking the initiative to ask a
question in class:
Sometimes I need to ask my teacher for help. There are lots of other kids in the
class and when someone wants to ask for help he goes up to the teacher and talks
to her. I will go up to the teacher’s desk and stand where she has told me to stand
to show her that I need help.
Note that most of the sentences in the script are descriptive, with only the last one
being normative or behavioral – ‘I will go up to the teacher’s desk…’ This feature
is important because what the child needs most is the rehearsal of the context –
the details of the situation – so that he can orient himself and take action. He will
forget what to do if he becomes overloaded with requirements.
Type this script out on the computer and print out a copy for the child in large
letters. Affix this copy to the inside of his daily organizer or three-ring binder for
his ready reference throughout the day. Cue his teacher to help him use the aid
enough times that it becomes second nature.
Many Asperger’s teens will accept the suggestion that they use this kind of
visual representation of a situation because, even though it may seem juvenile to
non-AS kids, the AS child knows that he needs the help to navigate through social
situations that may baffle him.
3. Teach him to visualize himself behaving assertively to help him deal with rigid
social behavior
Many Asperger’s children get stuck in feuds with other kids because their internal
picture of the situation shows them less powerful than the other child or bullied
by him. To enable the Asperger’s child to behave more assertively, teach him the
following visualization:
(a) Ask him to imagine himself with the other child. If he sees himself as
markedly smaller, ask him to imagine himself as the same size as the
other. If he sees himself looking down, away, or not moving while the
other moves, ask him to imagine himself facing the other and moving
in an animated way.
(b) After he has changed his internal visualization of the event, ask him if
he feels any differently about the situation. Most likely he will tell you
that he feels more confident about dealing with it.
(c) Ask him to imagine that he is interacting with the other child
surrounded by this new feeling of confidence. With this thought in
mind, work with him to develop a more resourceful, assertive,
conversational strategy for dealing with the situation.
(d) Finish by asking him to keep this image in mind while breathing down
to his diaphragm. Practice the breathing behavioral anchor a couple of
times. The deliberate, slow breath down to the gut should bring with it
the feeling of dealing confidently with his social hassle.
4. Make things easier on yourself with good planning

It is an understatement to say that it is difficult for an Asperger’s child to negotiate
transitions. Because he does not hold a picture of the future, he may get highly
anxious when expected to move from one place to another or one task to another.
Any novel demand may upset him greatly. He may yell, swear, moan, groan, and
cry. Good planning makes management of these transitions much easier.
If he has to get to school early for his field trip tomorrow, make sure that all
logistics are taken care of tonight. Have his clothes laid out, his pills, vitamins and
breakfast ready. Make sure that your own morning routine is planned, so that you
can devote your full attention to him. If your stress is handled, it will be much
easier for you to handle his.
5. Help him to take ownership of the problem by listening to his complaint and
using logical solutions
If he is in denial of the problem or experiencing agitation, you will not be able to
change his attitude by disciplining him or haranguing him. He will open up and
accept his part only after you have listened to his aggravation. Richard had been
complaining to me about his mother’s anger at him for the long showers that he
would take. When he showered, it seemed he couldn’t stop until all the hot water
was gone. This was either a mild obsession or showed his inability to keep track of
time in the shower, which was a highly stimulating experience for him. Whatever
the reason, Richard’s inability to know how long he was showering showed a sig-
nificant lack of common sense.
‘She bitches at me for no reason. My showers go for maybe ten minutes at the
most. What is she talking about?’ He was genuinely confused.
‘Do your showers tend to get cold after a while?’ I asked him.
‘Yeah. Every time. My parents need to get a bigger water heater.’ I suppressed a
chuckle. He was absolutely serious.
‘Oh, it’s a little one, too small for the house or something?’ I said.
‘No, it holds a hundred gallons,’ he replied.
‘OK. Do an experiment for me,’ I said. ‘Maybe this will prove your mom
wrong. Take a clock in there with you and measure the amount of time it takes to
go from hot to cold, OK?’
‘Sure.’ Richard seemed pleased to have a way to deal with his mother’s aggra-
vating behavior.
(When he came in the next time:)
‘So how did your experiment turn out?’ I asked him.
‘Well, maybe I was going on a little too long. It took about thirty-five minutes
to run out of hot water.’ He paused thoughtfully for a moment. ‘I guess I just kind
of space out in there, you know.’
6. To teach anything to an AS child, give concrete visual examples

A common denominator of teachers who are successful with autistic and
Asperger’s kids is that they use a lot of concrete, visual examples to illustrate their
lesson plans. They build carefully on what the child knows already with very
specific examples:
• To teach about the relationship between speed, distance, and time, talk
about how long it takes for the child to ride the school bus to school.
• To teach about politics, talk about the pecking order in the classroom.
• To teach math, build on known facts (if 4 + 6 = 10, then 4 + 7 = 11).
• Check frequently to make sure that the student understands the
material. Asperger’s children often will not ask for help.
• To teach spelling, ask the child to visualize the word and the thing it
describes at the same time – with the word running across the front of
the image. After giving him the correct spelling of the word, practice it
with him. (Some AS children are such excellent internal visualizers that
they can spell words backwards and do the alphabet backward from an
early age.)
• Monitor progress frequently. The best teachers test frequently for
concept retention and involve AS kids in frequent completion of tests
that give them continual feedback on their progress. This helps the
Asperger’s child overcome the difficulty he experiences remembering
what he has learned so that he can apply this learning to current
problems.
7. Help the AS child plan a stimulus-positive environment

Most Asperger’s children are eager to describe the kinds of stimulation that drive
them around the bend or that give them peace of mind. The first step in helping a
child deal with anxiety is to inventory his reactions to stimuli and get his idea of
how to set up a good environment at home and school. Educational research
shows that a child learns best and is least symptomatic when he is in the middle
zone of relaxed focus between understimulation and overstimulation. Ask him to
complete the following exercise, and then work with him to come up with
creative ways to put more or less of the stimulation he desires into his environ-
ment.
STIMULATION EXERCISE
Instructions: write a sentence or two in response to each of these points. You don’t
have to do them all at once.
(a) I hate these noises:
(b) I like these noises:
(c) I like this kind of touch:
(d) I hate this kind of touch:

(e) The best light for me is:
(f ) Smells that I like are:
(g) Smells that I dislike are:
(h) I like to look at:
(i) I hate to look at:
(j) My favorite teacher is:
(k) What he/she does that I like is:
Use the child’s responses to these points to get a better idea of what his particular
optimum stimulation conditions are. No two Asperger’s kids are alike, so it is
important to custom-tailor his school and home environments so that he can
function with minimum anxiety and maximum success.
8. Provide opportunities for the right kind of physical stimulation

(a) Legitimize the child’s sensory cravings and aversions. Children with
autism and Asperger’s Syndrome may experience shame as a result of
their unconventional orientations to stimulation. Let them know that
these effects are related to ‘being Asperger’s,’ that many other kids share
them, and that satisfying these needs should be part of the child’s
fitness program just as a regular aerobic work-out might be part of his
program. Use a consultancy approach to explore what he is
experiencing, and encourage him to talk about the things that he
considers the most weird. Then help him devise ways to experience this
kind of stimulation safely.
(b) Nurture the polar bear in him! Encourage him to take a cold shower or
accompany him to the local swimming hole to take a quick dip from
time to time, even in winter. Or, if he would like to work on
discriminating hot and cold, provide three bowls of water for him to
experiment with: one contains hot water, one contains cold, and one is
lukewarm. Suggest that he simply move his hands from one bowl to the
other and study the sensations that he experiences.
(c) Get him involved in sensory-integration training. In this kind of
therapy the child is exposed to many different types of sensory
environments involving pressure (pillow pressure is used), and the
ability to discriminate sensations is developed. This kind of training has
been shown to improve the whole range of functioning of Asperger’s

children, including their cognitive and social function.
(d) Give him a head rub. The depression and irritability that Asperger’s
children experience may be relieved by a gentle head rub delivered all
around the scalp with special attention paid to the base of the skull.
Research drawn from the field of craniosacral therapy (CRT), noted in
Chapter 6, shows that massage of the skull at the point where the basal
and occipital bones meet (behind and below the ear) may relieve
depression. Sometimes it just takes a little bit of good feeling to tip up a
kid’s mood and give him the courage to get out the door.
9. Make your AS child’s school environment appropriate to his learning style

Under US law, every child is entitled to a ‘free and appropriate education.’ Getting
your local school district to deliver this guarantee to your Asperger’s child may
require you to take legal action to bring the district into compliance. The changes
listed here may be resisted by your district, but they are essential to your child’s
success. See Chapter 15, ‘Managing School Caused Stress,’ of Survival Strategies for
Parenting Your ADD Child for more specific information on how to structure your
encounter with the district so as to ensure your child gets due process (Lynn
1996). Below are ten common denominators of educational settings that work for
Asperger’s children. The list is compiled, partly, from the research and writing of
Karen Williams, a specialist in the education of Asperger’s children (Williams
1995).
TEN KEY ELEMENTS OF AN ASPERGER’S-FRIENDLY EDUCATIONAL PROGRAM
1. The learning environment is highly structured; students know exactly

what they are expected to do at any particular time and they know how
to identify when a task is completed.
2. A ‘guiding hand,’ a staff member the child trusts, is identified. The
child checks in with this person first thing in the morning, to get her
daily schedule, and last thing in the afternoon, to sort out homework
and discard unneeded paperwork.
3. The child’s program is based on learning methods tailored to her
particular learning disabilities as identified in appropriate educational
tests.
4. Teaching materials are visual and auditory. Pictures are used to illustrate
all topics. The teacher draws on the board as she speaks.
5. Extensive use is made of computers in the classroom and the child has
one assigned for her personal use.
6. A lot of practical examples are used to illustrate concepts.
7. Teachers are skilled at using the concrete language of the AS child.
They avoid figures of speech and other abstract language.
8. Social behaviors are learned using storytelling techniques.
9. The child is taught a charting system for monitoring her progress.
10. Homework assignments are light and used only to review material, not
to teach concepts that she did not learn during the school day.
Parents who get appropriate services for their children know about the relevant
parts of the law and they know their child’s learning needs. They work with the
parents of other Asperger’s and autistic children to make sure that the educational
system provides appropriate services.
Conclusion: The four habits of highly successful Asperger’s families

The success of Asperger’s children is jeopardized by the rushed pace of our culture
which conflicts with the child’s ‘go deep, go slow’ learning style. The Asperger’s
child has a difficult time meeting the rapid-fire demands for greater personal ‘pro-
ductivity’ that are put on everyone in modern life. He runs the risk of being
labeled ‘oppositional defiant’ because of his inability to move around and make
decisions as quickly as others. But there is nothing pathologic or abnormal about
the AS style. It is easier to see social pathology in the frantic pace of modern life.
There will never be a medicine invented that can ‘cure’ Asperger’s because it is
not a disease, but a style of being in the world, of communicating, and of making
meaning of things. Medication does help the AS child manage the anxiety that he
experiences, but success in the long run requires that parents have a certain
attitude, a reflexive way of dealing with the stress that can be encapsulated as the
following four habits:
Habit 1: The parents accept their AS child as he is

The parents of happy, successful Asperger’s children see their kids as rare,
hothouse flowers who need a lot of extra care to bloom. These parents love his
character and willingly provide the extra support he needs. They accept the fact
that he may live at home longer than is the case for non-AS children. They provide
the right balance of risk, encouragement and security. They watch with loving
eyes for the emergence of his special gift and they help him get this gift into the
world.
Habit 2: The parents are successful advocates for their child at school
The most successful parents ensure their child’s success in school by making sure
that the ‘system’ is doing its part. Schools must not be allowed to slide past their
responsibilities by tasking the parents to do the teaching through homework.
Schools are bureaucracies. Nobody at school is paid to educate the child. Staff are
paid to move large groups of students from one class to the next, from one year to
the next. The AS child will fall between the cracks if parents do not monitor the
situation carefully and consistently to make sure he is actually being taught.
Habit 3: They parent their child as part of a community

Parenting a child with AS tends to isolate the couple. The child takes up all their
time and the judgments of former friends, parents of normal children, create social
distance. Asperger’s children need to feel part of a larger community; they need a
lot of role models. Because they tend to be visual learners and poor future pacers,
they need walking, talking ‘blueprints’ for living in the community.
Being so different is hard on the AS child and he may feel like he is from
another planet. He needs the affirmation and constructive criticism of older
mentors. He needs to have adults with whom he can share his fears, feelings,
thoughts, and theories and be heard with respect. This kind of attention is
extremely important in positive outcomes for the AS child.
Here are some specific ways to bring adult role models into his life:
(a) Consider joining a local Asperger’s support group (see the Appendix for
referral through the Learning Disabilities Association).
(b) Get your child into the martial arts. Many AS kids thrive in the highly
structured training environments of karate, aikido, or kendo (Japanese
sword-fighting). It takes them longer to learn the moves, but once they
do they are spectacular!
(c) Sign him up for an Outward Bound-type experience or get him into a
summer camp for kids with Special Needs.
(d) If he is old enough, get him an internship in some retail establishment
that carries products in his special interests such as computers. He may
do best in a technical capacity in which he does not have a lot of
customer contact.
(e) Hook into your local Big Brothers or Big Sisters programs. The strong
friendships and mentorships available from these organizations may be
as important as good psychotherapeutic and medical support for the
child.
Habit 4: The parents build his psychological muscularity

Asperger’s children have a powerful tendency to pull back into themselves into
the ‘inner world’ of their own experience and to avoid the ‘outer world’ of culture
and accomplishment. Donna Williams, cited earlier, says that non-autistic people
must ‘declare war’ on autism. They must not allow the anxiety that the child
carries with him to rule the day (Williams 1992, p.219).
Fear of something is reduced by its doing. The Asperger’s child transcends
anxiety by making himself do the things that he must to be successful. This kind
of ‘getting-back-on-the-horse-that-threw-you-off ’ approach builds psychologi-
cal strength, what I term ‘psychological muscularity’. The anxiety itself becomes
the force that the child must defeat to realize success.
Richard told me that he almost quit aikido when it became obvious that he was
so good that people would come to watch him fight. Already painfully
self-conscious, this added bit of notice almost pushed him away from an activity
that he loved. But his Sensei (instructor) did not accept Richard’s reluctance. His
bond with her was strong enough that he allowed her to scold him for even
thinking about it. He stayed in training and realized that he was getting less and
less fearful with every match that he completed. His instructor’s determination not
to lose him gave him the courage to go back, and each time he did he got stronger.
In most cases the Asperger’s child’s special interest will be the route to this kind
of functional extroversion. One child might find it in joining a local computer
club. Another might find it through nature study. Another might find it through
his chess or mathematics club. Worldly activity gives a child balance between his
inner life and outer life, the freedom that is his legacy.
CHAPTER 8
Sean’s Case
Helping a Child with the Dual Diagnosis
of Bipolar Disorder and Asperger’s Syndrome
Some of the most troubled kids that I work with show signs of having the dual
challenges of Asperger’s Syndrome and Bipolar Disorder. The lack of common
sense that comes with Asperger’s and the aggressive depression of Bipolar
Disorder are a combination that creates enormous challenges for the teen and his
parents. And this is a combination that is seen in about half of children with
Asperger’s Syndrome or Pervasive Developmental Disorder (DeLong and Nohria
1994).
In order to help a kid with this dual diagnosis, it is necessary to get an idea of
the feelings, perceptions, and stress that he experiences. Once you have an idea of
what he goes through on a day-to-day basis, you are in a position to help him get
what he needs in order to be successful. A good way to describe the inner life of
children with these challenges is to tell you about Sean, a smart, handsome
13-year-old.
Sean’s parents, Paul and Tricia, brought him to see me because of his refusal to
go to school, his pot use, oppositional defiance, chronic use of profanity to his
mother, and his involvement with a gang of kids who were into law-breaking
activities such as breaking into parked cars. Sean’s mother and father told me that
he refused to acknowledge their authority over him and was basically a loose
cannon at home, coming and going to his own schedule and behaving more and
more out of control.
The first glimpse I had of Sean was his shoulder-length jet black hair which
flew out behind him as he ran out of my waiting room to avoid the possibility of
conversation. He knew I was in league with his parents and he suspected that I was
sent by the Civilizing Forces in Society to bring him back. Sean inhabited the
Wild Boy archetype to a tee. He looked, spoke, and acted like Mowgli, the boy
with the animal spirit who is the hero of Kipling’s Jungle Book stories. Sean did not
possess Mowgli’s canny resourcefulness or ability to live in the wild, but he did
show his impulsivity and wildness of spirit, and like Mowgli, he was highly dis-
trustful of other human beings.
145
Following him out to the back porch of my office, I sat down on the floor a few
feet from him. Without getting into social niceties (Asperger’s children do not like
small-talk), I told him that I knew that life was hard for him, knew that he was real
smart, knew that he wasn’t ‘mental,’ and knew a lot of kids just like him. He
flashed an incredulous look at me as if to say ‘No. I’m the only one like this!’ But I
could tell he was intrigued. Here was someone (me) who might be able to under-
stand what he was going through. I finished my brief contact with him by letting
him know that I do not try to make kids obey their parents, but try to help them
have happier lives. I asked him to talk to his parents after our session and come
back only if he saw it as useful. Sean did return for a second session and continued
to work with me for about six months after that. When he and his parents termi-
nated with me, he was back on track at school and had a sense of purpose and
stability in his life. He had worked hard.
Impulsivity, obsessionality, and rage heralded early-onset Bipolar Disorder

in Sean by age five
As a pre-schooler, Sean showed several features of early-onset Bipolar Disorder
including the impulsivity, inappropriate sexual touching, rage, obsessionality,
problems with sleep, and pressured speech. And he was a runner. His parents had
to be very careful in parking lots or near streets, because Sean could take off in a
split second and he didn’t look where he was going. Typically, he was very
underaroused and irritable in the morning and overaroused at night. The most
prominent BD symptom was his rage, which was most pronounced between the
ages of five and ten. True to the Bipolar Disorder diathesis, his rage could go on
for a couple of hours during which time Sean’s personality seemed to disintegrate
to be replaced by a miserable, wailing, flailing, spitting little animal.
True to his Asperger’s temperament, Sean’s rage was usually set off by
overstimulation or anxiety. When the child has both Asperger’s Syndrome and
affective illness on board, it is the anxiety of his Asperger’s Syndrome that sets off
the rage and it is the terror of being overwhelmed that powers the anxiety. As an
enraged seven-year-old, Sean would make high-pitched screams that were
extremely aggravating to adults. In this state, his rage expressed the terror of the
Asperger’s child at being overwhelmed by everything around him, as if to shout
‘Keep away from me!’ His parents recalled how miserable they had been around
him during his elementary school years, because he was so anxious and always on
the edge of losing it.
Sean’s parents told me that from a very early age, he showed several other
prominent features of Asperger’s Syndrome. His social skills were severely limited.
He did not listen to anyone else but delivered his own monologue on whatever
came to his mind. He had very limited social interaction in elementary school, was
obsessional and rigid in his views, and showed an inability to understand the
SEAN’S CASE / 147
emotional nonverbal behavior of others. Added to these challenges were his

highly anxious nature and extreme sensitivity to noise and social stress. If his
parents made the mistake of getting him around too many kids, he would lose it
and start acting goofy to the point that he had to be removed.
Now, as a teenager, he no longer had rages. But Bipolar Disorder was still
calling the shots in his psyche and he suffered from both depression and
hypomania, which came to him in rapid cycles. From a state of fairly normal con-
sciousness at school he could drop into a depressed funk when he came home.
From time to time, he would show features of hypomania and would stay up all
night playing Nintendo or go on a midnight run that might last one or two hours.
In his hypomanic phase, he became energized, optimistic, and ambitious about
turning his life around, and he could deal with hassles at school. But he was not
able to follow through on all the plans that he made in his up phase because even-
tually he would crash and when he did, all the things that he had yet to accom-
plish became part of his great museum of past failures.
Sean had experienced a period of intense obsessionality when he was ten that
involved extensive checking rituals, and hand washing. His doctor had prescribed
Prozac for these issues and within a couple of weeks Sean’s obsessionality had all
but disappeared. When his parents took him off the Prozac a year later, he
developed the chronic irritability signature of Bipolar Disorder which had
remained with him since. It was unclear whether the use of the antidepressant
contributed to the onset of this characteristic or if it had developed simply as his
Bipolar Disorder became more pronounced.
He alternated between depressive numbness and manic wildness

Sean’s mother worried about him because he would often talk about drugs or
share his craving for weird, painful, or extreme sensations. He loved to go out in
the snow underdressed. His night runs sometimes exceeded ten miles.
But his Asperger’s challenge brought with it extreme anxiety. He was greatly
overstimulated at school by the ordinary demands of his teachers and noise from
the other kids. Things could be so overwhelming for him that he would often
choke himself (putting pressure on the artery and vein on each side of his neck) to
deliver a pleasant feeling of spaciness and dissociation from his classroom. He
stopped this practice when his family doctor informed him that though brain
damage from loss of blood was unlikely, damage to his heart could occur because,
in squeezing his jugular and grand aorta, he was also putting pressure on nerve
bundles that went to his heart. This could result in heartbeat irregularities or
cardiac arrest.
He told me that when he got depressed he felt like he’d go crazy from feeling
numb, feeling so devoid of any emotion or sensation that it was difficult to put one
foot in front of the other, let alone do his homework and go to school.
Sean as a Bipolar/AS child was a different person when his bipolarity lifted.
In the last chapter, I discussed four major challenges that Asperger’s Syndrome
can bring to a child: (1) a powerful predisposition for anxiety and stimulus sensi-
tivity, (2) auditory processing issues, (3) inertia or the inability to initiate action
when stressed, and (4) impaired ability to be practical about things. As I worked
with Sean in therapy, it became clear that these challenges were expressed differ-
ently, depending on where he was in his Bipolar mood shift.
When he was in the ebb tide position of his daily mood cycle, a place of relative
normalcy between bouts of dysphoria, his behavior was relatively typical of
Asperger’s Syndrome without other complications. He was somewhat passive, but
could be quite assertive. If he were in gym class, for example, he might take
another kid to task with a shouted verbal insult for bullying him. He was still
odd-looking and odd-sounding but could get by.
In this ‘normal’ Asperger’s mood, his stimulus-cravings were considerably
reduced from the level when he was hypomanic or depressed. He did not lose his
predilection for extremes. He enjoyed sleeping on cold nights with few covers
and the window open. He enjoyed extremes of hot, spicy foods. He was addicted
to nicotine and satisfied this craving by picking up and smoking cigarette butts.
This is an addiction that he shared with many children I have worked with who
have the Asperger’s with Bipolar Disorder presentation.
Sean’s stimulus-craving increased in his hypomanic phase

