Help- Is this Bipolar or something else???

[kidluvinRN]

Hi all, I could really use some advice. I am a community-based nurse who is working closely with a 13 yo with medical needs, developmental delay, and what I suspect maybe emerging bipolar (strong family hx). Child takes Zyprexa and is under psych care.

I have been a caregiver with this child for a number of years, which has required that I be very skilled in behavior management and aviodance of power struggles (this child has been known to remove trach as an attention getting ploy) Not easy but I have managed to establish a good rapport with this child and am able to provide the medical care needed.

Here is where this story begins: Over the last several weeks behavior has been severely escalated; self-abusive to the point of leaving bruises and marks; and yesterday erupted into a crisis where the immediate environment was trashed and restraint was needed. While attempting this I was hit, bitten and scratched until another person helped me with a two-person hold. This continued for close to one hour while we were transported home. Once there the child suddenly calmed and walked directly to the foster-mom and said "(name of child) hit and bit" It was eerie, like the child was talking about someone else. There was very little association with all that had just happened. Is this dissociation common with Bipolar or are we looking at something else here?!

During these periods of escalation it is like I do not know this child; nothing I have done in the past helps; all of my good rapport is for naught!!!! Ultimately I am afraid that the escalated behavior with precipitate a medical crisis. I am working closely with her home but no one seems to know what to do. Any advice?

[kidluvinRN]

Hello! It's me, wondering if anyone can give me some insight. I have not worked in psych and feel overwhelmed with this situation.

My community based training (person centered) would respond to this using 2 person holds, transports. Techniques like sitting against a wall using arms and legs to hold the center person still until they calm. This works well, but I have concerns with safety d/t this child with a trach, respiratory, and seizure disorder. What do you all think?

[steelcityrn, RN]

Her family should contact the physician who prescribed the zyprexa for a check up. Does not sound like bi-polar, but does need addressed to prevent injury. Zyprexa may need a dose change or a adjunct added.

[leslie :-D]

i agree that this young man needs an immediate psyche consult.

my 16 yo dd has bipolar and after months of research into adolescent bipolar, i have learned that mania does not always manifest itself as euphoria and countless nocs of sleep; but rather can present as rage, self-abusive behaviors.

the part i don't get is i recently have questioned if she can distinguish between reality and fantasy: with her most recent hospitalization, the psychiatrist stated she probably has some schizo-affective disorder which entails delusional thinking.

the priority here, is to get him to a psychiatrist asap to have him evaluated.

wishing you, the child and his family well.

leslie

[Thunderwolf, MSN, RN]

This is a very complicated case, with many issues and multiple risk factors. The psych eval, as well as ongoing assessments, are crucial in determining what is actually going on here. Too complex of a case to provide helpful information over a board. Also, psych testing may be in order to help root out more accurate diagnoses. Hope things improve.

[kidluvinRN]

Thanks for your replies.

[hbncns35]

Interesting -

First off being bipolar for 20 years beginning as an adolescent, I would advise you NOT to restrain the child. This does nothing but perpetuate the incident and put you further away in rapport with the child. Many people in Psyche relay their own fear on the child and the child senses that distrust and will only continue the self destructiveness. If you do approach the child, a stern understanding voice is in order. As far as the "dissociation" goes, I know in my manias as outrageous as they were, there was always a part of me that knew what I was doing and I also knew I was not making sense but I was unable to control it. I have never heard of using Zyprexa on a teen esp. for weight gain issues and I do not think it is the best drug out there. You must re-establish trust with this patient and teach them new techniques of anger management. Read - The Bipolar Child. A mood stabilizer sounds more like a treatment possibility. I am not so sure how "psychotic" the child is by your description but there is some manipulation going on by the child to the parent. Don't feel that is dissociation. Bipolar children are great manipulators in order to keep the illness functioning. Getting out of self-destructiveness takes years and alot of work done by the patient. Some children take to Equestrian Therapy covered by Ins.

Hope that helps - Done a great deal of work with this and have managed to "quiet" the illness, learn from it and move on..........

...Regards-Heather BSN May06