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 Appendix A - Reproducible Client Worksheets
Techniques Discussed on the CD

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Knowing Your Child
Replay CD track 1 for more information regarding this technique.
Parent of bipolar child client fills out the following questionnaire to help familiarize them with their child’s most prevalent symptoms.

  1. Does your child have attention problems?
  2. Does your child exhibit unusual sadness?
  3. Does your child seem irritable a good part of the time?
  4. Does your child express a grandiose sense of him or herself and his or her abilities?  Is everything too good?
  5. Does your child show significant changes in sleep, appetite, energy, or interest in friends and activities?
  6. Does your child have unexplained rages?
  7. Does your child have seemingly unfounded fears or worries?
  8. Does your child ever have hallucinations, delusions, or bizarre thoughts?

Separation Anxiety:  Parent Techniques
Replay CD track 2 for more information regarding this technique.
List of following techniques is given to parents to help them cope with a bipolar child who suffers from separation anxiety.

  1. Listen to the child's feelings.  The simple experience of being listened to empathically, without receiving advice, may have a powerful and helpful effect.
  2. Keep calm when a child is upset about separating .
  3. Gently remind the child that he or she survived the last separation . Reassurance goes a long way and may help reduce the child's anxiety.
  4. Anticipate transition points that can cause apprehension, such as going to school or meeting friends for play. If a child tolerates separation from one parent more easily than from the other parent, arrange school drop-off, bedtime, and other transitions to be handled where possible by the parent from whom it is easier to separate.
  5. Firmly, consistently, and caringly set limits .
  6. Teach relaxation techniques. Teaching children or adolescents how to relax will empower them to develop mastery over symptoms and improve a sense of control over their body.
  7. Praise the child's efforts to address symptoms. Young people often feel that they only hear about their mistakes. Even if improvements are small, every good effort deserves to be praised

Subtle Warning List
Replay CD track 3 for more information regarding this technique.
The following list of suicide warnings is given to parents to help them identify a bipolar child who might be suicidal.
Depressed mood
                History of a previous attempt
                Decline in school performance
                Increased social withdrawal
                Loss of interest and pleasure in easily enjoyable activities
                Changes in appearance—for instance, no longer caring about one’s hair or clothing
                Preoccupation with themes of death—the client may begin to read books with themes of                 death and dying
                Increased irritability and behavior problems
                Giving away important possessions
                Use of drugs and alcohol
                and
                Changes in sleep and/or appetite patterns

Survival Tactics
Replay CD track 6 for more information regarding this technique.
The following list of survival tactics could be used when a bipolar child client is having a manic or depressive episode.  Also might consider sharing these tactics with client’s parents.

  1. Let the child define his or her own mood.  What a parent perceives as sadness in a child might be expressed as "indecisiveness" or just plain "feeling bad".  Letting him or her know that you are interested in what he or she is feeling will give them a sense of understanding.
  2. Learn your child’s code words and actions.  This will help you interpret and communicate the mood cycles to therapists and psychiatrists.
  3. Anticipate triggers when you can, and plan to deal with them before they happen.  If you know that something is likely to trigger your child (i.e. time of day, candy at the checkout counter of the supermarket), schedule the shopping trip for another time or find a way to bypass the counter with the candy.
  4. Don’t let your child’s mood trigger an automatic reaction in yourself.  Wait until you know what you are dealing with before you act.

Rage Survival Tactics
Replay CD track 7 for more information regarding this technique.
Review the following plan with client’s parents to help keep a client safe when he or she is in a rage at home.

  1. Write a plan.  Create a safety plan when a bipolar child rages.  The plan should include what other family members should do in the event of a crisis.  A sibling might be instructed to lock themselves in their parent’s bedroom or run to a neighbor’s home.  Emergency phone numbers—a mobile crisis team if available, mental health hot lines, local police—should all be programmed into your telephone.  IF you’ve tried other measures and you believe that you, your child, or others are in danger, don’t hesitate to call for help.
  2. Check you own mood.  When your child’s mood is volatile, ask yourself if he or she is reflecting your own mood.  If you are not composed and collected, you will not be able to handle your child’s lack of composure.  The last thing you want is to fuel his fire.
  3. Detox.  If you are on the road or in a public place when the rage begins, try to eliminate or reduce all stimuli both auditory and visual, as well as smells and motion.  If you are in a car, switch off the radio and pull over.  If you are inside, go outside.  If you are in a crowded public place such as a supermarket, leave your shopping cart in the stores, and take your child to a quiet spot either outside the market or near the rest rooms, where she can "detox" from the mood.  Sit with him or her quietly and take deep breaths.  Hopefully, your child will follow your lead.
  4. Hydrotherapy.  There is something to be said for the healing powers of water, whether it is a warm spa bath with herbal chamomile aromas or a pounding shower to wash the angst out of the system.  If your child can be reasoned with, or as he or she is "cooling down" after an exhausting rage, draw her a bath or shower.  The water will refresh, rejuvenate, and help your child focus.