His craving for stimulation would get acute in the manic phase. At these times he
might go looking for someone at school who would sell him a marijuana joint. He
might smoke four to six cigarettes a day and his butt-picking-up behavior would
increase. On several occasions he showed me a large, smelly bag of cigarette butts
that he had collected from the street the morning before our session.
In his hyperenergized phase, Sean would seek out new stimuli including con-
duct-disordered friends who could manipulate him to participate in shoplifting or
take a dare to get involved in risky or dangerous behavior. Sean was at risk of
getting in serious trouble with the law. His acute hearing and eyesight were valued
resources for his delinquent ‘friends,’ several of whom talked him into standing
lookout while they stole things from parked cars. Sean wasn’t looking after his
own interests in this situation, and so the development of his assertiveness become
an important priority for us in therapy.
Sean had been picked up by the police for curfew violation several times, and
each time his mother had talked them into not taking him into detention. But they
were now telling her that the next time they picked him up he would go there
instead of home.
Sean was powerfully driven by urges known only to him. The moon would
call him, or a baying dog somewhere in the distance would excite him and off he’d
SEAN’S CASE / 149
go into the night. The wild pleasure he experienced at these times gave him
momentary relief from the painful competing inner pressures he felt between
numbness to any stimulation and painful oversensitivity to many stimuli. Clearly,
he needed help in getting this situation more under his control.
Major problems with inertia occurred in the depressive phase

of Sean’s Bipolar Disorder
From time to time, he would cycle into a fairly listless depressive phase. In this
situation he found it impossible to get along with people if they were too
demanding. The depression seen in Bipolar children and teens is pitiless. By and
large they are more dysphoric, apathetic, and miserable in the depressed phase
than are people who suffer from depression as a stand-alone issue. And depression
brings out the worst of Asperger’s Syndrome. Depressed, Sean’s natural tendency
for inertia would slow him to a stop. He could not go to school. He was totally
unmotivated to do anything but play mindless video games all day. He would seek
refuge in his tree house, where he would sit and stare into space for hours at a time.
He stopped eating and bathing. His craving for stimulation largely disappeared –
not even that could interest him. He became fully anhedonic (incapable of
pleasure), could easily cry, babble nonsensically, and suffered intermittent
night-time insomnia – he would get up in the middle of the night and not be able
to get back to sleep. His obsessions got much worse. His ability to focus at school
ceased.
His energy to make contact with the outside world disappeared, even his
interest in girls. On the positive side, he also lost interest in tramping around with
his conduct-disordered buddies and engaging in acts of juvenile delinquency.
Sean’s parents tried to take care of him, and accepted his growliness and
insults. It was all that they could do just to keep him from depressing them still
further with his negativity and lack of interest in things.
A depressed teenager may feel pain in just being alive, in getting out of bed in
the morning. Asperger’s Syndrome already carries with it abnormalities in the
sensation of pain (cold may be sensed as pleasure, touch may be sensed as pleasure
or pain). When Sean fell into depression, everything was painful. Talking with
him about his life, I sensed that he could be a suicide risk if he did not learn to get
better control of his depressed phase.
Healing from depression requires that a kid has something to look forward to.
Many of my pediatric clients have told me how important this is, even if what they
are looking forward to is something tiny by most standards: a snack after school,
playing Nintendo for an hour, or throwing a ball with the kid next door. One of
the key challenges of Asperger’s Syndrome is its ‘cognitive apraxia’ – the inability
to maintain an internal timeline that gives context to a person’s actions. A timeline
is an automatic sense of our recent past and near future that we hold as a continu-
ally running program right out of awareness. So doing, we are able to remember
what kind of action is appropriate in a situation and automatically plan back from
the picture we hold of the future. And we are able to motivate ourselves with the
knowledge that we may be moving toward future delights.
Kids with Asperger’s challenges do not possess this automatic sense of past and
future and so have a tendency to get stuck in the present without a clue as to how
to get to the next order of business in their lives. And they also get stuck in depres-
sion because they literally have nothing to look forward to.
Sean could be hard on himself in the depressed phase. As is the case with many
teens with the dual diagnosis, he developed fixations on things or got into perfec-
tionism; he had to do everything just right. His perfectionism and fixations were
made worse by stress, fatigue, and movement into the more depressed phase of his
mood shift.
Sean preferred dogs to people

Sean came into my office unkempt and foul-smelling. He found showering and
bathing to be painfully overstimulating and tended to wear the same clothes day
after day. Sean’s smelliness and unkempt appearance were evocative of the special
interest which expressed the Asperger’s side of his temperament. He was heavy
into dogs. He could recite statistics on any kind of dog breed in existence. He
knew how to train them, talk with them, and soothe their anger and ferocity. He
could talk a snarling dog into coming over and licking his hand. Sean’s mother
said that dogs had been Sean’s best, and sometimes only, friends since he was five,
when she was astonished to see him running down the street after a pack of them,
as one of the group.
His tree house in the Greenbelt woods behind his parents’ place gave him
sanctuary. He would go there to sit and stare for hours at a time or whittle crude
weapons, his bow and arrows, club, and other implements. He did not seem to be
lonely for other kids’ company. If he did need companionship, he’d climb down
and find one of his dog friends to play with.
Sean experienced sickening depersonalization and disorientation

Sean and others of my teenage Bipolar/AS clients have told me that feeling
uncomfortably depersonalized is one of their most prominent inner feelings. The
child feels as if he is floating above himself, out-of-body most of the time with no
idea who he is, what he is doing, what just happened, and what will happen in the
future. This feeling of being profoundly ungrounded and out of contact with
others may be excruciating, even nauseating. The lack of connection between
himself and the people, things and events around him is a core challenge of the
Asperger’s child. It is part of the internal misery of children with the dual
SEAN’S CASE / 151
Bipolar/AS diagnosis. If the child cannot connect the person standing in front of
him yelling (his teacher) with the paper on his desk (the task that he has no idea
how to finish), he will feel deeply powerless. His urge may be to call up the
‘dragon’ of his Bipolar Disorder to mount an attack on that ‘abusive’ teacher who
puts these unreasonable and silly demands on him. If the child lets his Warrior
temperament emerge in this way, he may deepen his isolation.
Bipolar Disorder brings with it a powerful sense of being driven, of being
overenergized, and the child may experience a strong need to relieve the tension.
The Bipolar child who is not Asperger’s may be able to find some way to discharge
this feeling of pressure; he has the means to plan his release. But children with the
Bipolar/AS challenge may lack this ability to take the initiative, to plan far
enough ahead to find some way to get relief. The pressure builds up and they
explode in miserable, aggressive, anxious depression.
Children with Asperger’s Syndrome are slow cognitive processors. The
Warrior aspect of the child (the Bipolar archetype) wants to react quickly to
people and events, to be decisive and aggressive. But the reactions of the child
with dual challenges are greatly slowed by his Asperger’s nature, and he reacts to
those around him like a drunken sword-fighter. Though not really a threat to
anyone, he is totally obnoxious, insulting, and depressing to be around.
Sean lived in Asperger’s time, not in culture time, and this caused him problems in
school
Fundamental to Sean’s temperament was the difference in his sense of time
between himself and everyone around him. He told me that he saw a particular
time of the day – getting the school bus at 8.30 a.m., for example – as a point of
light in a circle. Because of his lack of internal chronometer, he often did not
know when a task was finished but would perseverate on it long past its comple-
tion. Or he would be unable to manage ordinary transitions from one task to
another in the classroom and would require prompting from his teacher.
Sean had developed compensation for this lack of ability to hold a timeline by
forcing himself to act appropriately in the moment. To avoid missing the school
bus, he would sleep in his clothes and within five minutes of his alarm going off in
the morning, be out the door with a Power Bar in his hand which he would eat on
the bus for breakfast. Because he got lost between class changes, he would jump
up immediately when the bell rang to signal the end of the period and run, black
hair flying behind him, to his next classroom. He would be first there, and first in
his seat, sitting and staring blankly at the blackboard when the other kids started
arriving several minutes later buzzing with the pleasant social conversation that
they enjoyed between classes. Sean lost his opportunity to have this kind of inter-
action because he had to concentrate on one thing at a time, and just getting to the
next classroom took all his resources.
Sean’s Asperger’s temperament worked against his ability to understand

emotional cues from other kids. Unable to accurately decode nonverbal gestures,
he would often antagonize other children. This resulted in him being picked on
for ‘being weird,’ and in his involvement in a series of fist-fights for which he had
been repeatedly suspended.
He was fortunate to have a correct psychiatric diagnosis of Bipolar Disorder
comorbid with Asperger’s Syndrome, and doubly fortunate that his school
principal knew what that meant in terms of a child’s behavior. The district had
placed him in a self-contained Special Education classroom so that he could be
monitored closely. Unfortunately, the class was set up to provide educational
services for children who were classified as ‘SBD’ (Severe Behavioral Disorder) for
severe behavior problems and who were for the most part victims of domestic
trauma; they were angry kids, and were acting it out at school.
The SBD class was dangerous for Sean because, lacking the ability to plan his
social behavior, he was vulnerable to imitating other kids who got his attention.
The most dramatic children in his class were the most traumatized, and these were
also the kids with access to illegal drugs.
Sean had severe impairment in the ability to participate in team sports. Because
of his Asperger’s he was not able to remember and replicate movement, or make
the rapid shifts of focus required in coordinated sports activities with other kids.
When Sean was in his hypomanic phase he was capable of accomplishing extreme
physical activity such as the ten-mile night runs that he enjoyed. But his ability to
play a game of basketball with nine other boys on his team was severely limited.
He would end up sitting mournfully on the sidelines or bouncing a ball by himself
in the corner, totally ignored by the other kids.
If you could set his social problems aside, Sean was an excellent student. His
intelligence had been measured at the bright to very bright level. Like many
children with Asperger’s Syndrome he had a natural brilliance in math, and dem-
onstrated the ability to figure complex problems in his head. Though the literature
on autism has tended to portray this ability to do math as a relatively rare phenom-
enon, I have seen it in most of the cases of Asperger’s Syndrome that I have worked
with. It is as if the lack of emotional complexity of the child is compensated by a
powerful understanding of the pure logic of mathematics. Possibly, it is the pre-
dictability of the mathematical algorithm and the beautiful, seamless logic of
math that make this subject attractive to AS kids, who are so bedeviled by the
messiness and unpredictability of human relationships.
He did not talk about his feelings but tried to figure everything out
Sean told me at the beginning of counseling not to do what the other counselors
had done, which was to ask him a lot of questions about his feelings or ask him to
SEAN’S CASE / 153
draw pictures. I took him at his word, knowing how difficult it is for Asperger’s
children to access their feelings about themselves and others.
To Sean, the whole idea of talking about feelings was absurd. On one occasion,
he came in to counseling badly shaken from an encounter with his father that had
resulted in violent pushing and shoving and destruction of property in the family
home. The fight began when Sean kicked through a door his parents had locked
to prevent him getting some cigarettes that they had taken from him. His father
came home after a long day to find the door in splinters and Sean rummaging
through his things. A pushing and shoving match ensued as his dad attempted to
physically remove him from the room. Sean did not react with remorse to what he
had done. His only concern was ‘figuring out’ if his father could be held legally
liable for pushing him and stealing his property.
In a follow-up session I discussed the event with Sean and his father, Paul.
Though the fight with his dad had made him extremely anxious, Sean could not
identify or describe his feelings about the event. He showed a lack of empathy for
the suffering he had caused his parents. He seemed incapable of having the kind
of ‘heart-to-heart’ conversation with his dad that would prevent this kind of
situation from happening again.
Empathy wasn’t present to motivate him to repair his relationship with his
father, but he didn’t like the anxiety that he experienced and he was highly logical.
I needed to talk to these parts of his Asperger’s temperament to make things
better.
‘Sounds like that fight with your dad was extremely upsetting for you, Sean.’
‘Yeah. It was fucking child abuse. Next time I’m calling 911.’ He was still
angry but I sensed he was also scared.
‘911? Like they should be protecting you?’
‘Uh huh.’ He glowered at Paul.
‘So you felt kinda like “What’s happening here? He’s my dad. Why is he
attacking me? I’m scared?”’ I said.
‘Yeah.’ Sean’s clipped response did not hide his extremely anxious nonverbal
behavior; his eyes were wide, his face pale, and his posture tight.
‘Yeah. Logically speaking there should be a way to keep this from happening.
Any ideas?’ I asked.
Sean’s voice rose a bit: ‘I want those cigarettes. Those are my fucking ciga-
rettes!’
Paul broke into the conversation. ‘Well, son, you’re addicted to those damn
things, and I’m not going to support that addiction.’ Paul was in a bind.
I knew Sean was addicted to nicotine and that the cigarettes his father had
confiscated were a special treat in that they were not the soggy cigarette butts he
was usually forced to smoke. I decided to appeal to Sean’s innate selfishness and
sense of logic. ‘OK. Sean, how many cigs do you smoke a day?’ Minimizing his
addiction, he replied ‘Oh, maybe three a day.’
‘So what if your dad agreed to give you three a day, would you be willing to get
rid of your butt collection and just stick to that program?’
I had discussed this option with Paul privately before our session and he was
agreeable if Sean agreed to start medication for his issues, which he had resisted
doing to this point. Sean’s doctor had told Paul that buproprion (b. Wellbutrin)
might be a good starter medication as it had antidepressant qualities, would not
aggravate Sean’s Bipolar symptoms, and (Sean did not know this) would contrib-
ute to smoking cessation.
Paul cut in. ‘Well, that deal might work for me, but I’d only go for it if Sean
agreed to start on the Wellbutrin Dr Findley recommended. What do you say, son?
The doc told you this one is pretty mild on the side-effects and we can pull it if it
doesn’t help.’
Sean thought about the deal for a moment. His logical sense told him that his
father was holding the cards here and despite his angry bravado, it didn’t help him
get closer to smoking those cigarettes. He was also positively motivated to try the
Wellbutrin if there was a chance it could help him with understanding things a bit
better at school. He looked suspiciously at his dad, then at me.
‘Dad has no right to keep them. They’re mine!’
I allowed him to save face with this bluster and did not argue. ‘Yeah, you’re
right there, Sean. You paid the money to get them from your friend, but your dad’s
doing his job keeping them away from you. That’s the way it is.’
Sean looked away for a moment and then back at Paul. ‘OK. I’m OK with
keeping them in one place, like in the laundry room or someplace where everyone
knows where they are and they don’t get moved to some hiding place.’
‘Sure,’ Paul said, ‘I’m willing to do that, and I will maintain a count of them
which I will verify every day, Sean.’
‘Trust but verify. I like that,’ I said.
‘I’ll call 911 if he fucks with this deal!’ Sean said, flashing a fierce look at his
father. I ignored the impropriety of calling the police to force one’s father to
return his son’s cigarettes.
‘Good,’ I answered his concern. ‘That’s a right that you both have if there is
any violence.’
Paul and Sean came in several weeks later. Their deal had been holding up.
Sean had been on the Wellbutrin for two weeks and had already cut back on his
cigarettes to two a day and he was doing better in school.
‘You guys are doing the “trust but verify” thing, right?’ I said. ‘Any other places
where this might apply?’
SEAN’S CASE / 155
Paul pondered my question for a moment. ‘Hmm. Sean’s been after me to take
him paint-balling. I’ve been after him to stop swearing at his mother. Maybe we
could work a deal. The swearing is easy to verify.’
I figured this solution might work. ‘Sean, how about this? If you can keep the
remarks you make to your mother reasonably civil, and this means not use the “f
word” at her, your dad takes you paint-balling. But if you don’t, paint-balling is
off and will be, at least until you guys come back here and talk.’
His father affirmed this solution. ‘Works for me.’
Sean also liked the idea. ‘Paint-balling! Yes! Sure, I’ll chew on a washcloth or
something when I feel like cussing her out.’ He grimaced. ‘Her voice drives me
nuts. But for paint-balling, I’ll keep my f word to myself !’
Sean did get to go paint-balling. He was able to control his insults at his
mother, though the constant impulse to verbally abuse her remained because he
was hypersensitive to her voice and his stress reaction was set off when he heard it.
The little bit of movement in his relationship with his father on the cigarette and
paint-ball issues, however, eventually put his dad in more of a ‘good guy’ role with
Sean and opened the way for us to do family therapy with his mother present. The
stage had been set for several months of very productive family therapy that
resulted in a marked improvement in Sean’s relationship with his parents.
Sean also showed positive characteristics of the Asperger’s temperament

The child with Bipolar Disorder may be manipulative, devious, and aggressive.
These characteristics are infrequently seen in Asperger’s Syndrome. Most AS kids
are honest to a fault because they do not possess the emotional complexity
necessary to tell a convincing lie. Sean was scrupulously honest and he possessed
several of the positive qualities seen in Asperger’s children that offset his bipolar-
ity.
He had developed skills in logical analysis. He loved to argue and debate and
he was good at it. If it were not for his dismal social skills, he would be well
equipped to become an attorney or labor negotiator.
He had a high mathematical intelligence and an interest in science fiction,
which made him an interesting kid to talk with once you got past his oddness.
There was no doubt that he was capable of making friends if he were in the right
environment – probably around other high-functioning Asperger’s children.
He shared the quality of being relatively insensitive to pain that is seen in many
persons with Asperger’s. This feature contributed to his physical hardiness. His
favorite place to sleep was up in his tree house in the family’s back yard and he
enjoyed being up there in all kinds of weather. The Jungian archetype of the
Hermit is seen in Asperger’s children, and one of the central aspects of this
archetype is the ability to live with minimal creature comforts.
And as strange as it seemed, he wanted to please his parents. He went to school

and tried to be a success even though he couldn’t see much point in it and was
learning very little.
In order to be successful with him in therapy, I had to be able to see and accept
Sean’s oddness, the limits of his neurology, and his gifts.
Summary of Sean’s gifts and challenges as a Bipolar/AS child

THE GIFTS
• very high energy
• courage
• honesty
• skill in logical analysis
• skill in debate and argumentation
• high mathematical intelligence
• physical hardiness
• motivation to succeed
THE CHALLENGES
• high anxiety camouflaged by aggressive irritability
• impulsivity and hypomania
• lethargy and severe loss of focus under stress
• obsessionality
• low frustration threshold
• depression
• depersonalization and disorientation
• different sense of time
• lack of common sense
• social isolation
• learning disorders: planning tasks, following sequences, writing,
reading, negotiating transitions
Five survival strategies which help kids like Sean become

more resourceful and successful
Sean, as is the case with many children with the Bipolar/AS diagnosis, needed
help to be more purposeful, focused, and assertive in his life. I used the following
SEAN’S CASE / 157
five strategies over the six months that we worked together to help him turn his
life around.
1. Build communication and rapport

Lack of trust, problems listening and understanding others and mood shift are
issues that, taken together, make it difficult to communicate with the
dual-diagnosed child. Here are two good communication principles for getting
through to him:
(a) Appeal to his legalistic sense of justice. First, to build communication, I
appealed to Sean’s legalistic and logical nature. It did not work for me
to tell him to stop yelling threats at his parents on the grounds that he
should respect their authority. But he did listen when I told him that
threatening his parents with bodily harm is illegal (a verbal threat may
be considered an assault) and that he could be removed from the home
for making these threats. Like other kids with Asperger’s Syndrome, his
character is more rigid than devious. He was best influenced by clear
black and white reasons for why he should or should not do something.
(b) Accept his lack of empathy as normal and appeal to his selfishness. Working
with Sean, I did not lecture him on the virtue of selflessness, but argued
straight to his own sense of entitlement. The Bipolar child may lack
empathy and he may not appreciate how his behavior impacts others.
Research shows that this may be due to an underdevelopment of brain
structures in the frontal lobe. The Asperger’s child also may show a lack
of empathy or emotion when observing the suffering of others. A
favorite aunt of the AS child dies and the child says ‘Oh, yeah. She
died. Too bad. What’s for dinner?’
To get through to Sean, I accepted this basic selfishness and addressed his social
and personal problems in morally flat cause-and-effect terms. ‘If you continue to
steal money from your parents, they will not feel like buying you anything for
Christmas.’ Working with another Bipolar/AS child (whose parents had brought
him to me to decrease his bullying of his little sister), I told him ‘If you continue to
torment your little sister, she will tell your parents and you will not get that new
computer you’ve been wanting.’ The bullying of his little sister stopped when that
consequence became clear to him.
Sean’s communications with his parents improved as they stopped lecturing
him and started appealing to his own sense of self-interest. His trust for them
increased and he started listening to them and complying with their requests for
the completion of tasks at school and home. They knew that they would always
have a bumpy relationship with their son, but their change in tone had the
immediate positive impact of getting out of the push–pull power struggle that
they had been in with him.
2. Legitimize his sensory aversions and help him find safe ways to
realize his craving for extreme stimulation
Children with Asperger’s Syndrome may experience shame as a result of their
unconventional orientations to stimulation. They need to know that having very
unusual sensory aversions and cravings is a result of being born with a certain kind
of brain chemistry, and that everyone is different in this regard. I told Sean that his
strange stimulus aversions (which included his aversion to the feel of certain types
of clothing and the creepiness he felt when his mom tried to hug him) were related
to his ‘being Asperger’s,’ and that many other kids share these issues. I talked with
him to identify his sensory preferences and normalize these preferences.
Sean had shared with me that he often choked himself to numb out to stimula-
tion (such as that which occurred in his classroom). I discussed this practice in a
matter-of-fact way, suggesting that getting the right medication in place was more
efficient than choking oneself to decrease unpleasant stimuli.
And I helped him to find safe ways to experience stimuli intensity. Sean’s
interest in vigorous physical exercise led us to explore his participation in the
annual 26-kilometer marathon that is conducted every year near his home in
Seattle. He got into this activity with a lot of enthusiasm because he had already
built up his physical stamina and found it relatively easy to train for the run. Given
his problems following through on his plans, it was possible that he would not
actually run the course, but he told me that he felt a sense of confidence preparing
for it. Added benefits were seen in the powerful antidepressant effect of this
aerobic exercise along with its effect to limit Sean’s use of cigarettes and pot. He
needed to keep his lung capacity up, and smoking caused a direct and palpable
reduction of his ability to sustain the long haul in the run.
Every Bipolar/AS child is a little different when it comes to satisfying a need
for a peculiar kind of stimulation. Here are some ideas:
• If he craves hot, spicy food, find the best ethnic restaurant with the
hottest food and take him there frequently. Teach him how to make
chili hot enough to power a drag racer!
• If he craves legalistic banter, get him to sign up for his school’s debate
club where he can exercise his logical aggressiveness and get points for
it.
• Some Bipolar/AS children are drawn to body-piercing. They like the
wild look of it and easily take the pain involved in the process. They
also may find the use of an ear ring or nose ring to be pleasantly
self-stimulating. If he pesters to get some part of his body pierced or
SEAN’S CASE / 159
tattooed, work it out with him so that he can do so without seriously

disabling himself. Better that he get an ear ring than a tongue stud,
which can result in a permanent speech impediment.
3. Help him tune up his built-in danger detector

One of Sean’s major challenges was his apparent lack of ability to resist dares. He
clearly needed help to sense when someone was trying to manipulate him to do
something self-destructive.
As is the case with many Asperger’s children, Sean was a strong visualizer: he
thought in pictures. I built on his visual ability by asking him to picture a
computer screen in his mind when he was considering a dare from another kid.
On the screen, he should let the word ‘Yes’ or ‘No’ form in answer to the question
‘Is doing this in my own best interest?’ He could use this method when other kids
confronted him with any kind of request or suggestion. Sean and I practiced this
method in the office. I asked him to get back to me if he used it with his friends
and tell me what happened. In our next session, he told me he used the technique
to refuse a dare to steal from another kid’s locker, and felt proud that he was no
longer ‘a patsy.’ He was delighted at his ability to take better care of himself this
way and reported that he had turned down an invitation to go with some kids to
steal things from cars because he never got anything out of it anyway and ‘could
end up in jail and kicked out of school.’
4. Find his special interest and use it to tip up his mood and build his
resourcefulness one step at a time
In the last chapter I discussed how possession of a ‘special interest’ is diagnostic of
Asperger’s Syndrome. The AS child will have one interest such as computers, or
dinosaurs, or dietary practices, that he will obsess about, fixate on, and study in
great depth. Sean’s special interest was dogs. It became clear that this interest was
a way for him to get a sense of purpose into his life. With his affective illness and
Asperger’s on board, he didn’t have much to feel good about. But his interest in
dogs gave us an avenue for turning things around.
I spoke with Sean’s parents about a part-time volunteer position in a local
animal shelter. Sean agreed to try it out for a couple of weeks and before long had
developed a contagious enthusiasm for his work there and the job became
‘part-time, permanent.’ As is the case with many Asperger’s kids, he had a
genius-grade understanding of his chosen field and impressed staff with his
diligence and interest in taking care of orphaned animals. He had found his niche.
Everyone needs something to look forward to. The problem with having
Asperger’s Syndrome is that a child may not be able to keep a sense of future in his
mind; he lacks the past, present, future timeline which neurotypical kids take for
granted. He is incapable of delayed gratification. The problem with having

