Bipolar Children and Poo Smearing

I've read through a number of books on bipolar children. They all seem to have one brief paragraph somewhere in the book that says something about bipolar children urinating in inappropriate places and/or smearing feces. That's it. One brief statement and they're done. The really comprehensive books may say something like "Little is known about this." That's about all they say on the subject.
Yes! I know he does that! Why?! and more importantly HOW DO I DEAL WITH IT?!!
Well, after much research, I'm still coming up empty handed, so here's what we're doing. Maybe this will be helpful to someone else out there dealing with the same thing, or maybe one of you will post here about a good technique you've tried. I should probably also mention that it isn't just poo. He also pours urine in his heat vent, on the carpet, on his bed, in the window sill, etc. Poo he hides, plays with, or smears on carpet, walls, bedding, windows, curtains, and toys. At this age he rarely has much on his body. It's everywhere else.

Poo smearing can be for 4 main reasons: sexual, attention, sensory stimulation, or defiance. I'm lumping anger in with defiance for the sake of simplicity.
The approach to treating the first 3 is much more straightforward, so I'll touch on them because it makes sense to consider those strategies first. I believe Pajama Monster is the last category.

Sexual: In some cases a child who has experienced sexual abuse will act out with elimination issues such as fecal smearing, soiling themselves, bed wetting, etc. In these cases it's obviously the abuse and not the elimination concerns that you want to be addressing. In these cases the behavior is often also accompanied by other symptoms such as sexualized behaviors, tantrums, nightmares, and possible avoidance of the person abusing them. If you think this could be what you're looking at go see a therapist, and prevent unsupervised contact with anyone who had the chance to abuse, at least until you've had a chance to figure out what is going on. This is a case where discipline isn't the answer. This child needs protection and safety to talk about what has happened. Seek the help of a professional and be sure to avoid planting any ideas in your child's head about what you suspect might have happened with leading statements. Not all poo smearing has anything to do with abuse, but I thought I should mention it because it does sometimes happen.

Attention: This one is just straight up behaviorism. Don't provide any response (I know, I want to scream too!) and provide lots of praise and attention when the behavior is not happening. Have the child clean up as much as is developmentally appropriate, but don't clean with him/her because you're trying to minimize attention. Provide a consequence for the behavior but don't comment on it more than to assign the consequence, and make it clear that there are rewards to be had for those who do not do this behavior. It usually extinguishes fairly rapidly once you're not reinforcing it. The reinforcement is your big reaction. ("Rapidly" meaning about as long as you've been reinforcing it, plus a week or two.)

Sensory: These kids are doing it because the texture, feel, smell, etc. is very reinforcing. It feels great to them to squish things between their fingers or smear it on the wall. For these kids you want to provide a sensory appropriate outlet. Painting with shaving cream on the shower wall or a big piece of paper, washing plastic dishes with lots of gentle soap, play doh, finger painting, paper mache, water play, etc. Continue to do your best to limit chances for poo play and provide appropriate alternatives/redirect. Offer sensory play often, and coach the child on ways to ask for sensory play so they don't get the idea that smearing poo is the way to get to play with shaving cream.

Defiance: This one is where we are, and where I suspect most of the bipolar children are. Pajama monster uses a sock or cloth to grab the poo so that he doesn't have to touch it. He also doesn't always smear it. Sometimes he puts it in his dresser, or in a toy, or in his shoe. This tells me it's probably not sensory. He isn't left alone with anyone except daycare, and I've interviewed children and parents from the daycare, and can pop by at any moment to check on him. He also isn't showing any sexualized behaviors, so this tells me it's not sexual abuse. I've tried and tried with the behavioral route. The behavior doesn't respond at all to rewards or consequences. I can literally offer him a choice between pooing on the walls and having a day of scrubbing his walls, or just playing with his toys during quiet play time and then having a treat and going to the park. He picks poo almost every time. There's no lack of consistency with the rewards and consequences. they simply don't seem to have any impact on his behavior. Since I can't make him stop, and this has been going on for several years now, here's what our coping strategy had been, followed by a discussion on our new strategies and the role of anger in this behavior:

