CO-OCCURRING DISORDERS IN TEENS: Bipolar Disorder--The Great Imitator

Angry outbursts, erratic sleep patterns, sudden mood swings, and changes in personality. If you’re a parent of a teenager, these behaviors can be the status quo—actually, we often take these behaviors for granted. When teens are in trouble, when they are struggling to cope with issues that are too difficult for them to handle, drinking or getting high makes these behaviors worse often to the point of frightening us.

Symptoms of addiction often mimic other behaviors and make it hard to figure out exactly what’s going on in kids who are getting high. We know that kids (and adults) get high to help manage the difficult emotions associated with life’s challenges. And we know that adolescence presents them (and us!) with unique challenges.

Your parental instinct that something is wrong is often correct, but understanding the difference in the root causes of their erratic behavior will help you decide what course to take with your child.

Sometimes the issues are normal external pressures, like arguments with friends, academic expectations, real or perceived rejections by others.

Sometimes the issues are internal, relating to your child’s coping style, temperament, or ability to tolerate frustration. When bipolar disorder is present, however, the internal issues are also related to your child’s brain functioning.

HOW ADDICTION SYMPTOMS CAN MIMIC BIPOLAR DISORDER

It’s important to understand that bipolar disorder is a medical condition of the brain. The person experiences extreme highs (mania) and extreme lows (depression). When I explain below more about what bipolar disorder is, you’ll see how easily it can be misdiagnosed in children and teens as major depression, attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder.

During a manic episode, a person’s mood is noticeably euphoric, irritable, or aggressive. It is common for a person who is manic to think that nothing is wrong with their behavior even though it is extremely distressing to family and friends.

During a depressive episode, a person may feel sad or lose interest in previously enjoyable activities. When severe, thoughts of suicide may be present. Someone with bipolar disorder can experience a variety of mood patterns, such as having mostly episodes of mania or mostly episodes of depression. Another person may cycle rapidly between the two. It is also possible for someone to remain symptom-free for extended periods of time.

BIPOLAR DISORDER AND CHILDREN

Another important thing to know is that bipolar disorder looks different in children and teens than it does in adults. When children or teens have bipolar disorder, they have mood swings with extreme ups and downs. When they are up, they have brief, intense outbursts or feel irritable or extremely happy (mania) several times almost every day. They have a lot of energy and a high activity level. When they are down, they feel depressed and sad.

Children more often experience several severe mood swings in a single day versus the sustained and clearly defined manic episodes that adults have. These intense moods quickly change from one extreme to another without a clear reason. Some children may briefly return to a normal mood between extremes.

Many children change continuously between mania and depression, sometimes several times in the same day. Sometimes children with bipolar disorder have symptoms of both mania and depression at the same time, often showing itself as agitation or extreme irritability.

But because of the “normal” ups and downs of adolescents or for children with sensitive temperaments, times of mania or depression may be less obvious in children and teens than in adults. It’s often difficult to sort out what exactly is going on.

Normal ups and downs of adolescence are exaggerated greatly when kids are drinking or getting high. As with adults, children will resort to getting high in an attempt to feel “normal” or balance out the “feeling crazy” that bipolar contributes to. That’s why when substance abuse is in the picture things get even more confusing.

The good news is that bipolar disorder can be effectively treated usually with a proper combination of medication and counseling. Getting a thorough evaluation by a professional who is experienced with mental illness and addictions is your best bet in determining what course of action to take.

As always, education and support are the best antidotes to the fear and helplessness we feel as parents when our children are suffering from bipolar disorder.

Other excellent resources to learn about bipolar disorder and get support are the Depression and Bipolar Support Alliance and the Child and Adolescent Bipolar Foundation has a great site especially for kids.

HAPPY MOTHER'S DAY! CELEBRATE WITH MOM'S NITE OUT

In celebration of the great jobs moms do, The Partnership at Drugfree.org is promoting 'National Mom's Nite Out' to give moms a well-deserved night off and celebrate who they are besides being a mom--a girlfriend, a friend and a woman.

Locally, there's a fun nite planned here on Philadelphia's Main Line to give moms a chance to strut their stuff at a fashion show and silent auction.

Taking time out for yourself to re-energize and let off steam is crucial to effective coping with addiction in the family. Make sure you don't just wait for Mother's Day!!

WHAT ARE CO-OCCURRING DISORDERS?