Contract to Avoid Conflict
Replay CD track 9 for more information regarding this technique.
When a rage is over, only then can parents revisit the issues that instigated it.  Ask the parents to write down goals and rewards for preventing rages using the following guidelines.

  1. Keep it simple and be specific.  Make sure that the goals and terms of your contract are stated in language your child can understand.
  2. Make the requirements just challenging enough for your child to find interesting, keeping in mind that his or her ability to address these challenges may fluctuate with his or her moods.
  3. Make sure there’s a "buy-in".  For the child to succeed, he or she must buy into the deal.  Set goals together, and agree on the terms of your contract.
  4. Use feedback techniques to give the child pointers on his or her performance.  This can be done on a daily, weekly, or monthly basis.
  5. Remember to update and change the contract regularly.

Transition Form
Replay CD track 12 for more information regarding this technique.
Use list of following categories when an environment transition is imminent to help client avoid sudden manic or depressive episode.
Expected Transition
Date transition will begin
Date transition will end
Beginning Preparations date
Tactics:  (i.e. reading books about transition, talking about transition, work with child to design schedule for transition period)
Mood observations pretransition
Mood observations day before transition
Mood observations day of transition
Mood observations posttransition
Mood observations two weeks posttransition

Positive Questionnaire
Replay CD track 13 for more information regarding this technique.
Client completes following phrases to help him or her increase self-confidence and self-worth.
                I am proud of
                What I appreciate about me is
                My accomplishments are
                Ways in which I take care of myself are
                The personality traits that make me likable are
                What others have told me they admire about me are
                When I feel powerful I can

Young Mania Rating Scale
Guide for Scoring Items: The purpose of each item is to rate the severity of that abnormality in the patient. When several keys are given for a particular grade of severity, the presence of only one is required to qualify for that rating. The keys provided are guides. One can ignore the keys if that is necessary to indicate severity, although this should be the exception rather than the rule. Scoring between the points given (whole or half points) is possible and encourage after experience with the scale is acquired. This is particularly useful when severity of a particular item in a patient does not follow the progression indicated by the keys.

1. Elevated Mood: 0: Absent. 1: Mildly or possibly increased on questioning. 2: Definite subjective elevation; optimistic, self-confident; cheerful; appropriate to content. 3: Elevated, inappropriate to content; humorous. 4: Euphoric; inappropriate laughter; singing.

2. Increased Motor Activity-Energy: 0: Absent. 1: Subjectively increased. 2: Animated; gestures increased. 3: Excessive energy; hyperactive at times; restless (can be calmed). 4: Motor excitement; continuous hyperactivity (cannot be calmed).

3. Sexual Interest: 0: Normal; not increased. 1: Mildly or possibly increased. 2: Definite subjective increase on questioning. 3: Spontaneous sexual content; elaborates on sexual matters; hypersexual by self-report. 4: Overt sexual acts (towards patients, staff, or interviewer).

4. Sleep: 0: Reports no decrease in sleep. 1: Sleeping less than normal amount by up to one hour. 2: Sleeping less than normal by more than one hour. 3: Reports decreased need for sleep. 4: Denies need for sleep.

5. Irritability:  0: Absent. 2: Subjectively increased. 4: Irritable at times during interview; recent episodes of anger or annoyance on ward. 6: Frequently irritable during interview; short and curt throughout. 8: Hostile, uncooperative; interview impossible.

6. Speech (Rate and Amount): 0: No increase. 2: Feels talkative. 4: Increased rate or amount at times, verbose at times. 6: Push; consistently increased rate and amount; difficult to interrupt. 8: Pressured; uninterruptible, continuous speech.

7. Language-Thought Disorder: 0: Absent. 1: Circumstantial; mild distractibility; quick thoughts. 2: Distractible; loses goal of thought; changes topics frequently; racing thoughts. 3: Flight of ideas; tangentiality; difficult to follow; rhyming, echolalia. 4: Incoherent; communication impossible.

8. Content: 0: Normal. 2: Questionable plans, new interests. 4: Special project(s). 6: Grandiose or paranoid ideas; ideas of reference. 8: Delusions; hallucinations.

9. Disruptive-Aggressive Behavior: 0: Absent, cooperative. 2: Sarcastic; loud at times, guarded. 4: Demanding; threats on ward. 6: Threatens interviewer; shouting; interviews difficult. 8: Assaultive; destructive; interview impossible.

10. Appearance: 0. Appropriate dress and grooming. 1: Minimally unkempt. 2: Poorly groomed; moderately disheveled; overdressed. 3: Dishevelled; partly clothed; garish make-up. 4: Completely unkempt; decorated; bizarre garb.

11. Insight: 0: Present; admits illness; agrees with need for treatment. 1: Possibly ill. 2: Admits behavior change, but denies illness. 3: Admits possible change in behavior, but denies illness. 4: Denies any behavior change.

- Young MD, RC, JT Biggs MD, VE Ziegler MD, and DA Meyer MD; A rating scale for mania: reliability, validity, and sensitivity; British Journal of Psychiatry; 1978, 133: 429-435; http://www.neurotransmitter.net/bipolarscales.html

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