1. We stripped his room of everything but a washable toddler mattress and blankets and a couple easily washable toys.
2. I got a carpet shampooer. If I had the choice I'd just have linoleum in his room.
3. I painted his room in high gloss paint (He got to choose the color...light blue.)
4. I tied his ability to choose his own food and have treats to whether he'd smeared poo/urine in the past 24 hours. (I hate to use food as a reward/consequence, but I'm kinda desperate and I wanted to show that he could have more control if he's made good choices.)
5. When he smears poo I calmly remove any remaining large pieces and give him a scrub brush and a couple of wet cloth diapers and tell him he may come out when the room is clean. Without saying anything else I then shut his door and return periodically to check progress. If progress is made, I praise the effort and leave again. If no progress then I just shut the door. Once the room is clean (anywhere from an hour to a day and a half so far)to 4 year old level of capability, I have him sit in a chair till I finish cleaning. He doesn't get to sit with me or interact with me or play during this time. Once I've shampooed out any bad spots from the rug and wiped off any residual from the walls, he may wash up and return to normal life. Obviously he gets to come out for meals and school and doctor appointments whether he's cleaned up or not.
6. We have a toddler potty in his room so that he doesn't get creative in the main bathroom/ hall/ rest of the house after bedtime. It also prevents the "I have to go potty" every 5 minutes battle we used to have at bedtime. He'd spend 20 minutes playing in the bathroom and then would announce he needed to potty as we were putting him back in bed. If we didn't let him return to the bathroom he'd poo or urinate on his floor, despite having spent the last 20 minutes not using the toilet in the bathroom. If we did let him, the cycle would just continue over and over.
7. I keep a small jar of the paint for his walls and a paintbrush handy to do touch ups when he manages to damage the wall.
8. When he was younger we used several strategies to keep him in a diaper. We would put him in footy jammies that were pinned shut with a diaper pin, not a safety pin. Diaper pins have plastic covered heads that are less likely to come open on their own and poke the child. When the pin didn't work we moved to cutting the feet off the jammies and pinning them on him backwards, or even wrong side out and backwards. These helped for a little while, but my son can disable any childproofing device and nothing will stop him from getting out of his clothes now.
9. I explain the natural consequences of his action, such as no friends can come over because the house smells like poo, or we can't go to the park because Pajama Monster needs to clean, etc.
10. Minimize his chances to do it. Lots and lots of supervision seems to decrease his opportunity. I am especially careful when he uses the bathroom or at bedtime. This doesn't always prevent it because I can't be there all the time, but it does reduce it somewhat.
11. I put a cotton cloth about 2.5 feet down his heat vent. He can't reach it there but it will soak up any urine, etc. that gets dumped down there and prevent it from getting deep into the heat ducts where I can't clean it but will have to smell it every time we run the heat.
12. I make sure that the process of cleaning Pajama Monster isn't reinforcing. He gets any soiled parts of himself rinsed off with cool water from the shower sprayer, then quickly dried off and back in his jammies. We don't do the usual long toy filled bubble bath that he enjoys so much or else the smearing behavior just becomes a way to get a bath, thus reinforcing it.

The new strategy: We're using many of the same techniques with two noteable exceptions. We're no longer having him clean alone over whatever length of time it takes him, and we're no longer tying other consequences after the fact. I'm still expecting him to clean, but if he's not cleaning then I hold his hand and guide his cleaning till everything is done, then we wash up and move on with our lives. I'm not sure if this will work yet, but at this point all I know is that what we were trying wasn't working and I'm not willing to spank him (and also don't think that would help) so that leaves us with this.

When a child behaves this way, and it isn't sexual, attention, or sensory related there is usually an underlying anger component. I know this from my years in the field, but what I don't know is why Pajama Monster is mad. Usually I see this when the parent is on meth and neglecting/abusing the kids or there's some sort of extreme emotional abuse, but we have a pretty normal family, and I suspect most of you reading this do too. Pajama Monster is consistently praised and told that he is loved. He has toys and education and playdates and snuggles. The things that seem to make Pajama Monster angry always center around control, and they're unfortunately usually things I can't give in on. We give Pajama Monster age appropriate levels of control, and choices on almost everything else. I'm willing to problem solve and negotiate, but sometimes I just have to say "No." No, you can't take your sister's ice cream. No, you can't play with the electrical outlets. No, you can't have a sharpie. If I were my own client, the first thing I would be looking at once determining the anger issue is how to give Pajama Monster a sense of control, but in Pajama Monster's case there just doesn't seem to be enough control in the world to satisfy him. If he wakes on his own time and picks his clothes and breakfast and fun activities and lunch and generally has free range to make his own choices, he'll melt down because his sister got to pick the pink bowl and he wanted her to have the blue one (We have multiples of each color. He didn't want pink. He just wanted to make her choices for her.) If I structure his day so that everything is nice and predictable for weeks and weeks at a time, he still gets mad every time a choice isn't his, and doesn't seem to care about the routine at all. I feel like I'm trying to fill a bottomless pit of need for control, and as long as it isn't full there will be anger bubbling out of it. I'm hoping that by switching to a "fix it and move on" strategy perhaps I can minimize the anger a little bit and also break the long stretches of time that Pajama Monster is dealing with poo.