Please note: This is the first in a series of blog posts that will address the relationship between addiction and associated mental health problems. I'm starting with a general overview here and will add posts that will be more specific, focusing more on specific mental health issues as they relate to children and the family.

Comments, suggestions, and questions are always welcome and will help me develop and tailor the blog to your interests/needs.

Addiction doesn't happen in a vacuum.

Sometimes we take for granted what our brains are for. We are not robots--our brain controls everything that we do, from monitoring breathing and heart rate to deciding whether to eat a cheesesteak with or without fried onions or reaching for a salad instead.

We know that drug, alcohol, and other addictions are complex problems that involve the interaction among many variables:

• Biological, such as heredity or genetic makeup
• Environmental, such as family, school pressures.
• Social, or interactions and relationships with others
• Emotional, or feelings such as anxiety, depression, anger.

It's the emotional variables that underly and contribute to the symptoms we most often associate with co-occurring disorders and compromise our mental health. I've previously written here before about the interaction between addiction and mental health, but what I want to focus on now is what happens when an addicted person's emotional issues become prominent and seem to take on a life of their own.

'Co-occurring disorder' is a fancy term for mental health problems that occur alongside the addiction, when a person's ability to manage their emotional world becomes a problem in itself. The main types of co-occurring disorders are:

• Anxiety problems: panic attacks, phobias, generalized anxiety, obsessive-compulsive disorder
• Post-Traumatic Stress disorder (PTSD)
• Depression problems: Major depression and Bipolar Disorder
• Attention Deficit Hyperactivity Disorder (ADHD)

The first three listed above sometime start prior to the addiction, when the person turns to drugs (marijuana, cocaine, opiates, etc.), alcohol, or other compulsive behaviors (overeating, gambling, shopping, video gaming, etc.) to help manage their difficult emotions better. Choosing drugs, alcohol or compulsive behaviors helps to escape the painful and/or scary feelings by numbing, avoiding, or disconnecting from feelings altogether. Our emotions are often warning signs that something is wrong. Just like ignoring warning light on your car's dashboard can become a serious mechanical problem, not paying attention to our emotions can lead to coping-with-life problems.

ADHD, on the other hand is related to addiction and emotional well-being in a different way than the emotions described so far. ADHD is a neurobiological, or brain-based disorder, that contributes to increased impulsivity in behavior and emotional expression. Impulsivity often contributes to low frustration tolerance and anger management problems.

Sometimes, when a person becomes sober and lets go of their longstanding coping mechanisms, anxiety, depression, and ADHD problems become revealed and will need specific attention in addition to traditional addiction counseling and relapse prevention approaches.

It's estimated that 60% of people with a drug and alcohol problem also have a co-occurring mental illness. Symptoms of addiction--mood and personality changes, sleep and appetite disturbance, irritability and impatience--often mimic co-occurring disorders. Symptoms of depression are often expressed differently in children and adolescents, so that can complicate things even more.

Research suggests that the best treatment approach is one where both addiction and mental health issues are addressed at the same time. Finding a therapist skilled in treating both addictions and mental illness is crucial if there is any uncertainty of mental health problems.

Don't be afraid to ask a potential therapist if she/he has experience with co-occurring disorders, if you're at all unsure about your child or family member's situation. It will greatly increase the likelihood of getting the comprehensive treatment that's needed.

'NOT MY KID': THE ENABLING TRAP

An article in the Ambler Gazette last weekend about parents in Blue Bell, PA acquitted of charges of hindering a police investigation of their young adult son reflects the potential trap of enabling that many parents face when their children brush up against possible consequences from their substance abuse.

Please note: I’m not intending in any way to make a judgment about these parents, but I’d like to use their situation to identify a common issue among parents who are worried about their children’s drug and alcohol use.

Enabling occurs when you begin to lose your way and get confused about how to protect your children’s safety. You desperately want to believe your kids are telling the truth and therefore can be easily convinced that everything is okay, often telling yourself, 'Not my kid'.

Parents who are aware of their teenage children abusing drugs and alcohol are very familiar with enabling. When children are showing problems associated with getting high, a dramatic shift in the family often occurs.

The ‘not my kid’ mindset is a set up. The addict becomes an expert at manipulating and deflecting responsibility onto others and takes advantage of your love and protection to selfishly get what she wants without regard for the consequences or impact on others.