Bipolar Disorder is that the child can never predict from one day to another how
energetic he will be. If both Asperger’s and Bipolar Disorder are present, he needs
intensive help to identify his goals and go after them. Without coaching and
prompting, he will lose his momentum and fall back into inertia. Fortunately for
Sean, his parents were up to playing their part in this coaching process and were
enthusiastic about his progress.
5. When it comes to medication, treat the Bipolar Disorder first, then the
Asperger’s Syndrome
One of the most important breakthroughs in Sean’s recovery was the identifica-
tion of the right medication to treat his symptoms. About the same time that he
began therapy with me, his parents contacted a local psychiatrist who understood
the medication challenges that Sean faced from his dual diagnosis. Though his
depression could be merciless, he was highly reactive to antidepressant medica-
tion because of his bipolarity – when he had taken this class of medication in the
past he had become extremely agitated, and dysphoric.
Sean had agreed to take buproprion (b. Wellbutrin), an atypical antidepressant
that had been quite effective in raising his mood. Though he did not realize it, the
Wellbutrin had also greatly decreased his craving for cigarettes so that he was in a
position to terminate this addiction altogether. Of all the antidepressants,
Wellbutrin was the one that has been shown not to aggravate children suffering
from BD and it had worked marvelously for Sean to take the edge off his depres-
sion and compulsive smoking.
After beginning the Wellbutrin, Sean started becoming more successful at
school because the drug has a mild anti-ADHD effect and he was focusing better.
This little shot of positivity enabled him to cop to more of the problem he had
with his mood shift and agree to begin another medication to stabilize it more. His
doctor chose gabapentin (b. Neurontin), a newer-generation anticonvulsive that
has fewer side-effects than others in this class. Other medications that have shown
promise for helping children with problem behavior related to the Bipolar/AS
presentation include risperidone (b. Risperdal) to treat distorted thinking and
aggression, and the antidepressants to treat obsessionality and anxiety (L’Ecuyer,
Koenig and Martin 1999). Sean tolerated the side-effects of this medication well
(tiredness and slight dizziness from time to time), and was happy to finally experi-
ence some relief from the distressing mood swing that had left him feeling totally
out of control of his life.
SEAN’S CASE / 161
Conclusion: Sean expresses wisdom about his nature

I have a little porcelain box in my office that contains eight or ten small semipre-
cious stones which I replenish from time to time from a local rock shop. I use these
as transitional objects – physical reminders of some learning a child has from
therapy. Kids pick one and then, if appropriate, I relate some attribute of the rock
to their work in therapy. A child who has problems with low self-esteem picks a
piece of rose quartz. I tell her that it is said to have healing properties for the heart.
Just a little reminder to deal with her disheartenment around things in her life.
Boys love the coprolite (petrified dinosaur dung) I get at the rock shop. It’s the real
thing, looks gross.
On occasion I have used the rocks as a way to get a kid to talk about himself. I
asked Sean to sort through the pile and pick one. He found a little geode, a
volcanic rock that is ugly and ordinary-looking on the outside but if split in two,
reveals a beautiful intricate crystalline structure on the inside. He unwrapped the
cellophane that held the two halves together and made a little noise in wonder-
ment as the rock opened up.
‘That rock reminds me of you,’ I said.
‘Yeah,’ Sean said, ‘I guess there’s a lot of me people don’t see. There’s a lot of
me I don’t want them to see. And we both had fiery beginnings and go around like
little volcanoes,’ he grinned.
‘Like Mount St Helens, and Mount Baker,’ I went on. ‘What would we do
without those beautiful mountains to look at every day?’ I knew that Sean liked
hiking and had hiked both mountains.
‘Yeah,’ he joked. ‘Little Mr Hothead is like a volcano, but he can get his act
together sometimes.’
I was pleased to hear him state this natural reframe of his condition: chaos
happens, but beauty often follows as a result of it.
When Sean and his parents terminated therapy, he was well on the road to
turning things around in his life. He was enjoying a pattern of greater stability
between school and home, he had a couple of friends, good kids like himself who
showed features of the Asperger’s and Bipolar Disorder combined temperament. I
felt optimistic about his chances to have a good life. He was beginning to come to
terms with the extremes of fire and ice in his psyche. And he was beginning to see
the possibility that he had within himself the ability to nourish the development
of a noble and successful character out of the collision of these powerful elements.
Part Three
Soothing the Hurt of Tourette

Syndrome and Bipolar Disorder
CHAPTER 9
Tourette Syndrome
The Wild Heart of the Restless Explorer
The archetype: The Restless Explorer

The child with Tourette Syndrome is driven by powerful, unconventional creative
urges that express the wild energies of the limbic, animal brain. His physical and
psychic energy is great. His senses are hyperacute and he may have an intuitive
understanding of the animal world. If ADHD is a throwback to the Hunter
archetype, Tourette Syndrome is a throwback to those who guided the hunters;
who knew the territory and followed the ways of nature and natural power to
learn the secrets that nature held.
THE GIFTS
Quickness in thought and movement, radical creativity, and affinity for nature and
the ecology are the gifts of this archetype. The Tourette child follows power, espe-
cially natural power, and is intrigued by it. He may be fascinated with chemistry,
computers, and electrical energy. Or he may be drawn to the arts where he will
create new artistic forms. The presence of the limbic brain in his personality gives
him a physical glow that is evident from the moment of his birth.
THE CHALLENGES
The Tourettic child can be thin-skinned and combative. His sensitivity to the
world around him can be overwhelming and he may react against others as if they
have deliberately caused him pain. His rage may come out like thunder as physical
energy that needs expression: a wild pressure that needs to be let out so that he can
breathe and think. When this pressure pushes obsessions and compulsions, the
child may become a fanatic little king–priest who demands that others comply
with his rituals.
The requirements for diagnosis of Tourette Syndrome

The primary diagnostic criterion for Tourette Syndrome is that muscle and vocal
tics are present for over a year. The tics are semivoluntary movements that are
usually preceded by feelings of itchiness in the musculature known as premoni-
164
TOURETTE SYNDROME: THE WILD HEART OF THE RESTLESS EXPLORER / 165
tory sensations. A motor tic may assume any movement that a body is capable of
making.
Children will show a vast variety of tics from the simplest eye blink to a
massively complex tic sequence involving jumping, arm throwing, body twisting,
head jerking, spitting, tongue clicking, and clapping. Vocal tics also come in an
amazing variety – grunting, clucking, shouting, swearing, screeching, and
barking. A vocal tic may assume any sound a human is capable of uttering.
Tourette Syndrome also includes a strong measure of vocal perseverance – the
semi-voluntary repetition of heard sounds called ‘echolalia,’ or of swearwords,
called ‘coprolalia.’ Some Tourettic youngsters show a fascination with scatology,
body and bathroom function, and will shock adults with incessant talk about
excrement and copulation using the vilest words.
Thankfully many children experience a remission of tics in the mid-teen years
and may experience further improvement in the ability to concentrate as well as a
drop-off of obsessional thinking. These effects are probably a result of the last
stage of limbic-brain growth that happens at puberty and of frontal-lobe growth
that happens in the late teens. Kids with severe motor and vocal tics, or severe
obsessionality, have the least favorable prognosis for an early remission of
symptoms.
Most Tourette children also experience obsessions and compulsions. It is
difficult to differentiate the performance of a compulsion such as repetitive
light-switching, jumping to touch a door jamb every time he enters a room, or
endless hand washing, from a tic. Dr Mort Duran, a preeminent Canadian neuro-
surgeon, himself diagnosed with Tourette Syndrome, says that the tics are
movements in response to feelings such as premonitory muscle itching or hypersensi-
tivity to clothes, and other stimulation. His says that compulsions are movements in
search of a feeling (Duran 1998). The act is done to makes things feel right, to get a
sense of order and satisfaction. The common denominator of perseverance is seen
in obsessions, compulsions, and the tics.
Though many professionals and parents of Tourettic children do not like to
admit it, these children may also experience profoundly disturbing thoughts
about sex, perversity, horror, nightmarish scenarios involving dismemberment,
the Holocaust, hurting a favorite pet, gouging out the eyes of parents, or innumer-
able wild and shameful sexual fantasies. I have never seen a child take any action
to move to completion of these scenarios, but I have seen many suffer the experi-
ence of them in horrific fantasy.
The presence of horrific thoughts is an indication of the dysinhibition of
emotional centers in the limbic brain. As I mentioned in Chapter 1, the limbic
system contains many structures that enable us to experience and understand
emotions and sensations and to react to events in our lives. The limbic system is
properly called the ‘animal brain’ because its representations of reality are very
primitive, animal-like and instinctive. Its voice is seen in our emotional and sexual
response and in our dreams.
Though the presence of tics is essential for diagnosis, the essence of Tourette
Syndrome is seen in the power of the limbic brain in people with TS. Most, if not
all persons with Tourette, experience intense emotional states that are far in excess
of the normal population. Unlike neurotypicals, whose behavior is governed by
the civilizing influence of the cerebral cortex and frontal lobes, in TS these struc-
tures may sit respectfully at the feet of the limbic system. The result is a great pre-
dilection for emotional dysinhibition – for excess in the emotional arena, for wild
behavior.
A profile of Tourette Syndrome

Children and teens with TS experience a powerful need to express body energy
that seems to burst out of them. They also have a powerful tendency for persever-
ance as seen in their predilection for repetition of behavior, obsessions, and com-
pulsions. The rhythm of life is jerky: hurry up, stop, do it again. Living this way
can exhaust and depress a child.
Many children with TS are also diagnosed with ADHD and show the
ADHDer’s tendency to act without thinking, to follow stimulus-cravings, and
have the set of learning disorders related to inattention that is seen in ADHD.
These include handwriting problems (visual-motor coordination), trouble
following sequences and steps (auditory processing issues), and trouble making
sense of written information (spatial problems and symbol identification).
Tourettic impulsivity is different from ADHD in that the quality of emotional
explosiveness and emotional power is greater in TS than it is in ADHD.
Dual-diagnosed children (ADHD and Tourette) tend to be extremely mad when
mad, extremely sad when sad, and extremely glad when glad. When scared, they
experience terror. The expression of any emotion is greatly magnified.
Children with TS may also experience a powerful feeling of contact with
nature. John S. Hilkevich, a man with Tourette Syndrome and co-author of a book
on the subject titled Don’t Think about Monkeys (Hilkevich and Seligman 1992), has
this to say about living open to life this way:
Out of my pain came visions of interconnectedness with the earth and sky and a
profound feeling in both my body and soul of being animated by the same Spirit
whom the universe cannot contain. With the same intensity of a Tourettic tension,
I can feel in my body the hop of a rabbit or the surrender of a hawk in flight to the
winds. I physically and emotionally feel the life force gushing from the wound of
an injured animal or leaking from a plucked tomato, and so I pray my gratitude as
I take life, with mixed feelings, to feed my own. How thin and transparent are the
boundaries of life and death. (p.194)
It is plausible that it is these qualities of emotional explosiveness and profound sensi-

tivity to nature that give people with Tourette Syndrome abilities in music, the arts,
and in athletics. Both these qualities are central aspects of the persona of the per-
forming artist. You can see them in the incredible musical intelligence of people
like Mozart (whose personal correspondence was filled with Tourette-like ‘potty
talk’ and who was known to have vocal tics), or Mahamoud Abdul Rauf, the
Tourettic lightning-quick free-throw star of the Denver Nuggets basketball team,
or in the persona of Witty Ticcy Ray, the drum virtuoso that Oliver Sacks profiles
in his book of essays, The Man Who Mistook His Wife for a Hat:
He was [like many Touretters] remarkably musical, and could scarcely have
survived – emotionally or economically – had he not been a weekend jazz
drummer of real virtuosity, famous for his sudden and wild extemporizations,
which would arise from a tic or a compulsive hitting of a drum and would
instantly be made the nucleus of a wild and wonderful improvisation, so that the
‘sudden intruder’ would be turned to brilliant advantage. His Tourette’s was also
of advantage in various games, especially ping pong, at which he excelled, partly
in consequence of his abnormal quickness of reflex and reaction, but especially,
again because of ‘improvisations,’ ‘very sudden, nervous, frivolous shots’ (in his
own words), which were so unexpected and startling as to be virtually
unanswerable. (Sacks 1989, p.92)
Echolalia, swearing, inappropriate touching, and scatology

The predilection for echolalic mimicking of his teacher has gotten many a
Touretter in trouble. Though this child may have a difficult time understanding
the meaning of things that people say to him (auditory processing problems), he
has no difficulty imitating them. His talent for replicating vocal pitch is incredible,
as is his auditory acuity.
Other children swear. In TS there is a compulsive, repetitive tone to the
swearing that makes it sound unlike the use of swearwords to express anger.
Children may write swearwords (coprographia). If this happens in school, the
child can be coached to write out the words and then put them in a place specified
by the teacher. If the problem is TS, the chances are the child will agree to the
arrangement without protest. He knows he has a problem.
Younger, profoundly Tourettic children may touch others sexually, or inappro-
priately. Crotch grabbing, kissing, and breast fondling are indications that the
child’s frontal lobes are not working, not inhibiting the limbic brain at all. These
behaviors are called ‘copropraxia.’
Scatology is also seen in about a third of TS children. They delight in talking
about excrement, and enjoy hooking adults into scolding them for doing so.
Given the preeminence of the limbic brain in the personality of the Tourettic
child, it makes sense that he should express the animality of his nature with
themes involving all the bodily functions.
Hypercharged anger and rage in Tourette Syndrome

Many children with Tourette Syndrome have a problem with rage (Budman and
Bruun 1998). The rage may be caused by a comorbid Bipolar Disorder (described
in the next chapter). Or it may be less an expression of affective illness and more
an expression of the Touretter’s predilection for extremes in any domain. When he
is angry, he is just damn angry and you’d better get out of the way. There is a
bullish quality to the TS rage that is different from the Bipolar variety. Tourette
children generally have more control over their anger than kids with comorbid
affective issues.
Dr Mort Duran, mentioned above, tells the story of his own episodic anger in
his role as a neurosurgeon. He said that sometimes, in the middle of his rounds, or
at some point when his professional services were not being used in acute care, he
would get enraged. The staff knew about his TS and would just give him space
when he started ranting about this or that. The rage was there but the man was not
depressed. He would express it and get back to work.
Dr Duran’s example and that of many other TS kids I have worked with has
taught me that rage in TS may or may not be comorbid with pediatric Bipolar
Disorder. The locus of TS rage is probably the same area of the brain that is
involved in other rage conditions: the limbic system’s amygdaloid structure and
the temporal lobes of the brain adjacent to that structure. But the rage seen in TS
does not necessarily express the aggressive depression of early-onset Bipolar
Disorder.
Tourettic kids may also have the irritable personality that is the temperamental
signature of TS. I was delighted with the creativity of a psychiatrist colleague who
commented to one of his pediatric TS clients that he would make a great ‘pastry
chef.’ ‘You have the perfect personality,’ the doctor said. ‘You are irritable, brilliant,
and hard to live with!’ His TS client was able to hear this and be quite pleased
himself that there was somewhere that his temperament could fit in.
The Tourettic child follows natural power

The common denominator of many of these manifestations is the TS child’s
fine-tuned interest in power and how it is expressed in nature. These kids are not
interested in having power over people, though they, like their ADD and Bipolar
cousins, can be extremely oppositional. But they are interested in what makes
things powerful in nature and what gives a person power in the extraordinary
sense of human relations. They are natural scientists who are fascinated by the
power of energy, be it electrical, hydraulic, solar, chemical, cybernetic, or mechan-
ical. I have worked with many Tourettic children who are creative geniuses in the
physical sciences, though they often abhor the humdrum, everyday science of
researchers – the careful categorization of facts and details. They like to make
things work – and work in different and unusual ways. My own son Gregory,
diagnosed with TS and a genius with computers on both the hardware and
software side, once described the ‘twenty-five different kinds of sparks’ one can
get from making mistakes or through intentionally tinkering with electronic
instruments and computers. This is a wisdom gained through trial and error, and
the perseverant following of paths that power takes!
Tourette children also follow power in their expression of the disorder in a
social setting. The words that they repeat compulsively may shock other people;
they may be obscene, perverse, or racist. These words are delivered without
malevolence but they can be extremely hurtful. Many people wonder why
Tourettic persons choose certain terms for coprolalic expression. One hypothesis
is that these words were automatically locked into the hear-it-repeat-it loop
because of the emotional intensity with which they were first heard. The TS
child’s felt sense of ‘This is powerful, hot stuff. People get nervous around this
word,’ had the required signal strength to stick the expression into the limbic
brain where it became part of a perseverant loop for verbal or graphic expression.
Symptoms are suppressed in the flow state

Children and adults with Tourette Syndrome also manifest the peculiar ability to
suppress symptoms when involved in ‘flow state’ activity. This effect has been
noted by Oliver Sacks in his description of people with Tourette (Sacks 1992). All
symptoms go into temporary total remission. Mihaly Csikszentmihalyi
(Csikszentmihalyi 1990) calls the human ability for total focus in the face of
extreme challenge the ‘flow state.’ People with neuropsychological issues may
demonstrate extreme competence in an endeavor if the mix of challenge and moti-
vation is present. This ability for flow-state performance is seen in Tourette
Syndrome, ADHD, and Asperger’s Syndrome.
Research has shown that the human brain emanates energy at specific frequen-
cies when involved in different activities. Brain-wave states in the Alpha (focused
relaxation) and Beta (concentration) patterns are probably close to flow. It is as if
the activity is such an intense delight to the brain, possibly causing an Alpha/Beta
wave state, that the whole structure comes into line. In flow, the limbic and cortical
brains work together, read off the same sheet of music and provide smooth coor-
dination of higher and lower functions.
Many people with Tourette Syndrome say that there is another time when
symptoms stop – while making love. The seat of sexuality is the limbic brain’s
amygdala and its immediate neighbor, the thalamus gland. It makes sense that the
limbic system is deeply soothed by sex and for a little while is not symptomatic.
In stand-alone Tourette Syndrome, medication can treat depression

and obsessionality
Depression in Tourettic children can be treated with medication in the antidepres-
sant class if Bipolar Disorder is not present. The antidepressant class of medica-
tion including the tricyclics, such as imipramine (b. Tofranil), desipramine (b.
Norpramine), and clomipramine (b. Anafronil), and the Selective Serotonin
Reuptake Inhibitors (SSRIs) such as fluoxotine (b. Prozac), have been lifesavers for
many TS kids with obsessions, compulsions, and depression secondary to their
Tourette Syndrome (non-Bipolar related).
Other medications may help with the tics. These include the antihypertensives
such as clonodine (b. Catapres) and quanfacine (b. Tenex). In severe cases, medica-
tions in the neuroleptic class such as pimozide (b. Orap) and haloperidol (b.
Haldol) have been used, though the side-effects (mental dullness, weight gain) of
these medications do not put them in a first-use tier for treatment. The possibility
of developing Tardive Dyskinesia, a condition of disfiguring facial tics which may
last past the cessation of medication, is a big argument for avoiding the
antipsychotic class. The newer antipsychotic medications which include
olanzapine (b. Zyprexa) and risperidone (b. Risperdal) show less chance of
causing TD and they may also treat the severe cognitive distortion and obsessions
that afflict kids with TS. The use of neuroleptics is an acceptable option if a child is
experiencing TS symptoms so severe that he is completely impaired in his daily
function and nothing else works for him.
As of this writing, a new anticonvulsant, topiramate (b. Topamax), is showing
promise for both mood stabilization and reduction of the tics seen in Tourette
Syndrome.
Eight survival strategies for managing the most exhausting aspects

of Tourette Syndrome: Tics, obsessions, and emotional explosiveness
1. Help the child use his tics to focus himself
Dr Michael Norden in his useful book Beyond Prozac (Norden 1995) points out
that the repetitive motion of chewing gum raises serotonin in the brain. Picking
up on this notation, I have interviewed many of the Tourettic children I work with
to determine if their tics help them focus. The common assumption is that if a
child resists the performance of a tic, his ability to focus collapses because he is
focusing on not doing the tic (the ‘pink elephant’ effect). My interviews provide
evidence that, for some children, it is the tic itself that raises serotonin and
dopamine in the brain (to enable better focus) and not the avoidance of it that
distracts the child from his task. Donna Williams in her telling Appendix to
Nobody Nowhere: The Extraordinary Autobiography of an Autistic (Williams 1992,
p.213) says that the rocking motion and head banging that she performed as an
autistic helped her maintain continuity of her perspective and helped her focus.
Considering that the tic may have a beneficial effect on focus and concentration
suggests a new approach to dealing with tics in the classroom. First, the question
becomes not should the child have tics, but which tics should he have? And it
becomes clear that if he is not allowed to tic in class, his learning will be adversely
affected. Providing a refuge for the child to express his tics is a humane adaptation
but if that is where he is able to focus, he may be getting cheated out of the
education he is entitled to in the regular classroom.
This argues for looking at a child’s tics to determine which ones may be benefi-
cial and which, because of their severity or potential for muscle injury, need to be
extinguished with therapy, such as the naturalistic habit-reversal method
described below.
My own son Gregory has greatly enlightened me on this question. For years
Gregory has used calisthenics to improve his concentration. Recently he has
developed a whole-body vibration that he performs in his seat in class that he says
helps upregulate his ability to focus. It may be time for teachers to understand that
those annoying tics, leg shaking, running around, and ‘hyperactivity’ of Tourettic
children are necessary if they are to participate fully in the academic program.
As a survival strategy it becomes clear that two things have to occur. First, a
conscious choice has to be made about what tics are acceptable. Then a course of
therapy to treat those tics which are unacceptable must be identified. This prob-
lem-solving process should occur with the full participation of the child contrib-
uting information on his own experience so as to craft a plan that he can support.
2. Help him control the tics with natural habit reversal

In Survival Strategies for Parenting Your ADD Child, I outline a behavioral approach
for reducing and eliminating the tics seen in TS with a process titled ‘Habit
Reversal’ (Bruun, Cohen and Leckman 1988). This protocol, borrowed from the
tool kit of behavioral therapy, is a near cousin of the response exposure and pre-
vention method used with Obsessive Compulsive Disorder in that it involves the
performance of a ‘competing response’ to the urge to tic, along with a built-in
relaxation exercise. An example of a competing response would be the perfor-
mance of a quiet breath in through the nose instead of a throat-clearing tic, or the
slow, deliberate movement of the head to the left when the urge is for a violent
head throw to the right. The parent or therapist needs to work with the child to
identify specific tics and competing responses he can use for each tic.
With practice a child can learn to do habit reversal very unobtrusively. He may
rub his neck slowly while standing in line at school, appearing to be giving
himself a massage while he is completing a neck tic habit reversal. Some people
naturally stretch and tone all the time and it really doesn’t look that unusual.
People with tics and obsessions learn how to hide them, and this technique makes
that effort more efficient and more a part of the healing process.
• To deal with the anxiety that accompanies a tic attack, have him
breathe down to his diaphragm as if he were filling up a bottle from
the bottom first. Have him hold that breath and release it gently.
• To correct an eye-rolling tic, the child might be assisted by: (a)
devising a competing response in which he rolls his eyes slowly in a
different direction than the tic, and (b) using an eye-relaxing exercise in
which he puts the palms of his hand over his eyes, presses very gently,
and imagines black velvet or black night to soothe his eyes.
• To relax a full body tic during the day at school, the child may be able
to unobtrusively clench his body as he sits at his desk. The idea is to
curl the toes, tighten the arms and other muscle groups, and hold this
position seven seconds while holding his breath. When time is up, have
him breathe out and release all the tension and imagine that tightness
and discomfort are streaming off him on all sides and going into the
ground.
Staying motivated to participate in the healing process of behavior therapy is a
real challenge for kids with Tourette Syndrome. A kid has to know that there is a
reason for doing something difficult. It may be helpful to talk to him about how
habit reversal works by saying that it ‘closes the door’ on the bothersome premon-
itory sensations that come before the tics and permits the muscles to relax and
soothe themselves. Start with the least problematic tics and work from there.
3. Be calm and focused to help him calm and focus