Just in case anyone out there was wondering, I should probably also mention that there was nothing strange about Pajama Monster's potty training. We offered praise and rewards and never gave consequences around toileting. He was given a potty at about 18 months and allowed to use or not use it. It was just there in the bathroom when he felt ready. He was around 3 years old when he was done with diapers, but still wearing a bedtime diaper because he still wets the bed. He's never been scolded for bedwetting. We give him control over age appropriate things such as what he plays with, what he wears and what he eats (within limits of course-no marshmallow and chocolate dinners!). I truly don't know where this behavior came from, but it's been a long and very frustrating struggle.

The Heartbreak of Hope

Pajama Monster started Depakote on Sunday. We increased to 2 pills last night, which will probably be the final dosage. We do the blood test next Thursday or Friday to see if the levels are right. Today has been a great day. He soaked several cloths in his room with urine before I came to get him out of bed this morning, and he's had a couple very brief time outs for things like throwing things in the trash when he knew not to, but that's it so far. Other than that he's played in the yard and had lunch and gone for a "milk treat" at Starbucks, and played at the park, then ridden bikes with his sister. It's very very rare for Pajama Monster to have a day like this, and so I hope. I try not to, because I hope on every good day, and with every new med, and every new therapy or program. I hope and pray and then the next swing hits, and we're right back where we were, and I hurt. I'm trying not to hope this time. It's never brought anything but more pain, but I look into his smile and I can't help but hope, once more, that this time will be different.

ODD, ADHD, Fetal alcohol, and Bipolar, the laundry basket test

This is a little example I use to clarify the differences between the overall feel of these diagnoses. Every child is different, and severity of conditions also varies. This is meant as an example of the flavor of the diagnoses, not a set checklist sort of test. You can read all the checklists in the DSM IV, but really it comes down to feel, so here's how I think of the differences. Imagine you have 4 children. One child has ODD, one ADHD, one fetal alcohol syndrome, and one bipolar. You give each child a laundry basket full of their clean clothes and tell them to go upstairs, put their clothes away, and bring down their dirty laundry. None of the children bring the laundry back, but it's HOW they don't bring it back that shows what's going on. Just because your child didn't do as instructed doesn't really clarify anything about the problem. Here's the differences between the diagnoses as I see them.

The ODD child dumps the basket on the floor and stomps off, or goes upstairs and dumps it over the railing, but either way they're very clearly deliberately refusing.

The ADHD child takes the basket and goes half way upstairs. You find them sitting next to it 20 minutes later playing with a toy. They look at your irritated expression, see you staring the laundry and jump up, clearly surprised that they had forgotten to take the basket upstairs.

The fetal alcohol child will probably take the basket upstairs, assuming they were calm when you asked. When you ask them later why they didn't put their clothes away and bring you the dirty laundry they will look at you in confusion, as though there were no instructions after the first one you gave. Conversation around your frustration will likely skew on random tangents. Alternately they will refuse to take the laundry upstairs, but with reasoning that doesn't seem to line up, such as because her boyfriend is awesome and laundry is stupid and they're going to be super rich because they both want to be rich, so no, she won't do laundry today.

The bipolar child may do anything. Maybe they follow all the instructions. Maybe they throw the basket at you and start an hour long screaming/throwing fit. Maybe they politely take it upstairs, then poo in it. The response varies from minute to minute. The only thing predictable seems to be that something unpredictable will happen on a fairly regular basis.