The whole family begins to react in unhealthy ways to accommodate the addict’s behaviors, because confronting them directly creates messy, often embarrassing conflicts.

Out of love, concern, shame, and fear, you become uncertain about how to best intervene. Living with a child with a drug and alcohol problem is like being in the back seat of your car as you are driven around by your inexperienced, untested young driver—the daily out-of-control, often terrifying feelings become unbearable at times.

The world of the enabler is like a yoyo, jerked back and forth across the line between being over involved trying to protect and cover up for your child, to being so angry, scared, and helpless that you want to give up. You swing back and forth between looking the other way and wanting to stalk your child’s every move.

Intervening can feel daunting. Here are some guidelines to make it easier:

• Educate yourselves by arming yourself with facts about drugs and alcohol to be credible when talking to your kids.
• Learn more about the dynamics of enabling.
• Confront your denial: Parent's instincts about a problem are usually correct. Avoiding and ignoring the problem makes you part of the problem.
• Take care of yourself by getting support:

-- Reaching out for help is a way for you to take care of yourself. Start by sharing concerns with spouses, partners, and trusted friends to help feeling less ashamed, overwhelmed, and helpless.

-- Community programs like Al-Anon and Nar-Anon can be lifelines for families struggling to regain balance in their lives.

-- Online communities such Parenting the Addict Child are excellent resources for those who aren’t comfortable with groups or 12-step programs.

SUBSTANCE ABUSE COUNSELING 101 FOR PARENTS

Understanding some basic principles of substance abuse counseling will help you as parents develop an approach to intervening with your child.

Substance abuse is a problem that involves the interaction among physical, emotional, social (friends), and environmental (family, school) variables. In the course of our normal daily interaction with our children, we’re usually aware of any physical, social, and environmental issues. Since children are often not able to articulate their emotional struggles well, we need to look at their behaviors as possible signs of conflict.

Human behavior, no matter what age, reflects choices we make based on how we think and feel. Also, as humans we tend to move towards rewarding activities and away from uncomfortable activities. Problems with drinking and drug abuse are associated with the negative choices we make, often as ways of helping us feel better in the short run. Chemically, alcohol and drugs offer available options ways to self-medicate the uncomfortable feelings of daily life.

For example, a common example of uncomfortable feelings in teenagers is associated with their struggle with self-esteem. Children tend to blame themselves and feel excessive guilt for a loss or trauma in their life and often feel shame about having such feelings. Avoiding these feelings by not talking is like burying them, making children more vulnerable for ill-advised choices for relief.

Using ICE

In my work with clients I explore making healthy choices with them regardless of their age. With parents of teens and preteens, I encourage parents to follow these guidelines for being proactive with their children to lower the risk of drinking or drug abuse: Information, Communication, and self-Examination.

Information

· Accurate information is the best ammunition to counter the risk of problems associated with substance abuse. Arming yourselves with facts about alcohol and drugs as well as about your child’s development will keep you ahead of the curve and help you stay in touch with your child’s potential risk.

· Emphasize facts, not opinions. Certainly your opinion matters, but the idea here is to be a reliable resource for information for your kids. Offer your opinion, don’t force it on them. It’s likely they already know it by observing your behavior.

Communication

· Listening to what children have to say is often a more important communication skill than what you say to them. Talking about general current events and pop culture will give you an opportunity to hear their views and attitudes without them feeling “interrogated”

· Set and always enforce clear rules about drug, alcohol and tobacco use. Discuss substance abuse frequently and emphasize that experimentation is not okay.

· Engage in regular family activities such as eating meals together, “movie/game night”, and family meetings

· Emphasize and provide, safe, sober transportation

· Help children develop resistance skills. Discuss with them specific ways to counter pressure from peers to take part in risky behavior.

· Reward healthy choices and activities.

Self-Examination

• We often forget that we were once teens. Take a look at your own childhood for clues about what parenting approaches worked and what didn’t work for you and adapt those guidelines for today’s lifestyle.

• How do you cope with stress? What coping strategies do you use? How manageable is your family’s schedule? The answers here are usually transparent to your child; honesty is required if you expect respect and trust back from her. Reward healthy choices and activities.
• Examine your own substance use/abuse and model healthy, responsible behaviors. For example, never drink and drive; don’t use illegal drugs.
• Seek help for yourself if you become aware of your own substance abuse problem.