Tourettic children are extremely sensitive to the emotional moods of others.
Knowing this, you may be able to calm the hyperactivity and ticciness of your
child by deliberately calming yourself. ‘You must be,’ as the woman stated in the
example I used in the Introduction, ‘very quiet in your heart.’ Your child needs you
to absolutely have your feet on the ground, to have perspective, so as to help him
remember how to restore control in himself. Breathe down to your diaphragm,
affirm your love for your child to yourself, and put yourself unobtrusively around
him. He is so sensitive to you, that just your presence will help him focus.
Being quiet in your heart does not necessarily mean being passive. It may mean
that you take action to give him a sense of boundary over his wildness: if you’re in
the grocery store, you park the groceries and leave. If you’re waiting in line at a
movie, you do an about-face and return to your car. When you’re quiet in your
heart, you are experiencing empathy for him and in so doing, teaching him to
experience it for himself.
Your best bet of helping him through is to drop into the spiritual perspective:
to see yourself as the guide of an exceptional kid into adulthood who really needs
some help. Be aware that he is not trying to get you, but that he is miserable and
needs to blow off some steam. You must walk the tightrope between helping him
gain relief and protecting the rights of everyone around him.
4. Use pet therapy to help him manage his symptoms

Many of the parents of TS kids I work with tell me that family pets have played an
important role in easing the symptoms of their kids. Gregory had a series of pet
rats that were central parts of his life from the time he was eight until about the age
of twelve. They gave him companionship and loyal attention during these lonely
years.
Dogs are the most often cited therapeutic companions of children with TS.
The dog will anticipate the emergence of the mood that precedes the child’s
expression of rage and will alert parents to attend to the child by yelping and
making directive movements toward him. The animal will be extremely alert
during the rage and may visibly relax several minutes before it ceases. The pet’s
behavior gives evidence that it is able to read the child’s nonverbal signals, most
probably to include a change in body scents that are not detectable to humans. The
animal greatly relieves family stress by giving everyone warning that something is
afoot. It is much easier to handle the rage if you see it coming.
Pets exercise a calming influence on the child’s mood at other times. When he
feels that no one in the world can understand him, he has the meditative presence
and absolute love of his dog to depend on for consolation. This can be an
extremely important resource for him.
5. Minimize your involvement in obsessions

The general rules for parents should be: minimize your involvement in his
obsessionality, help him compensate as much as possible and get him into
treatment immediately. If he cannot eat until parents assure him that ‘The forks are
clean of germs, the plate is clean of germs, the food is cooked clean of germs,’ etc.,
have him get involved in monitoring the dishwasher and checking on dinner
preparation, but minimize your participation in his ritual. If he cannot tolerate the
sight of bare elbows, do not hustle around your house when friends come over in
the summer, trying to cover up their elbows. Suggest that he go somewhere else if
he has to. Expect an angry retort and let it go. If his obsessionality is severe, get
involved in medical or naturopathic treatment. Your child’s issues are caused by an
imbalance in brain chemistry and he needs to be helped by a doctor.
USE THE FOLLOWING STRATEGIES TO MANAGE OBSESSIONALITY

The type of Obsessive Compulsive Disorder that many Tourette children are
diagnosed with is generally less severe than when OCD is the stand-alone
diagnosis. The OCs of Tourette Syndrome tend to change from year to year and
can include:
• hand washing
• ritualistic behavior such as lining things up
• ritualistic eating behaviors and eating strange foods
• demanding that adults say certain things at certain times
• checking rituals, such as light-switching or doorlock checking
• compulsive perfectionism on written work in the classroom
• avoidance of certain words that set off compulsions such as ‘God,’ or
‘the devil,’ or any number of other words to which the child has
attached special meaning
• inability to sleep at night because of obsessional thought-loop
repetition
• fixation on certain visual images (the eyes in photographs or a person’s
uncovered elbows or toes).
6. Help him achieve a sense of redemption

Because Obsessive Compulsive Disorder often has a moral or religious dimension
– the compulsion keeps the child safe from an unimaginable evil – a compensatory
strategy may be to give him a safe and private place to express his sense of religios-
ity; to pray for good fortune and safety. Consider setting up a personal altar space
for him in his room that contains precious and positive symbols of his life success.
Better still, encourage his involvement in community work with churches or other
worthwhile activities in which he experiences a sense of accomplishment and
redemption.
Another compensatory strategy is the use of ritual to close obsessive loops,
such as teaching him to imagine that he has a lockable box in his mind into which
he can put obsessional thoughts, and once the box is closed, the thoughts are tem-
porarily removed from consciousness. See the exercise entitled ‘The Rose’ in
Survival Strategies (Lynn 1996) for an in-depth exercise in loop closing and the
mental filing of obsessions.
Never shame him or laugh at him. As difficult as the obsessions may make your
life and his, they are not remedied with anger or scolding or by ‘beating the devil
out of him.’ In fact, psychological attack on an obsessing child may make him
more reclusive, more isolated, and less available for treatment.
Psychotherapy can be useful for obsessing children in that it gives them an

opportunity to express their darkest thoughts without fear of recrimination. This
can be a powerful plus in terms of allowing the child to decompress and tip up his
mood from the depressed aspect of his Bipolar Disorder mood swing.
7. Use natural response prevention to nudge your child toward

a reduction in obsessionality
A child’s obsessions will wax and wane in the same fashion as do his tics, though
obsessions tend to last longer. The best way to encourage the ‘waning’ phase is to
give the child natural opportunities for the prevention of his responses. Though it
is not known how response prevention extinguishes obsessions and compulsions,
this type of exercise seems to eventually result in the lessening of control of the
child’s feeling that he is commanded to do something.
Early OCD studies showed that response prevention results in an upregulation
of the brain’s level of serotonin, the neurotransmitter that closes the door between
the parts of the child’s brain that contain the obsessive thoughts and the parts that
process them into consciousness (Baxter et al. 1992). Here are some examples of
natural response prevention:
• Encourage your child to eat with friends because he cannot practice his
dinner rituals at their houses.
• Gently expose him for a short period of time each day to a worrisome
stimulus; if he has an obsession about seeing bare toes and elbows,
wear sandals when you go shopping. If he has a hand-washing
compulsion, let him wash only once at the shopping center and then
hurry him away for a treat.
• Reward him for decreasing the number of times he clicks room lights
on and off upon entering a room. Have him keep a tally of his success
for the day and give him a small financial reward for his success at the
end of the week.
Dr David Comings’ research indicates that OCD may be present in various forms
throughout the person’s life once it emerges (Comings 1990). Managing
obsessionality needs to be a continual task that the person takes charge of himself.
This process begins as caregivers become more effective at managing the child’s
context so that he is required to exercise the psychic muscularity that he needs to
be successful as he grows up.
8. A technique for dislodging an obsessive fixation

Obsessive thought images, feelings, and words are often stuck in a child’s con-
sciousness at the center of his internal imagery – at the twelve o’clock position in
his mind, front and center. An image stuck in that place can get incorporated into a
child’s pressured speech or tendency to perseverate, causing him to either bother
adults incessantly or drive himself crazy with the thought of it. Here is a way to
move the obsessional fixation out of its central place in his consciousness:
1. Explain to the child that people tend to see internal pictures as follows.
They see the past on the left, the present in front, and the future to the
right. Ask him to test this by remembering what happened right after
he got out of bed this morning and then ask him where in his mental
landscape he saw this image. He will probably say ‘To my left or by the
nine o’clock position on the [analog] clock face.’ Talk with him about
how when things get stuck in our minds, they usually are stuck straight
ahead of us so that everything we do is seen ‘through’ our fixation.
2. Ask him to deliberately focus on the thought he is obsessing about, to
imagine visual details and really get to know the thought consciously.
Now ask him to picture it as if it is on a movie or computer screen.
When he has done this, ask him to tinker with the light value on the
screen so as to darken it or brighten it.
3. Now ask him to deliberately move the screen to the left of his visual
field and down so that it is moving behind him (the appropriate place
for things in our past). As he does this ask him to make the screen
much smaller, and turn down the illumination on it so that it is barely
visible. Suggest that he use a little clicking sound that he subvocalizes,
to lock the image into place down left behind him.
4. Make sure to replace the image with some thought that interests and
motivates him but about which he will not obsess. Talk about the fun of
playing soccer, going swimming, seeing his friends at school, or
accomplishing something that he has been looking forward to.
5. Finish the exercise by asking him to take a deep breath and experience
‘just feeling relaxed, knowing that we always can take things out and
look at them if we want to but that it also feels good to put them
behind us when we need a rest.’
Conclusion: Is Tourette Syndrome a curse or a blessing?

The French word blesser – ‘to wound’ – is the root of the word ‘blessed.’ Through-
out human history people have told stories about how heroes were wounded and
how dealing with the wound was the source of growth in their capabilities and
contributions. From the ancient Greek stories of Hercules, the biblical story of
Jonah and the whale, through the Arthurian legends, to the modern genre of
movies such as Schindler’s List and Star Wars, the hero could not have achieved
greatness without the wound. Children with Tourette Syndrome carry certain
wounds or challenges that are the central focus of their struggle for success and
normalcy. These include the perseverance, anxiety, overarousal, rage, intensity, and
loneliness that are seen in TS. Are these challenges a curse, or the path toward a
better world for themselves and others?
On a personal level, TS may be seen as a pathway to a child’s self-awareness
and self-acceptance on levels that are impossible for children without this
challenge. I have mentioned that Tourettic children seem drawn to break taboos
and to invent. Their echolalia, coprolalia, interest in every form of power, ardent
sexuality, irritability, rage, and tics all violate social taboos. The child is forced by
his own nature to come to terms with who he is. He cannot be what others want
him to be. He must be himself.
And he must invent new solutions and follow power. Be he a Mozart, a
Mahamoud Abdul Rauf or a Witty Ticcy Ray, he will follow his own urges to bril-
liance and his contribution will be original, creative, and fulfilling to himself and
others.
I have noticed that some Tourettic boys in the age range of eight to eleven or so
enjoy cross-dressing as girls. They are fascinated by the taboo on male–female
impersonation and drawn to the power that simply wearing a dress gives them
over adults. Cross-dressing in Tourette children does not signify emotional distur-
bance but is another example of how the TS child delights in uncovering the heat
beneath the surface of social taboos. He lives the Restless Explorer archetype as he
dives beneath social niceties to look at how things really are.
In primitive cultures, children with this predilection for shape shifting and
cross-dressing would probably have been chosen to train as shamans, the
medicine people who are able to communicate with the spirit world and bring
back the good energy of deceased ancestors to protect the tribe and heal illness.
The tribe would believe that the fundamentally unorthodox attitude of the child
was an asset – not a liability – which could be used to face the challenges too big
for the culture to handle. This capability for daring invention is the blessing for
humanity that TS holds.
CHAPTER 10
A Shoulder to Scream On
How to Help Children Living with the Fiery Extremes
of Tourette Syndrome and Bipolar Disorder
The child who is diagnosed with both Tourette Syndrome and Bipolar Disorder
has a different set of problems than the child who is ‘simply’ TS. These issues
relate directly to the presence of the directed dysphoria or aggressive depression
that is signatory of the early-onset Bipolar Disorder condition.
Tourette Syndrome typically includes mild OCD and ADHD (with very severe
impulsivity) as well as the classic symptoms – the motor and vocal tics. If a child
has these issues, he will need a lot of help, but his prognosis is good. There is no
reason for his self-esteem to be dangerously low, if he is given the right attention
at home and appropriate accommodations at school.
But if Bipolar Disorder is present, the child is at much greater risk. All the
excesses of BD, the hyperemotionality, rage, and depression, are made worse by
the overall systemic overcharge of Tourette Syndrome. For this reason, it is
important to know when Bipolar-related issues are present. Nine markers for the
presence of Bipolar Disorder are:
1. Presence of mood shift

The first criterion for Bipolar Disorder is that mood shifts occur or that the child
shows the ‘mixed-state’ mood condition noted in Chapter 1 that is signatory of
early-onset Bipolar Disorder. When BD is present, the child’s attitude will worsen
as a feature of his mood swing, every day or on a fairly predictable periodic basis.
And his dysphoric mood will have the potential for sudden downshift into violent
rage.
Children with Tourette Syndrome may have chronically cranky personalities –
they whine and complain and are difficult to be around from about the time they
start to talk. This behavior is probably a result of the low-level depression they
experience. A child’s tics, learning problems, and oddness make him a pariah at
school and interfere with his success in many aspects of his life. But the low
self-esteem and depression that he experiences are quite different, and less
178
A SHOULDER TO SCREAM ON / 179
profound, than the anguished despair or rage of Bipolar Disorder. And it is a

chronic feature, not an aspect of his mood dysregulation.
2. Severe cognitive distortion and tyrannical behavior

Though teenagers are notoriously self-centered, the Tourettic teen with Bipolar
Disorder will stand out in his inability or unwillingness to admit his part in the
problem. In fact, he may deny, straight out, the most obvious evidence of his cul-
pability. If his actions hurt someone else, he may justify them by saying that the
other person ‘had it coming.’ He will rage at or threaten anyone who tries to
reason with him.
Many children with Tourette Syndrome have gory thoughts that they cannot
shake (Comings 1990). Thoughts of suicide and death may represent the obses-
sional, somewhat gothic, state that is seen in TS or may, in more dangerous form,
express the suicidal ideation typical of Bipolar Disorder. This is an important dis-
tinction to make.
Empathy may be lacking in cases of the dual diagnosis. The Bipolar/TS child
may be cruel to animals or may torment younger siblings. Lack of empathy can be
confusing to people who live with gentle Touretters who do not have the dual
diagnosis. The essence of the disorder for these kids (with stand-alone TS) is their
connection with the ecology and spirit of things and, if anything, they seem
overly conscious of the hurt that they do to others. But when BD is on board, the
child may not experience this connection with others and behaves like a nasty
little dictator who willingly punishes others or inflicts pain on them if the spirit so
moves him.
Indicative of the essential difference between TS as a stand-alone issue and the
dual presentation is tyrannical behavior. In his Tyrant persona, the child tries to
take over the household by suggesting with great seriousness that he needs to be
in charge. This is not adolescent rebellion. It is an attempt at a coup d’état of the
family system. He may threaten his parents with weapons or get in their faces with
demands that they give him money, or control over siblings. If he does not get his
way, things may become violent and ugly very quickly. If he senses weakness in
the position of either parent, he will attack that weakness mercilessly, abusing the
parent psychologically and physically. ‘You must tell me exactly why I cannot go
downtown until two a.m.! You have not told me why! Give me three good reasons!
And don’t give me any of that tired old bullshit about my friends! So, what are
your reasons? What’s your problem? You are such a fucking wimp, you don’t
know, do you?’ This kind of language, aggressiveness, and contempt are qualities
that are not carried by Tourette Syndrome but express the misery of the child’s
affective disorder.
3. Presence of pressured speech, not echolalia

The TS tendency to repeat words, the ‘echo’ in ‘echolalia’, may sound somewhat
like pressured speech (indicative of Bipolar issues) but is quite distinguishable.
Unlike echolalia, pressured speech will organize around continual shifting
themes, not the sounds of words as is the case in TS. It is marked by a greatly
increased volume of words, and many children with Bipolar challenges will
demand that adults listen to it. The child may begin by ranting about his teachers.
Then he shifts gears to complain about all the kids at school who bully him and all
the things that are wrong with them. Interspersed in this stream of words may be
nonsensical questions to parents which they must answer, or the child will get
angry. Or the pressured speech may express some fixation about the child’s desire
to have his parents buy him something for which he pesters restlessly.
The presence of pressured speech is not in itself evidence of Bipolar Disorder.
This phenomenon is also seen in Asperger’s Syndrome, Pervasive Developmental
Disorder (a catch-all diagnosis which includes autism and Asperger’s) and in
ADHD to some extent. But if it is present with other symptoms, it may be caused
by the hyper-pressured cognitive process that occurs in the hypomanic phase of
Bipolar Disorder.
4. The child requires his parents to comply with his obsessional fixations
Children with Tourette Syndrome experience obsessions and compulsions but
they do not as a rule try to force others to comply with their obsessions. The
obsessions of children with the dual diagnosis can be heavily flavored with the
irritability, hyperexcitation, and psychotic thought patterns of the Bipolar con-
dition and they will inflict these phenomena on others. An eight-year-old girl
with the combined diagnosis may have an obsessional fixation on avoiding any
other child in her class outside of school, and may become enraged if her parents
drive near school. Another child will refuse to go to school because of a fear of
germ contamination. Or the child will destroy her toys, books, or behave cruelly
toward the family pet in obedience to an obsessive ‘feeling’ that told her to
commit the acts to ‘purify’ her family. In children with Bipolar challenges,
obsessionality may be accompanied by violent hallucinatory commands. If this
occurs, the family should investigate psychiatric hospitalization as an option.
5. The Bipolar/TS child is hyperenergized at night

The Tourette child without Bipolar Disorder may have no problem getting to
sleep. Though children with TS and ADHD may have night terrors, the ‘bad trip,’
sleep-awake hallucinations that signal an imbalance in the brain’s serotonergic
system, the presence of sleep-onset insomnia which may keep the child awake all
night is indicative of the presence of Bipolar Disorder. The child or teen will seem
lost in a half-awake fog working at his computer, raiding the refrigerator,

watching late-night TV, or disappearing into the night to meet his friends. The
next day his mood will be extremely ugly. Sleep deprivation causes the emergence
of mania in children with Bipolar challenges (Wehr 1991) and this mania may
assume the form of the aggressive depression of pediatric BD.
6. The condition may be worsened by stimulant and antidepressant medication

Negative reaction to psychotropic medication in the serotonin reuptake class or
tricyclic class may indicate the presence of Bipolar Disorder. Many children with
Tourette Syndrome seem to respond to SSRI medication such as fluoxotine (b.
Prozac) or the tricyclics such as imipramine (b. Tofranil) to control obsessionality
and limit hyperactivity. However, these medications may make things much worse
if BD is also in the picture by causing the child to become hypomanic, agitated,
aggressive, or psychotic.
7. Conduct issues express impulsivity

Research indicates that 69 percent of teens diagnosed with Bipolar Disorder also
meet the diagnostic criteria for Conduct Disorder (Kovacs and Pollock 1995).
Chronic lying, stealing, fire-setting, or substance abuse are listed as symptoms of
CD. Children with stand-alone Tourette Syndrome have no more chance of
ending up in trouble than normal kids. But if conduct problems are present, a
careful assessment for the presence of Bipolar Disorder is indicated.
Conduct problems of the Bipolar/TS temperament are caused by the child’s
impulsivity, the not-thinking-before-doing response, that is a major problem in
Tourette Syndrome and is made worse by the lack of empathy and remorse seen in
Bipolar Disorder. If you were just dealing with one disorder or the other, it would
be easier to get control. But the impulsivity caused by the presence of both condi-
tions can be extremely dangerous to the child and others around him. The
thievery, sexual misconduct, drug abuse, and destructiveness that occur keep the
whole family in a state of crisis.
8. Sexual hyperacuity as a clue to the presence of Bipolar Disorder

Hypersexuality is seen in some children with Tourette Syndrome – the child may
obsess about sex or be fixed on taboo images involving sexuality (Comings
1990). But Tourettic sexual hyperacuity is different from the Bipolar variation. In
Bipolar Disorder, inappropriate sexuality has a deliberate, directed, intentional
quality to it. In Tourette Syndrome, sexually inappropriate behavior will have a
more instinctive and developmentally delayed feeling to it. Younger Tourette
children (to age eight or so) may kiss other kids, may fondle the breasts of women
around them indiscriminately, may publicly masturbate, crotch-grab, or sexually
exhibit themselves. As shocking as these behaviors are, the Tourettic child will not
experience sexual arousal but will perform the actions in a tic-like fashion and
may be deeply embarrassed after the event. Inappropriate sexual behavior looks
like a tic or tic-obsession. By the time most Touretters are in their teens, they have
learned how to behave appropriately.
Many children and teens with Bipolar challenges will experience a predilec-
tion for promiscuity in the hypomanic phase. In Bipolar Disorder, there may be a
deliberate and manipulative quality to inappropriate sexual behavior, and this
behavior will show a development in sophistication as the child grows into her
teen years. She will report sexual arousal or appear to be planning a behavior.
Bipolar teenagers may quickly get the reputation of being promiscuous. They are
at greater risk for involvement in sexual behavior that is experimental,
anonymous, and spontaneous – the three hallmarks of dangerous teen sexual
expression.
It is important to look closely at the sexual issues of a child to differentiate if
she is experiencing these symptoms as a result of Bipolar Disorder or TS.
Different medication and psychotherapeutic treatment modalities are in order in
each situation. The Tourettic child who demonstrates inappropriate sexual
behavior may be helped with response prevention training and self-awareness
counseling. The Bipolar child may require psychotherapeutic intervention along
the lines of that used to treat substance abuse or sexual addiction, augmented with
support for self-esteem development. The SSRI class of medication may treat the
sexual hyperacuity of Tourette children (Prozac generally suppresses sexual
arousal) but may make the mania worse if a child has Bipolar Disorder.
9. Rage is expressed more violently in the dual diagnosis