These are stereotyped examples to show themes, not meant to be taken as a way to pre-judge someone based on their diagnosis. Sometimes by exaggerating the simplicity of the diagnosis you can more easily see which theme is happening within the complexity of daily life. I hope someone out there will find this helpful in avoiding a misdiagnosis.

Diagnosis: A little of everything

I'm sitting here with a copy of the DSM on my shelf wanting to rip my hair out. For those of you not familiar with the DSM, it's a book used to diagnose mental illness, etc. It has codes for all accepted diagnoses and has a list of accepted criteria for each diagnosis. When someone says they have a diagnosis, they mean that they meet all the criteria for that diagnosis listed in the DSM. I've heard talk that the next edition may contain both childhood onset bipolar and sensory processing disorder as new and accepted diagnoses. Here's the full current edition for anyone curious DSM Online

The frustrating thing about childhood bipolar is that because it's new, people are still agreeing on what it looks like. On top of that, it seems to have a very high rate of comorbidity (other diagnoses being present along with it). This muddies the waters in terms of what is generally seen in bipolar, and what is part of diagnoses often occurring along with bipolar. The childhood version doesn't seem to have nice clean cycles as are often seen in adults, and children often express depression through anger and irritability. As if that weren't enough, environmental stressors can make any child extremely moody and defiant as well. In short, it's a nightmare to try to diagnose.

I've hard many other parents echo this, and it's my constant lament: Any of the things Pajama Monster does could be seen as the far extreme of normal naughty behavior if it were the only incident. The thing is, it's not just one incident. It's hundreds, happening very frequently and seemingly without warning. Other kids show signs that they're getting frustrated and then lose control, but my little boy suddenly just smiles as though possessed and proceeds to destroy things.

I've tried so many different diagnoses on for size. He has a sampler platter of so many, but doesn't meet the full criteria for most. He's extremely active at times, but not as much as a child with severe ADHD, and he seems gleeful, not oblivious to the results of his actions. He is rigid in his thinking, but with social skills that clearly show he's not autistic. He meets criteria for ODD (Oppositional Defiant Disorder) but that's just a name for symptoms, not a cause. A diagnosis of ODD will get you insurance coverage in most cases, but is otherwise useless. It's the mental health equivalent of going to a doctor because your throat hurts and being given a diagnosis of "sore throat." You already knew your throat was sore. What you want to know is WHY and how to TREAT it. Before I launch into a list of what's going on with Pajama Monster, let me just give my gut feeling on bipolar childhood symptoms: If it looks like ODD, anxiety, sensory problems, ADHD, and a few autistic features just for flavor, you may want to consider evaluating for bipolar. It doesn't mean that your child doesn't have bipolar AND one or more of those other diagnoses, but it may help in gaining a clearer picture of what's going on.

So, that's my rant, and here's the giant pile of puzzle pieces I'm trying to put together over here.

Anxiety?: He seems to go "Deer in the headlights" when overstimulated or confused.

Autistic features?: He has trouble engaging in structured creative play, such as playing kitchen. He gets locked on certain ideas and can't readily change. He sits and draws patterns for long periods of time and doesn't like things being out of order.

Sensory?: He becomes frightened when upside down and will get stuck on play equipment unless he's done the exact motor activity several times. The school OT suspects poor motor planning. He runs into things and falls frequently and has trouble mirroring actions that are demonstrated for him, such as a jumping jack.

Mood disorder and etc?: Tantrums over seemingly trivial things, extreme defiance and need to control, destruction of property including his own favorite toys.

Just fooling myself?

There comes a time in any parent's life when he/she must make an honest assessment of their child's capabilities. This allows the parent to push for services their child needs, both in terms of providing chances to excel in areas the child is good at, and building skills where the child struggles. For the parent of a disabled child this also often involves grieving the potential we'd hoped our child would have. I've heard parents in denial around this step many times in my office saying things like "when we find the right med and he can understand things..." regarding a profoundly mentally retarded child for instance. That child may grow to be many amazing and wonderful things, but no medication in the world will change the retardation. Despite the need to be realistic, though, a parent must be very vigilant not to pigeon hole their child. I've met many a parent with charming and very verbal autistic children who were told early after the diagnosis was made that their child would never develop language.
I know it sounds noble to say that you're sure your child can do whatever he wants in life and you'll be there to cheer him on, but the truth is, this reality check isn't about settling limits for the disabled child. You should never tell a child not to try. This reality check is about letting go of your own dreams and expectations and accepting your child as they are, for who they are. It's hard to see all their real strengths if you're caught up in fooling yourself about the disabilities. The parent of the retarded child, for example, was so caught up in how things would be once the retardation was gone, that she couldn't advocate for the things she needed in order to function with the retardation. I wasted a lot of time thinking that I shouldn't bother to find a support group or research medications because surely we'd find some star chart or reward that worked and all of this would soon be nothing more than a memory.