HOW DO I KNOW IF MY CHILD HAS A DRUG OR ALCOHOL PROBLEM?: The answer isn't the most important thing...

As an addictions specialist, I get lots of calls from worried parents. It’s usually a bad news/good news scenario. The bad news is that most of the parents calling are beyond the point of wanting to know if their child is getting high--they’ve known it for a while by the time they finally pick up the phone to call.

The good news is that even though addiction is a progressive and chronic problem, without a commitment by the addict to maintaining a sober lifestyle, it can be a very treatable problem, especially with early intervention. And that initial call inquiring about a problem is a very important and necessary step in the process of getting help.

I use the word “process” because people come for help for a substance abuse problem with varying levels of motivation and ambivalence. Most people I see initially are being prodded or coerced to attend treatment: by a parent, spouse/partner, friend, doctor, or a lawyer.

Even parents, who are usually feeling terrified and often desperate when they are calling about their troubled teenager or young adult, have some level of ambivalence about seeking help. They’re scared, or guilty, or embarrassed or usually a combination of these or other uncomfortable feelings. They’ve probably put off for a long time making that first call. The process of reaching out for help mirrors the process of addiction recovery itself: it’s not a straight line but a series of steps: two forward, one backward, up and down, ebbing and flowing.

The importance of that initial call by a parent is not based so much on the content of the discussion--the specific information shared--but the fact that the first call represents two crucial factors that need to occur in the early recovery process to increase the likelihood of a successful parental intervention: the willingness to educate yourself about addiction and recovery; and taking steps to reclaim control of your parenthood.

Education

Accurate information is a front-line weapon in the battle against the disease of addiction. Addiction is a complex interaction of biological, psychological and interpersonal (social, family, peer relationships) factors. The more information you arm yourself with--for example, what addiction is, about the specific substances of abuse, types of addictions, the nature and process of addiction and recovery--the better position you’ll be in to figure out the action steps to take to feel more control of your child and his/her problem

Reclaim Control of Your Parenthood

I like to view that first call for help as the first step by a parent to get back in the driver’s seat of the family and reclaim control of parenthood.

An important shift in family functioning occurs when a family member is struggling with addiction. The addict is an expert at deflecting responsibility away from herself. Family members, out of love and concern, will be often willing to accept some (or a lot!) of the responsibility and even blame for the addict’s inability to take care of herself. So in addition to giving parents some specific information during that call, I’ll have them start the process of figuring out how they can begin to focus on which aspects of the problems associated with the addict’s behavior that they can control, or actually do something about. This is the first step in the parent’s own recovery.

Taking steps towards reclaiming your parenthood will begin the process of shifting the family functioning towards a healthier state and reduce the fear and helplessness for parents.

FYI: Elsewhere on PARC, I share some basic screening tools for getting a better sense of the difference between use and abuse:

HOW DO I KNOW IF IT'S A PROBLEM?

IT'S NOT NECESSARILY "HOW MUCH"

HOW TO HAVE HAPPIER HOLIDAYS

The holiday season is upon us in full force, and if we believe the media good-times advertising blitz, they'll be full of unlimited joy and good tidings. (I was never sure what tidings are. If anyone knows, let me know!)

My clients with addicts in their family often dread the holidays with the constant worry of the addict spoiling their good times with their unpredictable behavior.

Carole Bennett's post on The Partnership at Drug Free.Org's blog, INTERVENE, focuses on the importance of setting firm and "respectful" boundaries. Her guidelines for boundaries hold true 365 days a year, but establishing them during the holiday season will lower the likelihood of your holiday being disappointing.

Her suggestion about looking at the larger picture, that there are many other occasions down the road to celebrate, reflects an aspect of addiction and recovery that my clients often have a hard time grasping: addiction and recovery are a process that unfolds over time, with progress and relapse, ebbs and flows.

Managing your expectations is another important concept. Having a realistic and flexible sense of what to expect can make adjusting to the normal slips and slides of life in recovery easier.

Getting better at pacing ourselves with the expected ups and downs so we don’t lose sight of the larger picture of our lives is the idea. It’s easier said than done, for sure, but once we get the hang of it, we don’t feel as overwhelmed all the time, leaving more energy to enjoy ourselves.

HAVE A SAFE AND HAPPY HOLIDAY SEASON!