There are significant differences in how rage is expressed in TS as a stand-alone
condition and when the child has the Bipolar/TS diagnosis.
Tourettic rage is a result of the coming together of several stressors that may
include:
(a) exhaustion from tics
(b) low tolerance for stress
(c) interruption of obsessionality
(d) a tendency for emotional explosiveness
(e) ADHD-related deficits in self-control and problem-solving.
The volume of Tourettic rage may be frightening. The child feels terrified at this
loss of control and explodes in anxious frustration, hitting out, running away, or
crying and screaming so hard that blood vessels may break in his face. But the
volume and intensity in the blind fury of Tourette Syndrome cannot match the
much greater force of rage driven by Bipolar Disorder.
When Bipolar Disorder is on board with the TS, the child’s rage will have a
more directed effect. All the symptoms of Bipolar-driven rage listed in Chapter 3
will be seen. The rage will go on much longer and the child will not show remorse.
He will have severe thought distortion, a craving for the stimulation of a
violent encounter with his parents, and he will show the aggressive depression of
the mood disorder. In a TS rage, the child may punch a hole in the wall or dent the
refrigerator by hitting it with a pan. In a Bipolar rage, the child will taunt his
parents, deliberately trash their property, stab his brother’s pet frog, or fantasize
about going on a killing spree. The rage of Tourette Syndrome is felt as a random
explosion. The rage of Bipolar Disorder is directed fury; it feels like an act of war,
not like a violent act of nature that is the rage of the child with Tourette Syndrome.
The different challenges that children with the dual diagnosis experience as
they grow into their teen years
Dual-diagnosed children go through major changes in the way that their
symptoms manifest themselves at different times in their lives:
As young children (birth to eight years) they
• may be powerfully impacted by extreme cognitive distortion and
hallucinations and pushed by the extreme emotional pressure and the
physical pain of tics
• experience the inability to achieve satisfaction (Reward Deficiency
Syndrome) by nature of their Bipolar Disorder, and are pulled by
powerful cravings for stimulation by their Tourette side
• are cognitively disabled by the auditory processing difficulties of the
Tourette side (they have a hard time understanding what is said to
them) and the low-level chronic paranoia from the Bipolar side
• share qualities of impulsivity, poor behavior editing, and intense
emotionality with ADHD children.
As pre-adolescents they
• are pulled to complete openness to others by the Tourette side and to
anempathy by the Bipolar side
• experience extreme confusion about who they are, because Bipolar
mood shift makes their days totally unpredictable. This comes at a time
when their concept of self is firming up as they move through their first
big identity crisis (which usually happens around age twelve).
As adolescents they
• have a hypercharged desire for stimulation from both the Bipolar and
Tourettic sides, which makes them vulnerable to substance abuse and
law-breaking or conduct-disordered behavior
• are naturally moved to separate from parents and merge with the peer
group but their neurological challenges make this separation very
difficult. They are emotionally younger than neurotypical children and
need their parents’ help longer.
• find their gifts at the extreme end of the continuum. Touretters are
performers, musicians, artists, quick people – the heart of Tourette is
speed and intuitive knowing. Those with Bipolar-type challenges find
their art crashing into problems, diving deeper and higher than others.
Four survival strategies for parenting children and teens

with Bipolar/TS challenges
These strategies help the dual-diagnosed child reduce the tension that he experi-
ences and get better control of his life:
1. Parent from the perspective that ‘Today is a good day to die’

This homily, attributed to the Native American tradition, means ‘Live with total
commitment to what you have to do.’ This is good wisdom for parenting the child
with the dual challenges of BD and TS in his psyche.
Stay in control of your household and be willing to go all the way to a call to
the police to stay in charge. Contain the Tyrant in him for your good and his. Insist
that he live by your rules as long as he lives in your home. Allow negotiation but
also let him know that you expect him to behave responsibly. Take the lock off the
door to his room. Lock your own bedroom if you have to. Lock up scissors, knives,
matches, the silver and good crystal. Protect your computer, your credit card PIN,
and your passwords. Behave strategically.
Parents must be in charge. Professionals must do all that they can to support
the parents’ authority and improve the family negotiation process. The directed
ferocity of the Bipolar temperament combined with the wildness of the Tourette
side tests the strength of parental boundaries in the child’s life. But he must not be
allowed to demolish these boundaries. The heart of success for the child is the sure
knowledge that his parents are in control and will not protect him from the conse-
quences of his actions. Reference Chapter 3 for ways to maintain control of rage,
and Chapter 13 for ways to get back-up from community resources, including the
call to 911.
2. Balance the extremes of each diagnosis with the positive aspects of the other
The positive features of the Restless Explorer archetype of Tourette Syndrome are
fearless exploration, movement, curiosity and energy, mixed with a powerful con-
nection to nature. The positive features of the Warrior archetype of Bipolar
Disorder are its knowledge of intense states of being and its devotion to achieving
personal goals whatever the cost. Wise caregivers bring as much of the positive
aspects of these archetypes into the child’s life as they can:
• They get the child into nature a lot and give him time for solitary and
self-sufficient activity. They encourage him to hunt the wisdom of
nature.
• They promote his participation in artistic activities or scientific pursuits
and they are not offended or alarmed when the art he creates is very
disturbing.
• They encourage leadership qualities in the child (the Bipolar side) and
build his personal resilience to peer pressure to indulge in dangerous or
self-destructive behavior.
• They listen to him and try to understand what he is going through.
They have learned that it is more important for him to be able to tell
them his story than it is for them to deliver their guidance to him.
• They gently appeal to the deeply empathetic aspects of his Tourettic
nature to balance the anempathetic tendencies of his Bipolar side. This
process begins with the child’s ability to love himself. Kids with
Bipolar Disorder often are deeply self-contemptuous and they benefit
from the influence of the joyous and more self-accepting aspects of the
Tourette Syndrome in themselves. This is one of the positive aspects of
‘being TS’ that many of my young clients have told me they do not
want to give up.
3. Get a community of supportive elders in your child’s life – you cannot

make it alone
The painful tensions of the dual diagnosis create a lot of animosity between the
teen and his parents. He carries a lot of anger at himself for being so dependent
and he externalizes it on his parents, making them the villains for everything that
goes wrong in his life.
In my clinical practice I have seen that the child and teen with Bipolar/TS
challenges needs the counsel of older peers of the parents. He needs male and
female role models who give him the observer perspective that he lacks. I am con-
tinually amazed how closely these children can listen to the voices of people who
are not their parents. Uncles, aunts, grandparents, big brothers and sisters, counsel-
ors, athletics coaches, teachers, and others are sought out by the children because
these elders do not carry the taint of the child’s angry dependence. One father
told me the story of how his teen daughter with Bipolar/TS challenges was
stone-walling and wailing about going to summer camp. She was already an hour
late and was about to miss her bus. My client said that his first impulse was just to
tell her the heck with it, she didn’t get to go. Or to get angry. Instead he called the
girl’s therapist and had that woman call back. His daughter picked up the phone.
The conversation lasted about thirty seconds. At the end of it, the girl stuffed her
clothing into her bag, got her stuff together and indicated she was ready to go.
When my client asked his daughter what the counselor had said, she recounted
that all she had said was ‘Quit your bitchin’. Get your bag. Time to go.’ The girl
could hear and comply with the message as long as it was not her dad delivering it.
4. Medically treat the child’s Bipolar issues first

Keep a journal that documents when your child’s mood shifts and how this mood
shift is expressed. It may take the form of the aggressive depression seen in Bipolar
Disorder in younger children, or it may assume a more clearly split hypomanic-
depression profile. Keep a careful journal of these phenomena so that you can
share them with your physician as she evaluates how best to prescribe medication.
Your doctor needs this information so that she can prescribe the correct medi-
cation to get the mood swing under control. She will most probably recommend
mood stabilizers such as lithium carbonate or an anticonvulsant such as valproic
acid (b. Depakote) or topiramate (b. Topamax) to accomplish this purpose. Once
mood is stabilized, she may suggest other medications such as quanfacine (b.
Tenex) or stimulants such as methylphenidate (b. Ritalin) to treat the Tourette-
related impulsivity. And she may suggest the use of antidepressants to treat the
child’s depression or obsessionality. A mood stabilizer will be the first medication
she uses if a child has Bipolar Disorder. Read Chapter 6 for information on vegeta-
ble-based lithium if you choose to go the naturopathic route for treating the mood
swing aspect of your child’s Bipolar Disorder.
Conclusion
In this chapter I outlined the change of symptoms that a child with the
Bipolar/TS presentation goes through, from the behavioral wildness and random
rage of his early years to the directed power plays and abuse of his Teen Tyrant
stage.
As grim as this picture looks, the teenager has a good chance of making it to
adulthood if his parents are able to guide him through his childhood and teens.
The good news is that toward the end of adolescence, his brain goes through a
final growth spurt, and his prefrontal cortex gets a boost of development,
balancing its power somewhat with the fierce, self-centered energies of the limbic
brain. Though the issues of impulsivity, wild behavior, and depression may dog a
person well past adolescence, if the teen can make it that far with his self-esteem
intact he has a fighting chance of realizing success in his life.
Part Four
ADHD at Its Extremes

CHAPTER 11
A Matter of Degree
How to Know the Difference between ADHD
and Bipolar Disorder
The clinical features of children with ADHD and mania that lead to their
psychiatric hospitalization indicate the presence of mania, not ADHD. These
children are not admitted because of failure to complete homework.
Dr Joseph Biederman (Biederman 1998)
Hyperactivity, impulsivity, and inattention are seen in children with ADHD and
Bipolar Disorder, but these two disorders are radically different in terms of the
impact that they have on a child’s life. Determining what is causing a child’s
behavior problems is extremely important. ADHD is far less severe an impairment
than Bipolar Disorder. The most important thing for an ADHD child to learn is
how to slow down, focus, organize herself, and deal with stimulus-cravings. The
most important thing for a child with Bipolar Disorder to learn is how to manage
her mood shift from giddy, potentially destructive hypomania to a depression so
dark that it can be paralyzing or suicidal.
It may be difficult to distinguish Bipolar Disorder from ADHD

Better than 90 percent of children with the diagnosis of Bipolar Disorder also
qualify for the diagnosis of ADHD because of the presence of inattention,
impulsivity, and hyperactivity seen in the attention-deficit population (Biederman
1999). Conversely, 22 percent of those children diagnosed with ADHD fit the
criteria for Bipolar Disorder (Butler et al. 1995). It is extremely important that this
second group of kids with the dual diagnosis be identified so that they may
receive proper treatment (Biederman 1999).
190
A MATTER OF DEGREE / 191
Diagnostic criteria for Attention Deficit Disorder

Attention Deficit/Hyperactivity Disorder, predominantly
inattentive type (DSM-IV, 314.00)
Six or more of the following symptoms must be present. Some symptoms must be
present before age seven, with impairment present in two or more settings (school
and home):
• poor attention to details
• doesn’t listen
• poor follow-through
• poor organization
• trouble keeping attention in task and at play
• avoids tasks requiring sustained mental effort
• easily distracted
• forgetful.
Attention Deficit/Hyperactivity Disorder with impulsivity (DSM-IV, 314.01)

Six or more or the following symptoms must be present:
• fidgets
• leaves classroom desk
• runs excessively
• blurts answers
• interrupts or intrudes on others
• is unable to play quietly
• acts ‘driven’
• is easily distracted
• talks excessively
• has difficulty awaiting his turn.
Twenty-two percent of the children diagnosed with Bipolar Disorder after

puberty were diagnosed as ADHD as young children (Biederman 1998). The
symptoms of impulsivity and craving for stimulation now take on the more
troubling forms of hypomania and depression, as Bipolar Disorder emerges.
These children may have been Bipolar all along or they may have developed
Bipolar Disorder after they entered their teens, as do children who develop
Obsessive Compulsive Disorder or depression in their teens with no clear

precedent for these disorders in childhood.
Some percentage of children and teens with the diagnosis of ADHD experi-
ence challenges that are difficult to distinguish from those seen in Bipolar
Disorder. The predilection for dangerous, destructive, and risky behavior, the
abuse of substances and other addictive behavior, are characteristic of some
teenagers with ADHD and looks a lot like Bipolar Disorder in its manic phase.
Both ADHD and BD conditions are marked by a craving for high stimulation, and
it is unclear where the simply ‘dysinhibited’ behavior of ADHD leaves off and
where the cyclic manic phase of BD picks up.
Seven criteria for differentiating ADHD from BD

It is important to come up with good working definitions for analyzing the
ADHD vs. Bipolar issue if you want to be on target in terms of the medication to
use and the psychotherapy approach that will be best. Here are seven criteria for
differentiating these two conditions:
1. Are mood shifts or the ‘aggressive-depression’ mixed state present?

If a child has episodes of manic depression or shows the mixed-state aggressive
depression typical of early-onset Bipolar Disorder, there is a good chance that the
dual diagnosis of ADHD plus BD may be in order. Though the moods of children
with ADHD may be mercurial, especially when these kids hit their teens, they do
not show the severe highs and lows of Bipolar Disorder or the violent expression
that can occur in the mixed-state rapid-cycling variety which afflicts younger
children. ADHD children may experience discomfort and demonstrate consider-
able irritability during medication rebound, but they are not chronically irritable
as are children with Bipolar Disorder. And they do not usually show the behav-
ioral extremes seen in BD when they are in medication rebound. They do not
become overaroused and go screaming off into the darkness as do some kids with
the powerful dysphoric hyperarousal of Bipolar Disorder. There is a noticeable
difference in degree.
2. Does she have any family members diagnosed with Bipolar Disorder
or other affective disorders?
A meticulous study of her family history is very important for making the
ADHD/Bipolar distinction. Children with Bipolar Disorder often have the
condition in their family especially if they are diagnosed at an early age. You will
see BD in the family history in the occurrence of suicide and hospitalization
episodes involving the child’s ancestors, from grandparents to aunts and uncles all
the way back. Some parents tell me that their own father or mother was extremely
moody, depressed all the time, or obsessive-compulsive. These are all indicators
that affective disorder may exist in the family line. If it does, there is a high proba-
bility that it will be passed on (Goodwin and Jamison 1990).
3. Is her speech pressured or hypomanic?

Analyze the quality of a child’s verbal output to determine if Bipolar Disorder or
ADHD is on board. Pressured speech seen in BD is known by its outpouring of
words on continually shifting topics that may have little relationship to each
other. It is verbally powered free association in which the person will not appear
to be listening to others and in fact may interrupt them continually to deliver her
monologue. ADHDers may talk too much and too loudly, but they can be redi-
rected and their verbal delivery can be slowed by a request from the listener such
as ‘You’re going too fast for me and I’m getting breathless just listening to you.’
This same request to a child with Bipolar Disorder may cause her to pause for
about two seconds and then she will resume her monologue where she left off.
Pressured speech by itself is not diagnostic of BD because this phenomenon is
also seen in Asperger’s Syndrome and several other disorders. But if it occurs with
other challenges associated with Bipolar Disorder, it is a good idea to find out
whether it is an aspect of hypomania and thus indicative of the Bipolar presenta-
tion.
In Survival Strategies for Parenting Your ADD Child (Lynn 1996) I suggest that
many of the challenges experienced by persons with attention differences are
related to their inability to screen out stimulation. Pressured speech shows a diffi-
culty in screening out thoughts and editing them from verbal expression.
Children with Bipolar Disorder experience more of this intense pressure than do
kids with ADHD.
4. Is dangerous and risky behavior a result of impulsivity or hypomania?

The dysinhibition of ADHD is most often seen as a random search for stimulation
in any form – be it through danger sports, drugs, gambling, sex, or illegal
behavior. Though addictive opportunities are compelling to the ADHD teen, the
quality of hypomania is not present as it is for the BD teenager. The ADHD teen
will take stupid risks on a dare, or demonstrate extremely bad judgment in a
situation, such as letting herself be talked into an illegal activity, but the fol-
low-through is rarely there.
For the BD teen, dysinhibition and stimulus-craving can take over her person-
ality, and be directed with a purposeful energy in which she does not seem to need
sleep and can power herself energetically toward a goal for several days. She may
run away from home in the family car to pursue some wild flight of fancy and stay
away for days, only to return exhausted and sleep for forty-eight hours straight.
She may become fascinated by some pet interest and be unable to attend to
anything else but that interest day and night for a week or two – dropping every-
thing to go hunting for magic mushrooms, becoming fixated on an interactive
game on the Internet with other kids, or stealing her parents’ credit card number
and spending hundreds of dollars sampling every kind of porn available on the
Net or cable TV.
5. Does she rage (Bipolar Disorder) or does she get angry (ADHD)?
In Bipolar Disorder, rage is present from an early age. It may come up at the drop
of a hat. Once it is engaged, it is unstoppable. It may go on for over half an hour. It
can be violent, and it often results in exhaustion and rage-state-specific amnesia.
The child may report feeling pleasantly energized by rage. She may hate what
happens when she is enraged but she is drawn to the feeling of it.
ADHD children will get enraged because of frustration or simple hot-
temperedness. And there can be other problems on board such as depression or
obsessionality. ADHD children do not rage on a consistent basis as do children in
the mixed state of aggressive depression seen in BD. And they do not generally get
pleasantly energized by it nor do they experience state-specific amnesia of what
they did when enraged. They lack the expressed malevolence of the Bipolar child,
who can deliberately attack someone in a fit of rage and try to hurt them. It is
important to identify the severity of a child’s rage.
6. Are hallucinations, severe thought distortion, and tyrannical behavior present?

The child with ADHD may demonstrate extreme silliness and show a profound
lack of common sense because of her inability to focus on things and make good
decisions. But ADHD children generally do not have hallucinations.
The child with affective illness, on the other hand, may experience visual and
auditory hallucinations that are very disturbing to her. I have had many children
with Bipolar challenges tell me about these hallucinations, though they are loath
to discuss these with their parents for fear of being labeled crazy. When you
consider that these affects show the presence of the ‘awake-dreaming’ aspect of
Bipolar Disorder – the child is awake but her dreaming has not stopped – you are
in a better position to help her (Hobson 1995). Looking at the experience of hal-
lucinations as a defect in a kid’s ability to screen out certain kinds of stimuli makes
it easier to craft remedial strategies with her. This kind of mechanical problem can
be helped by teaching her how to ‘turn down the radio’ in her mind so that
though it still plays in the background, she can concentrate on other things.
ADHD children can be extremely oppositional. But most of them are able to
eventually see their own involvement in problem situations. The child with
Bipolar Disorder is unlikely to admit her part in the issue even when confronted
with evidence to the contrary. It is as if a ‘cognitive hallucination’ is present that
blocks her perception of reality. Unlike the ADHD child, who will most likely end
up as the underdog in an encounter with parents, defending herself from some
accusation of wrongdoing, the child with Bipolar Disorder will take the offensive.
She will attempt to impose her will on the family at all costs.
7. Does she show other aspects of Bipolar Disorder such as the night-time
hyperarousal pattern, the lack of empathy, and Conduct Disorder?
There are some additional challenges that Bipolar children typically have that
ADHDers don’t.
Night-time hyperarousal is sometimes seen in ADHD and is usually a medica-
tion side-effect or insomnia. Bipolar children come alive at night when their brain
levels of serotonin, the ‘civilizing’ neurotransmitter, are at a twenty-four-hour low.
They may become very nasty characters and can go into full-blown fits of rage or
attempt to tyrannize everyone in the family.
Many Bipolar children are anempathetic. They just don’t have much under-
standing of the feelings of others and may show a shallow affect themselves.
ADHD children tend to be, if anything, supersensitive to the feelings of others
when they can stop long enough to pay attention to them. ADHD kids wear their
hearts on their sleeves. This is part of their challenge and charm. Children with
Bipolar Disorder may show cruelty and be very circumspect when it comes to
their own feelings.
Many children with Bipolar challenges will also qualify for the Conduct
Disorder diagnosis (DSM-IV, 312.82) with its list of law-breaking, crimes against
people and animals, and lack of remorse. Though ADHDers do have a greater
chance of being diagnosed with CD than unaffected kids, they do not show the
high percentage of comorbidity (69%) that is seen in the pediatric BD population
(Kovacs and Pollock 1995).
CHECKLIST OF DIFFERENCES BETWEEN BIPOLAR DISORDER AND ADHD
1. presence of mood shift or mixed state of aggressive depression

2. a family history of affective illness
3. presence of pressured speech or hypomania
4. occurrence of dangerous behavior in hypomanic phase
5. presence of rage (Bipolar Disorder) or anger (ADHD)
6. presence of hallucinations, severe thought distortion, and tyrannical

behavior
7. presence of other Bipolar challenges such as anempathy and Conduct
Disorder.
Early correct diagnosis can save a child’s life

Dr Joseph Biederman (Biederman 1998) maintains that there is a serious lack of
knowledge among diagnosticians about how to diagnose the presence of Bipolar
Disorder. He points to research on the ‘kindling’ effect of depression to show how
misdiagnosis can hurt a child. The kindling effect is seen in the damage the brain
incurs as it is weakened by depression over time. The first depression may not be
that bad, but because it has happened the next one is worse, and so on; a small but
powerful heat bursts into flame after a temperature threshold is exceeded.
If a child presents with a mixed-state, rapid-cycling early-onset Bipolar
Disorder and is misdiagnosed ‘severe ADHD’ and given stimulants, she may be
thrown into a manic frenzy. Or the misdiagnosis can result in the child not
receiving medical or appropriate naturopathic treatment for her depression.
Ignoring this problem makes it worse.
If a child is comorbid with both ADHD and Bipolar Disorder, it may be
possible to use stimulant medication or antidepressant medication, but her mood
disorder must first be stabilized using a mood stabilizer such as lithium carbonate
or a newer-generation anticonvulsant such as valproic acid (b. Depakote).
Goodwin and Jamison (1990) assert that 15–20 percent of those with Bipolar
Disorder kill themselves. The misery that these people experience makes ADHD
look comfortably tolerable. Misdiagnosis of the child with Bipolar Disorder can
do her great damage because it not only cuts her off from help appropriate to her
illness, but sets the stage for her isolation from her community. It is this sense of
being alone in an uncaring universe that drives a kid to consider ending her own
life. This is a tragedy preventable with the right diagnosis at the right time.
Part Five
Hard Decisions
Schools, professionals, psychiatric hospitals,
and police involvement
CHAPTER 12
How to Choose the Best Neurologists,

Psychiatrists, Therapists, Schools,
and Teachers for the Child with Wild
and Extreme Behavior
I worked with Jerry, a 13-year-old boy in crisis as a result of his Bipolar Disorder,
and his mother, Laura. Though bright, Jerry was flunking all his classes in school.
He had threatened suicide on several occasions. He was hyperactive and impulsive
and had the habit of yelling the ‘f word’ at any teacher who asserted her authority
sternly. At home he would terrify his mother with frequent rages. And he was
being groomed for membership by a local gang of kids into sexual promiscuity
and drugs. His medication was being managed by the family’s doctor (their
‘Primary Care Physician’ or ‘PCP,’ for insurance referral) but it was not helping
him deal with his Bipolar-related challenges. Jerry’s teacher had advised Laura
that she should home-school her son, but Laura was a single mom and had to
work. Home schooling was out of the question. Children like Jerry need a lot of
help for multiple issues, and oftentimes very little real help is available.
Laura faced two major problems that she had to deal with immediately. First,
her PCP was not knowledgeable about Bipolar Disorder. She needed to get
another doctor and she needed to get a psychotherapist who would help Jerry on
an ongoing basis.
Laura’s second problem was lining up a good school placement for Jerry for the
next year. Jerry did not have Special Education qualifications. The school district
was dragging its feet and making threats to expel Jerry.
First things first – get the right medical and psychotherapeutic treatment
Laura knew that she had to change doctors, but she was at a loss for finding a new
physician who could prescribe the right medication for Jerry. She also wanted to
get her son into psychotherapy, but was concerned that if she made the wrong
decision, she could end up spending a lot of money on psychotherapeutic
treatment that did not meet her son’s needs. She needed someone who knew how
198
HOW TO CHOOSE THE BEST / 199
to work with children with affective disorders. I shared the following process
with her for guiding her search for these important caregivers for Jerry.
Neurologists and psychiatrists use the same medications to treat your children,
but the specialties are different in the treatment methods they use. A neurologist
will test for movement disorders in her work-up. She may evaluate how the brain
functions by asking the child to touch his nose, stand or jump on one foot, or she
may test for hearing and vision problems that could result from organic brain con-
ditions or delayed physical development.
Psychiatrists make a diagnosis based on interview and a psychological evalua-
tion of the child. Because they search for psychological causes as well as
neuropsychological issues, they would likely use the Diagnostic and Statistical
Manual IV, the diagnostic list written by the American Psychiatric Association. A
psychiatrist may have physician privileges at an inpatient psychiatric hospital, and
may be part of the hospital’s crisis management team who would be called if
parents were to request their child’s admission.
Either specialty may manage your child’s medication. Talk to several practitio-
ners before making your choice of doctors. It is not a good idea to go with a partic-
ular doctor until you have talked to her personally, and feel that she is a good fit
for your child.
If your child has complicating neurological issues such as seizures or a
movement disorder, involve a neurologist in the assessment process. He is more
apt to be knowledgeable about physiologic causatives and syndromes. Tilt toward
a psychiatrist if your child’s challenges are fairly clear and fit a standard diagnosis,
such as Asperger’s Syndrome, Bipolar Disorder, ADHD, or depression. Many
parents choose to have a neurologist make the primary diagnosis and then switch
to a psychiatrist for ongoing medication management. This makes sense in terms
of the professional orientation of each specialty (a psychiatrist will more likely be
involved in an ongoing supportive role) and in terms of cost. The services of a
good neurologist who may employ a large professional medical staff are generally
more expensive than the hourly fees of a psychiatrist.
Interview several neurologists and psychiatrists before making your choice

It is important that the doctor you choose has experience treating children with
attention differences. A good way to develop your list of candidates is through
attendance at chapter meetings of your local support group. These groups include
CHADD (Children and Adults with ADD), the NMDA (the National Manic
Depression Association) and the ASA (the American Society of Autism). Talk to
other parents and attend lectures by local practitioners.
Find out what percentage of the doctor’s patients are similar to your child.
Figure you will have this person in your child’s life for years. Choose someone
whom you can afford for that amount of time or who is covered by your insurance
plan. Change plans if you have to.
Five criteria for choosing the right physician for your child
Laura had attended a lecture given by a psychiatrist who was associated with a
clinic for kids with affective disorders in her area. She was pleased that the doctor
listened to several of her questions after his talk without rushing her, and gave her
answers that reflected his knowledge of Bipolar Disorder in children and that
communicated his respect for her as a parent of a very difficult kid.
In the several days that followed her meeting, she assessed the doctor using the
following five criteria (getting Jerry’s input after a visit with him in his office), and
decided to set up an ongoing schedule with him for medication management. She
was relieved to find someone who had expertise and a sense of humility about his
job (he did not get up on his high horse and present himself as a know-it-all).
1. DO YOU HAVE EASY ACCESS TO YOUR DOCTOR FOR CRISIS MANAGEMENT?