My struggle is this: While being truly honest about Pajama Monster's disability and his many strengths, what does this mean for his future? What is the best case scenario? What does success look like? Could my son become a neurosurgeon, a CEO, president? Could my son be a computer engineer, or would just holding down any job be a success for him? It's not that I expect that he will necessarily want to be a neurosurgeon, but I'm wondering if his disability would stop him if he did. What sort of extra supports will my son need long term? Where will he be next year? The answer is, no one seems to know. Maybe the meds will work and next year I'll be pushing for the gifted program instead of working on the IEP. Maybe next year will look exactly like today, with me typing my frustrations out while my son refuses to scrub the poo off his walls. Even hope feels painful sometimes, because it always comes just before the new med sends Pajama Monster into mania or the next swing hits. I wish so much for a glimpse of the future, but even if I could look, I'm not sure I'd have the courage to do so.

A comic that sums it up.

I just thought I'd share this. It reminds me very, very much of life with a bipolar preschooler, expecially the part about potty training. http://theoatmeal.com/comics/tyrannosaur_crack

The Therapist in Me

I feel like I need to mention this, just because I've seen it so often in my practice. Bipolar disorder with childhood onset is a bit of a hot topic now, and is therefore getting more publicity. It's a fairly new idea that a child can have bipolar disorder, and this leads to a boom of diagnosis, hopefully mostly accurate, but because of the newness and lack of familiarity, some may not be accurate as well. Just because your child is acting out, even in the same ways you see listed in books you're reading, does NOT necessarily mean that he/she is bipolar, or has any mental health condition for that matter. Before Pajama Monster was diagnosed, the psychologist did extensive looking at my husband and my own parenting skills, our home environment, the possibility of abuse from home or another source, medical problems, family history of mental health problems and medical issues, major transitions or changes, and longevity of the problem, to name just a few. He did this because it is very often one or more of these factors. A child can appear to be bipolar as a result of poor parenting skills, or medical problems, sexual abuse inside or outside the home, trauma, etc. There are also many overlapping symptoms between bipolar, depression, anxiety, sensory processing disorder, OCD, ADHD, and ODD.
I'm writing this blog to talk about how I'm coping with life with a bipolar preschooler, and all the heartaches and joys and setbacks, but please, please, PLEASE, never diagnose your child yourself! I'm a therapist. I'm qualified to diagnose bipolar in a child, and still I would never have considered making the final diagnosis myself. I'm just too close to the situation. There's too great a risk that I'll see what I want to see and not see what I don't want to see. Beyond that, for the nonprofessional, reading a list of symptoms just isn't enough to make a diagnosis. That's why no therapist will diagnose until he/she has seen the child. It's how all the pieces fit together that informs diagnosis, not just a list of check boxes. We see supervisors and learn over time what the diagnosis really looks and feels like before we diagnose it in others.
I just want to make sure I don't give the impression, by jumping in with where we are today, that we skimmed over all the other steps of diagnosis. They are incredibly important, and unfortunately very time consuming. Be honest with your child's therapist. It's the only way to get an accurate diagnosis, and be willing to wait while all the information is being gathered. It may be the diagnosis you suspect, but then again it might not. I once met a little girl diagnosed with autism because of headbanging, screaming, failure to develop language, flailing motions, no interactive response to other's attempts to speak to her, etc. Autism? Everyone thought so, that is until someone took a look in her ears and discovered the horrendous ear infections she had behind both eardrums. She couldn't learn language or engage in attempts at speaking because she couldn't hear, and the rest of the symptoms were her frantic attempts to deal with the pain in her head and to express her needs without words. The diagnosis isn't always what it first looks like. Take your time and never be afraid to question.