You should be able to speak with your child’s doctor personally when a crisis
occurs. Does the physician you are interviewing give you this access? If your
primary physician is not available, has she assigned a competent assistant to take
parents’ calls and interface for her when she is with other patients? You should not
have to suffer long games of telephone tag to get help.
2. IN HER INTERVIEW DOES SHE TALK WITH YOU OR AT YOU?

If a doctor cannot collaborate with you to determine treatment for your child, she
does not have access to an important source of information and her treatment plan
will reflect this. No one knows your child better than you do. Be assertive. Write
down your questions beforehand if need be. Expect your doctor to treat you as an
equal and if she cannot, or if you feel that she is humoring you, keep looking.
3. DOES SHE SEEM WILLING TO DISCUSS HER TREATMENT PLAN

WITH OTHER PROFESSIONALS IN YOUR CHILD’S LIFE, INCLUDING
YOUR CHILD’S THERAPIST AND TEACHER?
What are her fees for a short consultation over the phone? Is she available to
attend your child’s Individual Education Plan (IEP) at reasonable cost to yourself
or the school district? Make sure that she does not have any professional biases
against alternative treatments. Naturopathic and homeopathic physicians have a
generally good reputation for helping children with attention differences. The
contributions of alternative medical practitioners to your child’s treatment plan
should be welcomed by your primary doctor.
4. WHERE DOES SHE HAVE HOSPITAL PRIVILEGES AND WHAT IS

THE REPUTATION OF THAT FACILITY?
See Chapter 13 for a discussion of guidelines for choosing a psychiatric facility. If
a doctor is associated with a private psychiatric hospital, you need to be especially
watchful that she does not nudge you to admit your child there. Many parents
prefer to use a doctor who is associated with a large public hospital or university
medical center because there is a better chance of getting specialized service in a
better-funded public facility.
5. DOES YOUR CHILD LIKE THE PHYSICIAN?

Listen to your child’s evaluation of a potential doctor after your first visit. The
physician–patient bond is extremely important. The child will follow the advice
of a doctor whom he respects and will be less resistant to taking the medication
the doctor suggests. Kids tend to put doctors ‘up’ as important people in their
lives. It is important to use this as an advantage in gaining the child’s compliance
with treatment and not settle for someone the child dislikes just because this
physician may be taking new patients.
Four criteria for choosing a psychotherapist for your

Attention Different child
In order to be effective, your child’s psychotherapist should be his spiritual,
emotional, and intellectual ally. He affirms your child’s character, creativity, and
giftedness. The therapist should approach his work with the child with this sense
of reverence for his spirit and respect for his family’s spiritual values.
A therapist may advise parents on disciplinary procedure, but he does not get
into the parental role himself. He acts in a neutral and supportive way to help the
child meet his own goals. Here are four essential criteria for choosing this
important member of your child’s team:
1. DOES THE THERAPIST POSSESS A GOOD KNOWLEDGE OF THE INTERACTION

OF BRAIN CHEMISTRY AND ENVIRONMENT IN FORMING BEHAVIOR?
The therapist does not put a family-of-origin dysfunction template on your child,
and is able to separate neurology from other causative factors such as family stress.
He knows the specific stresses that a child’s attention difference can put on the
family, and can help family members avoid dysfunctional interaction. He has a
good knowledge of brain chemistry and the combinations of disorders that may
affect children. He possesses a set of therapeutic tools to help the child develop
self-esteem, ownership of his problems, and resourcefulness in dealing with them.
Parents should be careful to interview a potential therapist to determine if he sees
their child’s Bipolar-related challenges as Reactive Attachment Disorder (RAD) or
Borderline Personality Disorder.
A diagnosis of RAD means that it is the child’s early experience of trauma or

abandonment that is causing his symptoms. This assumption could prompt the
therapist to suggest that hundreds of therapy sessions will be needed to ‘cure’ the
child. The Borderline Personality Disorder diagnosis also suggests that early
childhood psychological trauma is the cause of the child’s manipulativeness,
mood swing, irritability, and controlling attitude. Extensive psychological talk
therapy or ‘reparenting’ approaches may not be indicated for the child whose
issues are caused by atypical brain chemistry.
2. DOES THE THERAPIST HAVE A STRATEGIC FOCUS?

A good therapist targets all his interventions to specific problems, is creative in
coming up with solutions, and keeps track of changes so as to adjust the approach.
Practicing strategic therapy means that he has a clear idea of the changes that are
most important, and persistently works to achieve these changes. He spares the
child and his family the experience of endless conversations or lamentations
about the situation. The guiding philosophy of therapy is ‘action-research,’ a term
borrowed from the social sciences to denote the deliberate testing of methods to
change a situation, guided by practical experience. If an approach works, it
becomes part of the plan. If it doesn’t, it is changed slightly, and re-evaluated.
3. DOES THE THERAPIST ENJOY BEING AROUND CHILDREN

WITH ATYPICAL NEUROLOGY?
Attention Different children tend to be characters in their own right and a good
therapist will work from that position; he will be interested in the child’s gifts,
perceptions, and dilemmas.
The right therapist for younger children will be comfortable with ‘floor work.’
This term describes the practice of providing playthings and creative materials,
while delivering therapeutic suggestions or listening to the child as he describes
his life and challenges.
Playing chess on the floor with shoes kicked off, with a genius-grade but very
lonely Asperger’s child, affords the opportunity for the therapist to implant many
positive suggestions in the child’s psyche. As the therapist duels with the child’s
superior skill in the game, he comments on his opponent’s strengths as a logical
thinker and a respectful, polite person. The therapist encourages another child,
this one diagnosed with Bipolar challenges, to bring his pet boa constrictor to
counseling. As the therapist handles the snake, he talks about how hard it is to be
seen by others as scary or evil (like the snake). Communicating this way, he helps
the child be more self-accepting and loosens the depression and low self-esteem
that grip the boy’s consciousness.
The right therapist for teenagers will be good at forming rapport with them
and will work to help them realize their social and occupational goals, as they see
these goals. A teen is surrounded by adults telling him what they want from him,
but rarely do these caregivers listen to hear what he wants out of life, even if that
goal seems odd.
One sixteen-year-old ADHD boy who consulted with me said that his goal
was to work in his local 7–11 convenience store as a clerk. This limited vision of
his potential was bitterly contested by his parents, who wanted him to buckle
down at school and set his sights on college. I encouraged his personal goal,
knowing that this kind of work was exactly what he needed. It would afford him
the opportunity to learn arithmetic, responsibility, and improve his social skills.
When his parents accepted this rationale, the year-long power struggle between
them and their son ended in five minutes. I was not surprised to learn that once
they gave him their blessing for his convenience store job, he lost interest in it.
Underneath all his bravado, he was looking for his parents’ affirmation of his
ability and independence, even though the prospect of being more independent
was frightening to him.
4. DOES THE THERAPIST HAVE GOOD INFORMATION ABOUT COMMUNITY

RESOURCES AND USE THE CONTRIBUTIONS OF OTHER PROFESSIONALS
IN HIS TREATMENT?
A good therapist should be able to help the family craft strategies to help his
clients navigate their way through the maze of doctors, educational consultants,
attorneys, school personnel, and other professionals involved with the family.
The therapeutic alliance is strengthened by the therapist’s understanding of
the contributions of other professionals involved with your family. He under-
stands the components of a neuroeducational report. He knows the positive
benefits and side-effects of the medication the child is taking. He is up on the
latest developments in educational law.
The therapist should be able to relate information gained from other caregivers
to practical issues in the psychotherapy. If, for example, a neuroeducational report
shows that the child has difficulty with social stress, the therapist should be able to
work with him to give him specific techniques for meeting kids at school and cul-
tivating friendships. If evaluation reveals his very poor organizational skills or
problems following sequences, the therapist should be able to consult with staff at
the child’s school to devise ways for him to organize his school day and get from
classroom to classroom.
Jerry’s case illustrates the challenges parents face getting educational services
for the child with Bipolar challenges
Laura’s next priority was getting Jerry back on track in school. He had flunked
eighth grade and she had no options in sight for him except to repeat this failure
experience next year. She was so frustrated with the lack of response from the
local school district that she was contemplating pulling Jerry out of school.
I advised her to hold off on taking Jerry out of public school. The system is
legally responsible for providing an education to children with learning impair-
ments. Though it might take a few months to get a plan in place, it was definitely
worth the effort to do so.
Many Attention Different children, especially those with ADD, Obsessive
Compulsive Disorder, and Bipolar Disorder, become expert at faking it to get
through school. They are audacious enough to bluff their way through or scare
their teachers with a glare. But when these kids hit the sixth grade, they collapse
academically. The system begins expecting them to be independent learners, and
removes the one-to-one attention they had been getting in lower grades. The
failure that the AD child experiences at this juncture can mark him for life.
Teaching methods and goals should be based on your child’s

tested learning disabilities and strengths
If her local school district could not provide these services, I suggested to Laura
that she ask them to fund her son’s enrollment in private school. One way or the
other, the district is required to meet Jerry’s educational needs. I told Laura that it
was important for her to identify what kind of classroom experience she wanted
for Jerry. To do that, she needed to have him tested for learning disabilities. The
first step was for her to send a letter to the Special Education Director in her
school district requesting that Jerry be tested by the district, or that the district pay
to have a private consultant complete testing.
The right classroom environment will teach to your child’s learning needs and
help him overcome his learning deficiencies. The only way for you to evaluate the
learning style–classroom fit is to get your child tested for learning disabilities. If
this is done by a private consultant it is called an independent evaluation. The
Woodcock–Johnson Psycho-Educational Battery (Revised) is the principal test
battery used by public schools and independent consultants to evaluate AD kids’
learning deficits.
Getting an independent evaluation is important for kids like Jerry because it
identifies the gaps in his academic knowledge and his learning deficits. Test
results identify the problem that the parents and school district must address.
Bipolar Disorder often occurs with other conditions and so it is a good idea to get
a quick overview of some of the typical learning issues children with ADHD,
Asperger’s, and Tourette have to deal with in the classroom.
The computer is a useful metaphor for the way kids take things in and solve
problems. First, it inputs information (stimulation for children). It stores this data
in its active memory. It then processes it. And it delivers an output. In the child’s
case, output is seen in the production of work in class.
LEARNING INVOLVES FOUR STEPS

Input (perception) èèè active memory èèè processing èèè output
Kids take things in and process them visually (in pictures), auditorily (in words
and thoughts), or kinesthetically (by feeling or touch). Each child is different, but
most tend to favor one of these three modalities. You can identify a child’s learning
style by cross-comparing the modalities he uses to process information at different
points in the process.
Table 12.2
Input Sees pictures Hears sounds Touches things
Active memory Remembers pictures Remembers words Remembers feelings
Processing Sees movies Thinks words Makes ‘gut hunch’ decisions
Output Draws pictures Speaks words Expresses feelings
Attention Different children tend to have predictable learning issues. Each

diagnosis will show a distinctive pattern of issues. Staff should be trained to
identify these issues and build techniques into the child’s learning program to
compensate for his disabilities.
• Children with Asperger’s Syndrome need a lot of structure and a
reduction of environmental noise. They need instruction that is very
structured, very concrete, and very visual. Strategies should be used to
reduce the anxiety these kids experience from noise, harsh lights, and
crowding in the classroom. They may not do well in mandatory
physical education programs and need help planning types of exercise
that do not involve a lot of rapid-action teamwork (such as team
competition in PE).
• Children with ADD and ADHD need a lot of hands-on, tactile
stimulation within a structured, interesting environment. They are
extremely visual learners and notoriously slow processors. They need to
have the pace of instruction slowed and often benefit from peer
instruction in which they are matched up with another child in their
class who helps them review material.
• Many Asperger’s children and ADDers have a ‘central auditory
processing’ (CAP) problem. These kids have a hard time learning from
what is said to them. Words don’t sink in. Suggestions for remediation
of CAP are listed in Chapter 6.
• Children with Bipolar Disorder need to be closely monitored for ‘holes’

in their academic ability that they may try to hide. Typically brilliant at
learning language and driven to high accomplishment, these kids may
suffer from auditory memory and verbal processing issues. They may
not decode and remember what the teacher is saying. Many Bipolar
children need very firm limits on their behavior, but they do not
respond to punishment and may react by refusing to go to school.
Five characteristics of the best education plans for children with Bipolar
Disorder and other attention differences
1. THE RIGHT TEACHER

A wise parent once told me that her child was always successful when the fit with
the teacher was right. It didn’t matter if the teacher was in mainstream or Special
Education, or in a public or private school. The teacher herself made all the differ-
ence.
It is not a good omen if the teacher says that she’s never taught children with
his kind of attention difference. In a good school for your child, staff are educated
in the learning issues of children with Asperger’s Syndrome, Tourette Syndrome,
Bipolar Disorder, or ADD. You can assess for this factor by querying the principal
about staff training, and her priorities for her staff ’s participation in continuing
education funded by the district. It is a good sign when you see a large contingent
of Special Ed staff at professional conferences and workshops.
2. PRESENCE OF A ‘GUIDING HAND’ AT SCHOOL

Many Attention Different children need a ‘guiding hand,’ a specifically desig-
nated staff person to interface with parents and to be a touchstone for the child
during the day. If learning issues around personal organization are present, the
staff member may help the child get organized for his day, and check him out at
night to help him sort out his homework and organize his notebooks.
This person may also function as a conflict resolution consultant for the child
in his dealings with teachers and other kids, and should be part of the IEP team.
The guiding hand does not need to be Special Education-qualified and could be a
volunteer, but she must be assertive in defense of the child’s rights and learning
needs.
3. LOW HOMEWORK HASSLE

If the school is teaching to the child’s learning style and his IEP is on target, he
should not have to take home an inordinate amount of homework. If he is taking
more than an hour of homework home in elementary and middle school and more
than two hours in high school, there is a good possibility that the school is dis-
placing the burden for the child’s education on to his parents. Better to call this
arrangement ‘home schooling’ because this may indeed be what is happening.
The purpose of homework is to keep learned concepts current, not teach new
concepts that the child did not get in school. If the latter situation is occurring,
parents have the right to do what one mother of a brilliant Asperger’s kid did: she
requested and received instruction for herself in algebra from the district, under
the provisions of the law that say that parents of children who have English as a
second language are entitled to training in English if this is required to help their
children do homework. Her son’s school was doing such a poor job teaching him
algebraic concepts, that the district was required to ‘deputize’ his mother to do
their job.
4. EDUCATION GUIDED BY WEEKLY MEASUREMENT AGAINST GOALS

The right educational setting for Attention Different children is data-based. The
child works to achieve fluency – the ability to demonstrate learning quickly and
easily on demand – in his subject area and is continually tested to measure
progress and recalibrate the instructional approach. He does not progress to the
next subject unless he can work efficiently in the current subject area. Nothing is
taken for granted in terms of his learning. AD kids typically process material more
slowly than neurotypical children. For this reason children with attention differ-
ences need to be taught at a slower pace and their accomplishment should be
measured at least weekly. This ongoing testing process is not done to penalize the
students or set a grade but to allow the teaching staff to continually calibrate their
approach to meet the children’s ongoing needs.
5. STAFF COMFORTABLE WITH CONFLICT, RAGE, OR DEPRESSIVE COLLAPSE

Holding it together in the modern classroom may be extremely stressful for the
Attention Different child. The anxiety and failure that she experiences every day
can build up to the point that she boils over into shouting, swearing, rage, or
sullen withdrawal into inertia and depression. The best schools are comfortable
with these demonstrations of anxiety and rage and know how to deal with them.
In these schools staff know how to spot the build-up of tension in a child and they
know how to get on the situation early to cool things down. If a behavioral
explosion occurs, they know how to calm the child. Finally, they are expert at
reintegrating her back into the flow of things in the classroom when she is ready.
Failure of the public school system in the US is paced by the increase in the
system’s tendency to punish and expel first, and ask questions later. Children with
attention differences do not do well when staff are too high-handed, disci-
pline-oriented, or reactive. Our children need a lot of wiggle room. The best
learning environments for them provide opportunity for de-escalation,
remediation, and face-saving before the cops are called.
Conclusion: The importance of respect in the caregiving relationship

Laura told me when she first brought Jerry in for counseling that she wanted to
know if I thought she was a good mother. She said that, in her opinion, she was
doing a good job with a very difficult situation. But it was important for her to
know, straight out, what my biases about her parenting style were. I was moved by
her honesty and was glad to share my evaluation that she was doing an excellent
job bringing him up.
Laura wanted a spirit of mutual respect to exist in our consultation. She had
suffered the treatment of other caregivers who acted as if they had all the answers,
if only she would listen. Of course, they didn’t say this outright. But Laura got the
definite impression that that was their message. When their advice did not work or
stopped working, they would lament that ‘the child was beyond helping and you
may as well accept that.’ She was determined not to go through this ordeal again.
Ask yourself when you are interviewing a potential professional caregiver for
your child if the spirit of your conversation is mutually respectful. The word
‘respect’ is derived from the Latin respicere, meaning ‘to look at again.’ The wisdom
of language informs this situation: your most powerful professional allies will
know that they have to keep looking at the situation with fresh perspective and
have to stay creative. There are no ‘one size fits all’ solutions. The best
professionals will approach their work with your child with humility and
patience. They will collaborate with you to study the phenomena of your child’s
issues. They will affirm and acknowledge your struggle and the contributions you
have made to his life and success.
CHAPTER 13
The Hardest Decisions

How to Make Police Involvement or Psychiatric
Hospitalization Part of Your Healing Plan
When I learned that Linda had Bipolar Disorder, I realized that my life was going
to be a marathon, not a quarter-mile race with her. Now, as she gets into her teens,
it feels like I’m running the marathon through machine-gun fire.
Maria, mother of a 13-year-old girl with Bipolar Disorder
It is impossible to describe the stress it puts on parents to call 911 and to have the
police take their child to detention or to a psychiatric hospital. But many parents
of children with Bipolar challenges have had to face the task. The purpose of this
chapter is to describe how to put together a plan so that if you have to make this
call, it is part of your child’s healing process. This may be the most difficult
decision that you will ever make in your life and so it is extremely important to
give it careful attention ahead of time.
How to decide if juvenile detention or psychiatric hospitalization

is the best option
A good rule of thumb is to assess the degree to which a child’s behavior is under
his control. If he has less control, and is younger, hospitalization is the best option.
If he has more control, is a teenager, has broken the law and physically attacked
others in his family, detention may be the best choice. Unfortunately the absence
in the US of affordable medical assistance for children with Bipolar Disor-
der-related challenges means that many parents have to take their chances with
the juvenile justice system.
If you call 911 because your 16-year-old punched you, he will probably be
arrested and spend at least one night in juvenile detention. If he says that you
punched him, the police may arrest you as well and sort the truth out later. If this is
the teen’s first offense, you may request the court to defer charging him if he
completes community service. He should be able to get through without incurring
a police record if his behavior in the home has not been too serious.
The process of being taken to detention may be extremely shaming and fright-
ening to a teen. Having to wear jailhouse clothes and participate in the strict
209
routines with other prisoners may cause him to dissociate from the whole experi-
ence. Parents who choose the detention must weigh the psychological agony that
their child will experience in detention against the psychological or spiritual
agony he is inflicting at home.
How putting your child in police custody serves his healing plan
Children and teens with Bipolar Disorder are natural boundary pushers. They will
try to get away with anything they can. Younger kids become expert at going
right up to the demarcation of prohibited behavior again and again without
crossing the line, but causing great aggravation to adults. An eight-year-old with
BD challenges may devise hundreds of ways to bug his teacher and distract the
other kids in her classroom. When the teacher threatens a consequence, he
switches tactics and comes up with another way to annoy her. Teenagers tend to
be more blatant. They will snarl angrily at their parents, insult them repeatedly
and do what they please, deliberately sabotaging parents’ attempts to get behav-
ioral compliance.
This is the Warrior archetype in action, transformed into a petty tyrant. The
child is pulling on the energy of his limbic brain and defying any attempt to curb
his wildness and anarchic nature. My clinical research on the lives of children with
Bipolar Disorder suggests that those who survive experienced firm limits in the
home and at school. On many occasions, the kids themselves have told me this in
counseling: ‘My parents better be in control of me because there are times that I
am not in control of myself.’
To stay on top of the situation, you must have the attitude that you will not be
pushed around and are willing to go the distance to ensure behavioral compliance.
You have to be willing to engage in the encounter with all your will. Children with
Bipolar Disorder ‘take no prisoners.’ Trying to negotiate with a child with Bipolar
challenges who is trying to take over the house will not work. The model of
Neville Chamberlain, the British Prime Minister who thought that he had
charmed the tyrannical nature of Adolf Hitler in 1938, comes to mind. ‘Peace in
our time’ was Chamberlain’s famous motto. Hitler humored him and seized
Czechoslovakia soon after Chamberlain got on his airplane back to London.
Bipolar Disorder may bring out the Hitler nature in a child. Give him an inch and
he will take over the landscape.
To maintain control of the situation you must decide what your bottom-line
requirements (BLRs) are. This means that you identify clearly to the child the most
important house rules, and that you are willing to call 911 to enforce them.
Your BLRs include any issue involving family health and safety: the child may
not behave violently toward anyone in the household or insult and torment
others. He must be out of the family area by a certain time and in his bedroom. He
must not bring drugs into the house, light fires, or play with knives dangerously.
THE HARDEST DECISIONS / 211
You have a right to expect that the child obey you when you direct him to cease
some behavior that is disturbing the common peace. Other aspects of his behavior
may be negotiable, but these are not.
Parents of teens with Bipolar challenges must be willing to call 911 if their
child attacks them physically. And the child must know that this will be the conse-
quence for attack. If a teenager indulges in chronic verbal abuse or tormenting of
his parents, they should take action to remove him to his room for a period of time
and cease giving him privileges. If, in the process of attempting to physically
move him, they are attacked, they should not hesitate to call the police and let
them handle the situation.
Physical discipline involving spanking, putting Tabasco sauce in a child’s
mouth, taping his mouth, or other forms of ‘corporal punishment’ do not make
the situation better and may cause the violence to escalate. But parents must know
their rights when using physical force to protect themselves or other family
members from a kid who may be out of control.
It is a good idea for you to get a copy of the law in your state which governs
physical discipline of your child so that you know what you can do without
getting in trouble for abuse. Common standards in most states around discipline
are that caregivers may not hit a child with a closed fist, throw him, bite him,
shake him, or use implements like knives, rods, belts, or other objects to punish
him.
The standard assumption that guides most family therapists is that everyone is
equal and that if a child is violent there is a good chance he has learned this
behavior from his parents. In families with Bipolar children, a child may behave
tyrannically simply because of his brain chemistry. The conventional models do
not apply in this situation because it is the parents who must protect themselves
and the other kids in the family from the child with Bipolar challenges. Therapists
do the family a favor by helping parents maintain the chain of command and stay
in charge all the time. Parents who try to abide by a therapist’s ‘Neville Chamber-
lain rules’ and not hit, restrain their child, or call the police will be victimized
many times over before they finally let the authorities take over. Better this be
done sooner than later.
If that call to 911 has to be made, you must be willing to accept the conse-
quences. Police presence in the home is totally invasive. Police officers get killed
breaking up family fights and so they may come in with their weapons drawn if
the child menaces them with an object such as a knife. If you call 911, advise your
child to sit down by the door with his hands in view so that when the police
respond they do not feel threatened by him.
In many states, police responding to a call are required to file charges against
the child if he has struck one of his parents. The police have no choice in this
regard. When an arrest is made, the child will be handcuffed, searched, and
marched out of the house into the police cruiser to be taken to detention. This
experience may be terrifying for him. Parents who choose this option are making
a grave choice, a last-ditch attempt to help the child control himself by suffering
the pain of a period of time in juvenile detention.
Plan for emergency-room evaluation of your child

In many states, police responding to a 911 call from parents may elect to take the
child to the emergency room of a local hospital, where he will be evaluated by a
mental health professional who may recommend temporary short-term place-
ment (usually not to exceed 72 hours) in a psychiatric facility. This option may be
taken in lieu of transporting the child to detention. This is the preferred option if a
child’s dangerous acts are clearly the result of his emotional disturbance and he
has not committed a crime. Parents should plan for this possibility by assessing
involuntary commitment procedures in their locality. They can get this informa-
tion by calling local medical facilities or their state’s department of health and
social services. If parents are considering placement of the child in a private resi-
dential facility, they may find that the child’s arrest record blocks their options in
this regard. This is why the temporary involuntary commitment possibility may
be the best first choice.
The dangers of juvenile detention

The quality of treatment given to children in juvenile detention facilities in the US
varies greatly. If the facility is well funded and well run, and staff are educated in
emotional disturbance in children, there is a good chance that the children will be
relatively safe from physical assault, perhaps even safer than they would be in a
psychiatric facility.
The biggest danger is that your child will meet up with other children who
have developed criminal patterns in their lives and that he will be influenced to
contact them after he is released. You have no control over who he is put with in
detention. Many children with dual diagnosis of BD and Asperger’s Syndrome or
Tourette Syndrome may be extremely impressionable and naïve. This puts them at
double jeopardy from predators in the facility: they are dissociated from the terror
that they experience while they are targeted by experienced ‘artful dodgers,’ kids
who know the penal system already and use other, more innocent, children for
their own ends.
You militate against this kind of danger by attending as much as possible to
rapport with your child when he returns. You listen to his experience. You question
him knowing that this has been traumatic for him. And you pay careful attention
to his report of contacts with other kids while in detention. This information
helps you decide how much freedom he is capable of handling so that you can
establish rules for his behavior. For many children, the experience of detention
makes them especially open to acceptance of parental control. They now know
that parents mean what they say. The game is over.
One of the paradoxes of Bipolar Disorder in children is that though the
condition is caused by dysfunction of structures deep within the limbic brain,
extreme consequences or the threat of extreme consequences may be what the
child needs to maintain control over his own impulses. Many of the BD teens I
work with who have been sent to detention because of their attempts to take over
the house have profited from the experience. Their natures are so wild that it is
only the sure and certain consequence of being separated from their family and
going to jail that gives them the strength to control themselves.
The importance of having a plan for psychiatric hospitalization

The behavior of a big 13-year-old lost in a fit of limbic rage who is in the process
of tearing up the house needs to be contained. The depressed child who is danger-
ously suicidal – she is considering the means to do it and her behavior changes
from depressed to placid and accepting – may need more than parental reassur-
ance or the wise counsel of a psychotherapist. She may need to be put within the
safety of a psychiatric hospital so that her suicidal depression may be stabilized.
An elementary-school-age child with Bipolar challenges may use rage or
physical attack (to include spitting in the parents’ faces) to get his way with
parents. Parents draw the line in this situation by removing the child to his room
immediately until behavioral compliance occurs, or by using physical force to
protect themselves and other family members. If the child does not calm, it may be
necessary for you to call 911 to have him transported to the psychiatric hospital
that you have chosen.
If you do not have a plan that covers your loss of control of the situation, you
may reflexively cling to strategies that don’t work and will be ineffective in
dealing with the crisis. Without this certainty, you may experience dangerous
indecision and delay when what you need to do is dial 911 to transport your child
to a hospital.
The purpose of psychiatric hospitalization – to heal the child, not punish him
Hospitalization should never be considered as punishment, or a way to reduce a
child’s oppositionality. It must only be used to facilitate medical evaluation (such
as in the planning of medication and psychotherapeutic intervention) or limit
dangerous behavior. Medication refusal might be a good reason for hospitaliza-
tion if the child is endangering his health or others’ safety in refusing medication.
Hospitalization may also be in order if the child’s behavior becomes suddenly
erratic or psychotic as the result of an adverse effect of a new medication.
Long-term psychiatric hospitalization is probably not necessary for most of

the children and teens who are discussed in this book. If a child is schizophrenic
or severely conduct-disordered, a long-term stay might be in order, but if the
reason is to stabilize his Bipolar Disorder, depression, or severe obsessionality, a
shorter stay is probably sufficient. The primary determinant will be the time it
takes for the evaluation of the effects of the medication used to stabilize the child’s
mood which, in most cases, takes no longer than three weeks to a month.
Know the warning signs for a child at risk of suicide

In my clinical practice, I am frequently contacted by parents of children in the age
range of eight to twelve who have made statements indicating that they see
suicide as an option or that ‘the world would be better without me.’ I take these
comments very seriously and check them out in therapy against a set of factors
that have been established in research as indicating that a person is moving closer
to an attempt to kill him- or herself. Five indicators have emerged as especially
important in this regard (Fawcett, Busch and Jacobs 1997):
1. The child has verbalized that suicide may be an acceptable choice for
him to escape the misery that he is experiencing.
2. He has discussed the means that he might use to kill himself.
3. He has given away precious toys and other objects and seems to be
tying up his affairs.
4. The child manifests a high degree of anxiety and agitation, and at least
one of the preceding factors is in evidence.
5. He becomes calm, happy, and seems at peace with himself and others
after a period of mental agony and agitation. This change in mood
often comes a day or two or hours before the suicide attempt itself.
Though many children make suicide threats to console themselves that they have
some way of controlling the chaos that they experience in their lives, and do not
have real intent to follow through, if any of the indicators noted above are present
it is a good idea to have the child evaluated by a psychiatrist in the emergency
room.
Teens with Bipolar challenges are especially vulnerable to suicide because of
the pressures that they experience from the internal sense of chaos and depression
in the face of the demand to take greater responsibility to make better choices and
conform to societal norms. Things may seem hopeless indeed to the teenager who
lacks the ability to big-picture his situation, and he may attempt what one pundit
has termed ‘a permanent solution’ to the ‘temporary problem’ of his affective
misery.
Planning begins well before the request to admit in-hospital

To put together your hospitalization plan you need to do three things before the
event of actually asking for inpatient admittance:
1. GET YOUR CHILD INTO TREATMENT WITH A PSYCHIATRIST

If you believe that psychiatric hospitalization may be necessary, it is important to
seek out a psychiatrist who can evaluate your child and manage his medication.
This will be the person you will call if you decide that inpatient hospitalization is
necessary. The psychiatrist will do an initial evaluation of the severity of the issue
and determine, with you, the desired outcome from treatment in-hospital. This
doctor may not be your primary psychotherapist, but should know enough about
your child to order inpatient hospitalization on your request.
2. RESEARCH AN APPROPRIATE HOSPITAL FOR YOUR CHILD

• Get a list of psychiatric hospitals in your area and evaluate the one best
suited to your child. Visit your top three choices in person.
• Interview staff to find out how they would deal with your child.
Determine their treatment approach. Consult the section below titled
‘Psychiatric hospital occurs in the first of three recovery stages,’ to
structure your inquiry.
• Get a sense of the philosophy of the place and what kinds of pediatric
psychiatric issues are treated there. Try to find out the percentage of
residential children with diagnoses of Conduct Disorder, Antisocial
Personality Disorder, sexual disorders, or schizophrenia. Children with
these diagnoses are generally more dangerous than those with affective
disorders. You want to put your child in a facility that has
state-of-the-art knowledge of neuropsychological issues such as Bipolar
Disorder, ADHD, Obsessive Compulsive Disorder and depression.
3. CONSIDER HOW YOU WILL PAY FOR YOUR CHILD’S STAY

The average current cost of inpatient psychiatric treatment is $1000 a day. Many
insurance plans do not cover psychiatric hospitalization. Those that do cover it
usually only pay for a few days of inpatient treatment. Shop for your insurance
plan on the assumption that this cost may occur. Change plans if your plan does
not have this benefit. It will be worth your while to pay the extra premium. If your
child is eligible for treatment under Social Security (Disability) Insurance (SSI),
that fund will probably pick up the full cost of hospitalization. To be eligible for
SSI medical (called MEDICAID), the child must be evaluated to have a disability
by the Social Security Administration and his family must meet an income test. To
determine if your family meets the SSI income formula and have your child
assessed for SSI, contact your local Social Security office. Staff there will contact
your psychiatrist and your child’s school to determine his eligibility for SSI.
The need for psychiatric hospitalization may come as a sudden emergency
when your child loses the ability to pull back from neuropsychological distress
and goes ‘condition red’ on you. You may have to call 911 at the same time you are
calling his psychiatrist. It is a good idea to have your options in place. If 911
responds, staff on the scene will look to you and your doctor for a suggestion as to
what they need to do. It is very important to have your preferred options lined up
so that you can get help for your child quickly.
The downside of psychiatric hospitalization

The act of turning your child over to caregivers in a psychiatric hospital, even for a
short time, may have powerful negative side-effects:
• Your child may feel betrayed and abandoned. Your decision may sever
trust between you for months or years.
• In hospital your child runs the risk of being assaulted by children more
ill than he. In most cases the environment is tightly controlled, but it is
impossible for staff to be everywhere all the time, and the passivity of
many Attention Different children puts them at greater risk.
• It is possible that your child will be assigned the wrong diagnosis and
will receive the wrong inpatient treatment and outpatient referral based
on this diagnosis.
• It is possible that mistakes may be made in medication management
that cause pain or damage to him. The child with pediatric Bipolar
Disorder who is misdiagnosed as Unipolar Depressed may be given
antidepressant medication that makes the mania much worse, or
antipsychotic medication that causes the permanently disfiguring facial
tics known as Tardive Dyskinesia (TD).
• The financial cost may bankrupt your family.
Psychiatric hospitalization occurs in the first of three recovery stages

Psychiatric hospitalization takes place in the first stage of your child’s recovery,
which is the acute stage. Two stages follow: the early recovery stage and the stabi-
lization stage. The child’s early recovery and stabilization take place at home, with
outpatient counseling care provided by the hospital.
1. THE ACUTE STAGE (2 TO 10 WEEKS)

The child begins the acute stage unmedicated, and florid (dramatic) in his
symptomology. This stage is seen in the emergence of violent behavior, rage,
ranting, extreme depression, hypomania, mania, psychotic features, and severely

disrupted cognitive abilities. The child screams, runs into traffic, destroys precious
objects, or is wildly obsessive and compulsive. If depressed, he is lost in a
mindless, inconsolable depressive state. Suicidal thinking or gestures occur. The
end of the acute phase is defined as the point when the child no longer manifests
violent, psychotic types of affect, cognition, and behavior. There is a reduction or
elimination of screaming, self-mutilation, craving for drugs, destructive obses-
sions, running into the street, or paranoid or suicidal thinking.
2. THE EARLY RECOVERY STAGE (ADDITIONAL 3 TO 12 WEEKS)

This stage is manifested in the elimination of violence and psychotic thinking, the
reduction of depression, mania, and hypomania, and the partial return of
cognitive ability. Mild paranoid thinking may still be present – it’s always
‘someone else’s fault.’ The child may be quick to anger and verbally abusive with
parents, especially in the morning upon waking or at times of exhaustion, stress,
or mood swing.
In the early recovery stage, the child may also experience obsessive fixation on
getting his own way, demonstrate perseverance (chronic pestering), pressured
speech, obsessions, compulsions, and hypomania, but he is somewhat responsive
to parental control. He may also be lethargic and lack motivation – only rousing
from this state by the promise of some cherished reward. The motivational effects
of rewards do not last long.
3. THE STABILITY STAGE (FROM 12 WEEKS)

A child achieves stability when he is able to exercise a certain amount of observer
perspective over his actions, to self-correct his impulsivity somewhat, communi-
cate his mood shift, express grief, and accept the fact of his affective issues
including genuine remorse for the damage they cause. He may accept and
welcome counseling and may express his feelings in art, writing, or music. He is
completing the grief cycle in the stability phase.
In-hospital psychotherapeutic treatment

Once the child is stabilized, in the latter part of the acute stage and as he enters
early recovery, there is an opportunity for the psycho-education of family and
friends, and the building of a collaborative therapeutic relationship with the child.
This may occur in the hospital or in a day/partial treatment format where the
child checks in for treatment or school and returns home at the end of the day.
Hospital staff may also deliver psychotherapeutic services in the home. Children
at this stage may be able to take in brief, simple, focused psychotherapeutic inter-
ventions – the expression of understanding, empathetic listening, and the simple
expression of feelings.
Psychotherapy should assist parents with stress-management training, grief

work, and emergency management techniques. A therapist with a social work
background and knowledge of affective illness can help the family write a crisis
management plan for the in-home management of behavior. Essential features of
this plan are described in Chapter 3. In the early recovery stage, psychotherapy
moves toward assisting parents in the implementation of firm household rules to
be backed up by law enforcement if this is necessary. If violent behavior has
occurred, the fact of it must be broached directly with the child, and the therapist
must support parents in insisting that verbal or physical violence will not be
tolerated.
The therapist can identify community resources such as parent respite
programs, which are state-provided in-home daycare for the child (usually admin-
istered by the state’s Social and Health Services department), and group homes.
Psychotherapy can also help the family develop a plan to normalize the child’s
sleep patterns. Restoration of first- and second-sleep-quadrant sleeping habits
(getting to sleep by midnight) is essential for the reduction of mood shift seen in
pediatric Bipolar Disorder. Psychotherapy can facilitate the process of detoxing
the child from drugs (nicotine, alcohol, cocaine) and put the family in contact
with drug counselors in their community with whom they can set up drug coun-
seling for their child.
Police detention or psychiatric hospitalization may be a needed

breakthrough experience
The decision to call 911 to get police intervention for your child is excruciating.
Many parents who have done this have told me that it broke their hearts to have to
take the action. It is a horribly wrenching experience to see the child taken away,
but this may be the wake-up call that finally gets through the layers of neurologi-
cal fog and blind rage that are Bipolar Disorder. Calling the authorities to come
and get your child may be the ultimate expression of tough love. It is a statement
that the world is not run by crazy people and tyrants and that you will not let him
grow up thinking that it is. As hard as he pushes you, you must demonstrate the
grit to push back harder and keep everyone safe. As painful as it is to draw this
harsh line, you are giving him the best chance to grow up to be a civilized human
being.
And the decision to send your child to a psychiatric hospital will also be
terribly painful for you. But it may be absolutely necessary. Psychiatric hospital-
ization, at its best, provides shelter from the storm and stability for the child’s
healing process to get back on track. It provides a way for the family to air out its
emotional ‘parachute’, to learn how to survive future crises and begin to turn the
situation around.
CONCLUSION
When All Is Said and Done

Six Keys to Personal Wellness for Families
of Children with Bipolar Disorder
There is no denying it is a hard, hard road, loving someone with bipolar disease
… It is their problem, not yours, and yet it becomes yours if you love the person
suffering from it. You have no choice. You must stand by them. You are trapped as
surely as the patient is. And you will hate that trap at times, hate what it does to
your life, your days, your own sanity.
But hate it or not, you are there, and whatever it takes, you have to make the
best of it.
Danielle Steel, from the Introduction to His Bright Light (1998, p.xxii)
The mother of a son with Bipolar Disorder once told me: ‘Some days are hard
because my son’s behavior puts so much stress on me that I think I’m going nuts
myself. And some days are hard because they’re not: you’re stuck in place just
waiting for the worst to happen.’
This mother and every other parent of a child with this condition is faced with
a sobering statistic: suicide takes the life of upwards of 15 percent of those
diagnosed with Bipolar Disorder. And whether a child lives or dies may depend
on the way he is parented. Some kids (as was the case with Danielle Steel’s son)
will not survive, even with the best parenting. But even though it may seem
impossible, as Steel puts it, ‘you have to make the best of it.’ Here are six principles
for surviving the enormous stress of parenting these most difficult-to-parent
children and teenagers:
1. Build the relationship but do not tolerate abuse

Younger children with Bipolar Disorder terrorize their families with rage. To help
your child you have to maintain your relationship with her; the child has to know
that you are there for her, as bad as it gets. Though her rage may be a great
challenge to your own sanity, you must deal with it. The young child in a rage
needs skilled management of the event, as if she were having a seizure.
219
Teens with the condition may be verbally abusive or may attempt to intimidate
their parents with threats of violence. Manic depression can have a very nasty
edge. As a result of it, teenagers are vulnerable to law-breaking, substance abuse,
and dangerous behavior. The teen with a conduct problem needs to face the con-
sequences of her own actions. She needs to know that she cannot push you
around. You listen. You try to help. But if she is not willing to communicate, you
remove yourself, put on the earphones, or put physical distance between your
child and yourself. If she gets physically abusive, you call 911.
2. Surrender to the situation and see the misery behind her behavior
The child’s anxiety and depression can infect the lives of everyone in your home,
as if the molecules of air were red-hot. It is hard to keep one’s perspective. But it is
a little easier if you consider that you are dealing with a disorder that is psychically
contagious; if you are not careful, you can end up as depressed as she is. Your child is
suffering greatly and she is trying to control you and everyone else in order to
relieve that suffering. Relate to her misery with empathy, but try not to be infected
by it. Your child does not want to be depressed. Your real opponent is not your
child but the brain chemistry that causes her psychological dynamics. This is
illness as surely as if she had some major physical disease. Give her your empathy
but do not be infected by her disease by getting into combat with her or running
away. Empathize with the scared little kid in her. Communicate with her. But do
not give up control.
3. Nurture every moment of observer perspective

As a result of his successful participation in an intense outdoor summer camp, a
boy with Bipolar Disorder gained a new understanding of his own limits,
working as a team member with other kids. He came back from the camp with a
new humility. His parents were silently ecstatic when he shared his new awareness
of his limits – ‘Sometimes you have to count on other people to get you through.’
They delivered quiet praise, being careful not to overdo it: he was paranoid about
compliments.
Quite a few of the kids I counsel for Bipolar Disorder tell me that they experi-
ence chronic dread of ‘losing it.’ They are very matter-of-fact about their inability
to hold themselves together: to inhibit rage or extreme emotionality. Every little
instance of being able to rise above the situation, see themselves in the context of
others around them, and take responsibility for their actions, is a gem, a part of
their healing. The ones who survive have more moments of observer perspective
than the ones who don’t.
CONCLUSION / 221
4. Avoid endless argument – the spirit of consultancy must prevail

This is a skill practiced with acumen by the true veterans of the parenting of
Attention Different children, including those with BD. You give them choices. You
listen. You approach the situation from the position of one who offers ideas when
they run into difficulty. You keep your cool and don’t argue. You set boundaries
and rules but give them a lot of freedom and wiggle room. And you choose your
rules carefully. The child’s health and safety should be the primary consideration
in making a rule. Everything else, including (for teens) attendance at school and
medication, should be negotiated with him. There is an art to this process and you
must be convinced that you have enough of the Warrior archetype in yourself to
meet the Warrior in him. This frees you up to consult with him from a place in
which there is no question about your authority.
5. Supplement medication with wellness strategies

The medications used to treat Bipolar Disorder have powerful side-effects.
Weight gain, cognitive dulling, acne, sleep problems, and liver toxicity are just a
few. Wise parents follow the literature on promising naturopathic treatment and
work with medical and naturopathic physicians to devise treatment options for
their kids. The National Institute of Mental Health-funded research group and
clearing house, the Stanley Foundation, at 1 800 518-SFBN is a great resource for
current information. Many children and teens with Bipolar Disorder eventually
refuse medication because of side-effects. Naturopathic medication tends to be
much gentler in this regard. Keep looking for alternatives, so you don’t get caught
short with a child spitting his pills and going downhill.
6. Let yourself grieve the loss of your illusion that your love is enough
to make your child normal
This brings us back to Danielle Steel’s words (Steel 1998). Reading her moving
account of the life and death of her son Nick, I could see how the experience
tempered her to the place of wisdom expressed in those words. Her path, like that
of many parents of children with Bipolar Disorder (Nick also showed signs of
severe ADHD), was marked by the loss of the illusion that she could make him a
normal person if only she loved him more. Steel got to a place of knowing that
though there was a lot she could do for Nick, she eventually had to let him go. She
was not his guardian angel. She could not be.
Bipolar Disorder can make life hell for your child, but this condition doesn’t
need to make your life hell. To help him, you have to keep your own perspective
and not give in to creeping depression in your own life. Remember the example of
Carol, the heart-centered grandmother from the Introduction to this book? The
background to her ability to cope with her grandson, Johnny, was the fact that she
had other work in her life that she enjoyed and people around her who loved her.
These two assets helped her have the ‘quiet in her heart’ that enabled her to be
there for Johnny. Life is full of trouble. The research on stress and hardiness is clear
that you need love in your life, and some purpose other than your parenting, to
prevail over the parenting challenges that you face. Take care of yourself, and you
are in the best position to take care of your child!
APPENDIX
Ten Essential Online Sites for Families of Children

with Bipolar Disorder and Related Conditions
These Internet sites are not necessarily the largest ones on the Net, but they are
among the most helpful in terms of parent-to-parent contact and professional
resource information.
http://www.bpso.org
Bipolar Disorder for Significant Others provides up-to-date information about BD for
families with members with Bipolar challenges. It is also a vital parent contact source.
http://www.bpkids.org
The Child and Adolescent Bipolar Foundation is an excellent resource for information about
Bipolar Disorder in children and for referral to professionals and useful books.
http://ndmda.org
The National Depression and Manic Depression Association is a comprehensive resource for
information on both depression and Bipolar Disorder.
http://www.udel.edu/bkirby/asperger
A good site for information on Asperger’s Syndrome, including classroom pointers
and parenting tips.
http://wrightslaw.com
Pete and Pam Wright are attorneys who work with parents of Special Needs kids. Pete
successfully represented parents in a case brought against a school district in the Supreme
Court in 1993. A highly informative and useful site!
http://www.ldonline.org
LD OnLine offers information about learning disabilities for parents, teachers,
and children. Find here also information on the local chapters of learning disability
associations which can provide information on professionals who serve families
with neurologically involved children.
223
http://www.bridgetounderstanding.com
An invaluable resource for reviewing residential school options.
http://www.conductdisorders.com
A unique source of information for parenting teenagers with Oppositional Defiant Disorder,
Conduct Disorder, and Bipolar Disorder. Also includes great referral links for legal,
professional, and academic services.
http://neuro-www2.mgh.harvard.edu/TSA/tsamain.nclk
The National Tourette Syndrome Association is a central source of information
and local linking for parents of kids with TS challenges. Also a recruitment
source for research subjects.
http://www.stanleyresearch.org
The Stanley Foundation is the clearing house set up by the National Institute of Mental
Health for families with members diagnosed with Bipolar Disorder. It is an excellent source
of up-to-date information about advances in the treatment of Bipolar Disorder.
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Sacks, O. (1992) ‘A surgeon’s life.’ New Yorker, March, 85.
Schopler, E. (1987) ‘Autism today and the health care professional’s role.’ Feelings and
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Sherman, C. (1999) ‘Novel anticonvulsant appears effective in PTSD.’ Clinical Psychiatric
News, July, 18.
Sobo, S. (1999) ‘Mood stabilizers and mood swings: In search of a definition.’
Psychiatric Times, 36–41.
Steel, D. (1998) His Bright Light? New York: Delacorte.
Strakowski, S.M., DeBello, M. and Sax, W. (1999) ‘Brain structural abnormalities in
Bipolar Disorder.’ Archives of General Psychiatry 56, 254–259.
Strober, M. (1994) ‘Relevance of age of onset in genetic studies of bipolar affective
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606–610.
Strober, M., Schmidt-Lackner, S., Freeman, R., Bower, S., Lampert, C. and DeAntonio,
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Williams, D. (1992) Nobody Nowhere: The Extraordinary Autobiography of an Autistic. New
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Williams, K. (1995) ‘Understanding the student with Asperger Syndrome: Guidelines
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Young, R.C., Biggs, J.T., Ziegler, E. and Meyer, D.A. (1978) ‘A rating scale for mania:
reliability, validity and sensitivity.’ British Journal of Psychiatry 199, 429–435.
archetypes 13–15, 18, 120, Bipolar III Cyclothymic
Subject 164, 185
Asperger families, successful
Disorder 22–3, 24
Bipolar IV
Index 142–4
Asperger’s
antidepressant-induced
hypomania 23, 24
Disorder/Asperger’s Bipolar V major depression
Syndrome 123–4 23
Asperger’s Syndrome 11, 14, Bipolar VI Unipolar Mania
acetylcholine 42, 114 110, 123–7, 160 23–4
ADD (Attention Deficit anempathy 88, 97–8 Bipolar Disorder 10–12, 18,
Disorder) 12, 13, 110, anxiety 51 21–4, 36, 196
191, 199, 205 AS/Bipolar 145, 150–1, in adults 20
ADHD (Attention Deficit 156–60 archetypes 13–14
Hyperactivity Disorder) attention differences 12 assessment 26–39
11–12, 166, 190–6, learning needs 205 change strategies 73–86
205 meltdown 51–3, 133 differentiating from ADHD
adolescence 89, 125, 183–4, Asperger’s-friendly education 192–5
186 program 141–2 medication 110, 160
see also teenagers assertive behavior 137 survival strategies 39–40,
adrenaline downregulators Ativan 47 78–86
100 Attention Deficit Disorder Bipolar Disorder/ADHD
aggressive depression 24, (ADD) 12, 13, 110, 190–6
192 191, 199, 205 Bipolar Disorder/AS 145,
akathisia 27 Attention Deficit 150–1, 156–60
Alcoholics Anonymous 104 Hyperactivity Disorder Bipolar Disorder/TS 178,
alcoholism 90 (ADHD) 11–12, 166, 181, 183–6, 187
Alexithymia 88, 91–3 190–6, 205 Bipolar rage 51–2, 53–6,
Alpha/Beta wave state 169 auditory hallucinations 33, 131, 132, 146
alprazolam 47 38 with ADHD 194
American Society of Autism auditory processing issues with TS 168, 182–3
199 122, 126, 127, 128, see also rage
aminergic system 42 129 birth 35–6, 39
amygdala 43, 91 managing strategies for Borderline Personality
Anafronil 170 135–41 Disorder 201, 202
anempathy 88–98, 157, 195 autism 125, 127, 199 brain see human brain
survival strategies 98–107 brain lock 29
anticonvulsants 45–6, 100, Barrie, James M. 14 breathing (RBG method) 70
160, 170, 186, 196 base brain 41 buproprion 154, 160
antidepressants 25, 32, 38, behavior BuSpar 53
46, 100, 160 assertive 137 buspirone 46, 53, 100
antidepressant-induced dangerous 31, 37, 104–5, Byron, George Gordon, Lord
hypomania 23, 24 193 13, 50
for Bipolar/ADHD 196 stimulus-seeking 127,
for meltdown 53 148–9, 158–9, 193 calcium 113
for Tourette Syndrome 170 tyrannical 33, 38, 179, CAP (central auditory
antihypertensives 170, 186 194–5 processing) disability
antipsychotics 46, 101, 170 wild 27–8, 36, 166, 187 128, 205
Antisocial Personality benzodiazepines 47 carbamazepine 45, 47, 100
Disorder (APD) 94 Ber, Dr Abram 111 Catapres 47, 100, 170
anxiety 27–8, 51, 121, beta carotene 112–13 Celexa 46
127–8, 134–5 binary decision-making 136 central auditory processing
managing strategies for Bipolar I Disorder 22 (CAP) disability 128,
135–41 Bipolar II Disorder 22 205
apraxia 129, 130, 149
231
CHADD (Children and divalproex sodium see Hermit archetype 14, 120
Adults with ADD) 199 Depakote Hitler, Adolf 210
Chamberlain, Neville 210 doctors 200–1 homeopathic physicians 200
Children and Adults with dopamine 42 Hopkins, Gerard Manley 14
ADD (CHADD) 199 DSM-IV 20, 21, 124 hospitalization 209–14, 216,
choline 114 Duke, Patty 85 218
cholinergic system 42 dysinhibition 89, 165, 166, choosing a hospital 215
Chopin, Frederick 14 193 costs of 215–16
chromium picolinate 114 plans for 213, 215–16
citapram 46 early-onset Bipolar Disorder recovery stages of 216–17
clomipramine 170 24, 25, 26–39, 74, 146 human brain 29, 48–9,
clonazepam 53 ten markers for 53–6 128–9, 169
clonidine 47, 100, 170 echolalia 165, 167, 180 base brain 41
cognitive apraxia 149 ECT (electroconvulsive cortex 41, 88
cognitive distortion 179 therapy) 116–17 frontal lobes 42–3, 88–91
combat stress 96 education, 139, 141–2, 143, limbic brain 41–4, 50, 89,
common sense 130 203–7 91, 165
communication skills 80–2, Effexor 46, 100 human relationships 132–3,
157 Einstein, Albert 14, 120 152
conversational skills 126 electroconvulsive therapy hyperactivity 27–8, 36,
coprographia 167 (ECT) 116–17 181–2
coprolalia 165 empathy 87–8, 153 hypomania 20–1, 23, 24,
copropraxia 167 Epstein–Barr titer 35 48, 147, 193
corporal punishment 211 exercise, physical 63 hypothalamus 43
cortex 41, 88 eye contact 126
craniosacral therapy (CST) imipramine 23, 170, 181
111, 115–16 family history 23, 35, 74, impaired judgement 28, 36
Crinnion, Dr Walter 111, 192–3 impaired practical ability 127
112 family therapy 155 impulsivity 28, 36, 89, 146,
cross-dressing 177 family wellness 219–21 166
CST (craniosacral therapy) fatty acids 112 in Bipolar/ADHD 191,
111, 115–16 flow state activity 169 193
Curie, Marie 120 fluoxitine 11, 23, 46, 100, in Bipolar/TS 181, 187
Cyclothymic Disorder 22–3, 181, 182 exercise to control 104–5
24 for depression 114, 170 in-hospital psychotherapy
effects of 32, 74 217–18
dangerous behavior 31, 37, for meltdown 53 inattention 29, 31, 37, 191
104–5, 193 fluvoxomine 23, 32, 53 Inderal 47
Depakote 32, 45, 47, 100, food and drink 63 inertia 127, 129, 130,
186, 196 force field psychotherapy 135–41, 149
side-effects 76 76–8 inositol 114
therapeutic effects 76 frontal-lobes 42–3, 88–91 internet sites 223–4
depersonalization 150–1 irritability 30, 37
depression 25, 114, 149, gabapentin 45, 160
170, 187 Gardener, Dr Robert 111 juvenile detention 209–14
major depression 21, 22, Gould, Glenn 120
23 grounding (RBG method) 70 Klonopin 53
desipramine 23, 170
Dexedrine 47, 100, 125 Haldol 170 Lamictal 45, 100
dextroamphetamine 47, 100, hallucinations 33–4, 38, 44, lamotrigine 45, 100
125 180, 194 learning 122, 130, 141,
discipline 102–3, 184, 211, haloperidol (b. Haldol) 170 143, 204–6
213 Hermingway, Ernest 85 disorders 166
distractibility 29, 37
SUBJECT INDEX / 233
lesson plans 139 methylphenidate 186 parent/child relationship,

see also education; schools; Midler, Bette 73 building 132–3
teachers parental control 184
Mood Feedback Scale 81, 82
lethargy 34–5, 38–9 parents and family wellness
mood shift 26, 36, 83, 108,
see also inertia 148 see survival strategies
limbic brain 41–4, 50, 89, in Bipolar/TS 178–9 Pervasive Developmental
91, 165 stabilizers 32, 45–6, 100, Disorder (PDD) 125,
limbic wave 43–4, 75 186, 196 126, 145
linguistic techniques 65–6 triggers 82–4 pets 150, 159, 173
lithium 19, 32 morbid fantasy 31, 37–8physical discipline 211, 213
lithium carbonate 45, 48, motor tics 165 physical restraint 64–5
100–1, 186, 196 Mozart, Wolfgang Amadeus
physical stimulation 140–1
lorazepam 47 167, 177 physicians, choosing 200–1
Luvox 23, 32, 53 pimozide 170
National Institute of Mental planning
magnesium 113 Health (Stanley the day 137–8
major depression 21, 22, 23 Foundation) 20, 117, education 139, 206–7
management strategy see 221 for hospitalization 213,
survival strategies National Manic Depression 215–16
mania 20–1, 23–4, 147, 193 Association (NMDA) play, dangerous 31, 37
media, misleading images in 199 Poe, Edgar Allan 13, 85
93 natural power 168–9 police custody 210–12, 218
MEDICAID 215 naturopathic medication Post Traumatic Stress
medication 32, 44–7, 76, 111–15, 186, 221 Disorder (PTSD) 88,
99–101, 110 naturopathic physicians 200 95–6
adrenaline downregulators Neuro Linguistic Povich, Maury 15
100 Programming (NLP) 67 power, natural 168–9
anticonvulsants 45–6, 100, neuroleptic haloperidol 170 pragmatics, lack of 135–41
160, 170, 186, 196 neurologists, methodology of premature birth 35–6, 39
antidepressants see 199–200 pressured speech 53, 73,
antidepressants Neurontin 47, 160 124, 146, 180, 193
antihypertensives 170, 186 neurotransmitter systems 42 profiles
benzodiazepines 47 niacin 112 Jessie (Warrior archetype)
fluoxotine 11 Nietzsche, Frederick 13 19–20
lithium 19 NLP (Neuro Linguistic John (Alexithymic teen)
mood stabilizers 32, 45–6, Programming) 67 92–3
100, 186, 196 norepiniphrine 42 Martha (Bipolar
naturopathic 111–15, 186, Norpramine 23, 170, 181 Disorder-related rage)
221 56–60
neuroleptics 46, 170 obsessionality 165, 170, Richard (Asperger’s
refusal 213 173–6 Syndrome) 121–3
Selective Serotonin fixation 123, 146, 147, Sean (Bipolar/Asperger’s
Reuptake Inhibitors 180 Syndrome) 145–61
(SSRIs) 32, 46, 100, Obsessive Compulsive Tom (Bipolar Disorder
170, 181 Disorder (OCD) 174, teen) 73–86
side-effects 160, 170, 221 175, 192 Tourette Syndrome
stimulants 32, 38, 46–7, olanzapine 46, 101, 170 166–70
100, 108, 196 Omega–3 fatty acids 112 propranolol hydrochloride
tricyclics 181 online websites 223–4 47
melatonin 113–14 Orap 170 Prozac see fluoxitine
meltdown 51–2, 53, 131–2 orbitofrontal cortex 88 psychiatrists 199–200, 215
survival strategies for psychological muscularity
managing 132–5 144
metaphenyldate 47, 100 psychopathology 93–5
psychosis 88, 94, 95, 108 SBD (Severe Behavioral stress 88, 95–6
psychotherapy 76–8, 91, Disorder) 152 suicide 31–2, 37–8, 196,
175, 198–200, 217–18 scatology 165, 167 214, 219
choosing a therapist 201–3 schools 103–4, 141, 151–2 of war veterans 96
puberty 89, 125, 183–4, script writing intervention support groups 199
186 136–7 survival strategies
secretin 114–15 for anempathy 98–107
quanfacine (b. Tenex) 47, 57, seizure 25, 45–6, 48 for anxiety 135–41
100, 170, 186 Selective Serotonin Reuptake for auditory processing
Inhibitors (SSRIs) 32, problems 135–41
rTMS (repeated transcranial 46, 100, 170, 181 for Bipolar Disorder
magnetic stimulation) self-centeredness 29–30, 37, 39–40, 78–86
117 87 for Bipolar Disorder/AS
RAD (Reactive Attachment self-esteem 121, 122 156–60
Disorder) 201–2 sense of humor 126 for Bipolar Disorder/TS
rage 25, 27, 36 serotonin 42 184–6
four phases of 60–2, 66 setraline 46, 100 family wellness 219–21
management strategies Severe Behavioral Disorder for inertia 135–41
62–72 (SBD) 152 for lack of pragmatism
medication 47–8 sexual issues 34, 38, 146, 135–41
rage freeze 67–9, 135 167, 181–2 for meltdown 132–5
see also Bipolar rage siblings, protection of 64 for rage 62–72
Rauf, Mahamoud Abdul side effects of medication for Tourette Syndrome
167, 177 160, 170, 221 170–6
Ray, Witty Ticcy 167, 177 Single Photon Emission swearing 167
RBG (refuge, breathe, Computed Tomography symptom suppression 169
ground) method 69–72, (SPECT) 35
82 sleep 30, 37, 84, 180–1, taboos 177
RDS (Reward Deficiency 195 Tardive Dyskinesia 46, 101,
Syndrome) 55, 90 sleep log 29 112, 170, 216
Reactive Attachment sleep patterns, normalizing teachers 139, 206
Disorder (RAD) 201–2 218 teaching methods 204–6
refuge (RBG method) 70, 82 Social Security (Disability) teenagers 75–6, 80, 182,
religiosity 37, 174 Insurance (SSI) 215 214
repeated transcranial special interest 124, 150, dysinhibited 89, 193
magnetic stimulation 159 gifted 122
(rTMS) 117 SPECT (Single Photon hypomania 147, 193
residential schools 103–4 Emission Computed John’s profile 92–3
Restless Explorer archetype Tomography) 35 therapists for 202–3
14, 164, 185 SSI (Social Security Tom’s profile 73–86
Reward Deficiency (Disability) Insurance) see also adolescence
Syndrome (RDS) 55, 90 215 Tegretol 45, 47, 100
Risperdal 46, 47, 101, 160, SSRIs (Selective Serotonin Tenex 47, 57, 100, 170, 186
170 Reuptake Inhibitors) 32, tension feedback scale 62–3,
risperidone see Risperdal 46, 100, 170, 181 69
Ritalin 42, 47, 100, 125, Stanley Foundation 45, 221 terror 127
186 stimulants 32, 38, 46–7, thalamus 43, 91
role models 143, 185 100, 108, 196 therapy
stimulation exercise 139–40 craniosacral therapy (CST)
SAM-e stimulation, physical 140–1 111, 115–16
(s-adenosylmethionine) stimulus aversion 128 electroconvulsive therapy
115 stimulus-seeking behavior (ECT) 116–17
127, 148–9, 158–9, family 155
193
SUBJECT INDEX / 235
force field psychotherapy Xanax 47

76–8
in-hospital psychotherapy y-aminobutyric acid 111
217–18
psychotherapy 76–8, 91, zinc 113
175, 198–200, Zoloft 46, 74, 100
217–18 Zyprexa 46, 47, 101, 170
choosing a therapist 201–3
for teenagers 202–3
tics 45, 165, 170–2
Tofranil 23, 170, 181
Topamax 45, 100, 170, 186
topiramate see Topamax
tough love 40
Tourette Syndrome 11, 12,
14, 164–6, 182–3
medication 45, 110, 170
profile 166–70
survival strategies 170–6
TS/Bipolar Disorder 178,
183–6
tricyclics 181
trigger-situation warning list
84
two-hand mood-integration
method 80
tyrannical behavior 33, 38,
179, 194–5
Unipolar Mania 23–4
valproic acid see Depakote

vegetable-based lithium 48,
114, 186
venlafaxine (b. Effexor) 46,
100
visualization techniques 137,
159
vitamins 112–13
vocal tics 165
war, cruelty of 96
Warrior archetype, in BD
13–14, 18, 185
websites 223–4
Wellbutrin 46, 100, 154,
160
wild behavior 27–8, 36,
166, 187
Woodcock-Johnson
Psycho-Educational
Battery 204
Woolf, Virginia 14
Hilkevich, J. 166 Wilens, T.E. 44, 100
Author Hobson, J.A. 44, 194
Houston, J. 85
Williams, D. 122, 144, 170
Williams, K. 122, 141
Index Jacobs, D. 214
Wozniak, J. 24
Jamison, K.R. 35, 74, 193, Young, R.C. 22

196
Johnson, C. 127
Akiskal, H.S. 10, 18, 24, 34, Jung, C.G. 13
47
Amen, D.G. 35 Kipling, Rudyard 145
APA Online 116 Klerman, C.L. 22
Asperger, H. 123 Koenig, K. 160
Attwood, T. 97, 120, 129 Kovacs, M. 87, 181, 195
Kruger, S. et al. 33
Baxter, L. et al. 175
Biederman, J. 24, 190, 191, Leckman, J. 171
196 L’Ecuyer, S. 160
Biederman, J et al. 26 Lewin, K. 76
Blum, K. 55, 90 Lynn, G. 12, 43, 82, 111,
Bruun, R. 168, 171 117, 132, 141, 174,
Budman, C. 168 193
Busch, K.A. 214
Butler, S. 11
Butler, S. et al. 190 Martin, A. 160
Mate, G. 88, 132
Minuchin, S. 95
Chen, Y.W. 27
Cohen, D. 171
Comings, D. 55, 88, 90, Nohria, C. 145
175, 179, 181 Norden, M. 21, 30, 170
Crinnion, W. 111, 112
Croft, P. et al. 35 Orsillo, S.M. et al. 96
Csikszentmihalyi, M. 169
Pollock, M. 87, 181, 195
DeLong, R. 145 Popper, C. 27, 54
Dilsaver, S.C. 27 Post, R.M. 26, 45
DSM-IV (Diagnostic &
Statistical Manual of the Ratey, J. 127
American Psychiatric Roedema, T.M. 91
Association) 10, 191,
195, 199 Sacks, O. 12, 167
Duran, M. 14, 165, 168 Seligman, A.W. 166
Selye, H. 82
Fawcett, J. 214 Sherman, C. 100
Fristad, M. 34 Simons, R.F. 91
Sobo, S. 45
Goleman, D. 94 Stacy, A. 136
Goodwin, F. 35, 74, 193, Steel, Danielle 219, 221
196 Strakowski, S.M. et al. 41, 43
Gray, C. 136
Greene, R.W. 51, 52, 131 Wehr, T.A. 181
Weller, E. 34
Hartmann, T. 13 Weller, R. 34
236

Survival Strategies For Parenting The Child & Teen With Bipolar

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What topics are covered in the document?

What topics are covered in the document?

What conditions may occur with bipolar disorder in children?

What conditions may occur with bipolar disorder in children?

Survival Strategies for Parenting

Children with Bipolar Disorder

Finding Out about Asperger’s Syndrome,

Learning to Live with High Functioning Autism

Parenting the ADHD Child

Attention Deficit/Hyperactivity Disorder

The ADHD Handbook

Jessica Kingsley Publishers

First published in the United Kingdom in 2000 by

© Copyright 2000 George T. Lynn

Library of Congress Cataloging in Publication Data

British Library Cataloguing in Publication Data

ISBN 1 85302 921 1

Printed and Bound in Great Britain by

I. Bipolar Disorder in Children

II. Asperger’s Syndrome and Bipolar Disorder in Teens

IV. ADHD at Its Extremes

Appendix: Ten Essential Online Sites 223

Being in control of an out-of-control situation

Bipolar Disorder is often diagnosed with Tourette Syndrome,

Bipolar Disorder (BD)

Asperger’s Syndrome (AS) and Bipolar Disorder

Tourette Syndrome (TS) and Bipolar Disorder

Attention Deficit Hyperactivity Disorder (ADHD) and Bipolar Disorder

degree of ‘comorbidity’ (the term psychiatrists use to designate the presence of

Why call all these disorders ‘attention differences’?

The archetypes of Attention Different children

The Warrior archetype in Bipolar Disorder

The Hermit archetype in Asperger’s Syndrome

The personality of the Restless Explorer in Tourette Syndrome

The archetypes are creative descriptions, not prescriptions

SHAWNA’S SEARCH FOR PEACE

own defense mechanisms of denial, oppositionality, and distorted thinking. But if

Bipolar Disorder in Children

Enter the Warrior

The archetype: The Warrior

Jessie: Profile of a child living the Warrior archetype

What Bipolar Disorder in adults looks like

Hypomania and mania

The depressed state is described well by another Bipolar patient:

The six variations of Bipolar Disorder

Bipolar I Disorder is described as the presence of a single episode or several

Mood shifts but there is no major depression.

Bipolar II Disorder is described as the presence of recurrent major depressive

Major drops into depression with no mania.

Four other types of Bipolar Disorder have been identified.

(a typical 48-hour cycle)

Cyclothymia may be expressed in rapid cycling on a daily basis, beginning with a

baseline return to baseline after discontinuance

Tricyclic use is especially associated with the development of the disorder. It is

Depression as a stand-alone issue will show the symptoms that Dr Norden

The ‘space-out’ or ‘little seizure’ of Bipolar Disorder in kids

in behavior a few moments before it happens. This enables them to implement a

Markers of Bipolar Disorder in children and teens

1. Presence of mood shift or a mixed-state mood disorder