Family Assesment: The Gallaghers and Bipolar Disorder in adolescents

Family Assessment: The Gallaghers and Bipolar Disorder in adolescents

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By Eugenia Dellamary

The Family The Gallaghers live in the South side of Chicago and are headed by an alcoholic, drug-addict father named Frank. The household and the family are taken care of by the eldest daughter, Fiona, a high school drop out, who takes care of all the other five children. Fiona’s other brothers and sisters are Phillip “Lip�, Ian, Debbie, and Liam. The mother, Monica, also has substance abuse issues and has Bipolar Disorder. She refuses to take medication, lithium, which in the past has helped with her symptoms. Monica left Frank and her 6 children five years ago, due to her mental health and her inability to be able to be their mother. Recently, Monica returned back to the Gallagher home claiming she wanted to start over and try to be a mom again, and that did not go well.

On Thanksgiving day, Monica attempted to commit suicide by slashing her wrists but was taken to the hospital on time to save her.

The Gallaghers in the living room with friends.

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Ian Gallagher Ian, who is 17 years old and a senior in High School, recently has been diagnosed with Bipolar Disorder and refuses to go to the doctor and take medication because he believes he “is fine”. It began when his behavior turned erratic. He would have a lot of energy, grandiose ideas, and act extremely giddy. He would then have periods where he wouldn’t get out of bed all day, be very depressed, and irritable, and socially isolate himself from his boyfriend and his family. Ian’s brothers and sisters are very concerned about Ian and his wellbeing. They are afraid that he can put himself or others at harm, like their mother did. They want Ian to voluntary commit himself to a psychiatric unit and to take medication.

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About Bipolar Disorder in Adolescents “According to the National Institute of Mental Health (NIMH) the diagnosis of Bipolar in children has increased 40-fold in the last 20 years and some literature sources even state that up to 2 - 3% of all adolescents have been diagnosed with Bipolar.” Children and teenagers experience “ups and downs,” but Bipolar disorder is characterized by “profound and unusual behavioral shifts” that can have an impact on friends, school work, and even result in suicidal thoughts. Symptoms include periods of mania followed by periods of depression. Manic symptoms include being unusually silly, or joyful, racing thoughts, getting little sleep, jumping from one activity to the next, and engaging in risky behavior. Depressive symptoms can manifest as the adolescent sleeping a lot, having long periods of sad moods, gaining or losing weight, being irritable, feeling worthless or guilty and thoughts of death or suicide. Bipolar Disorder usually develops before age 25 in late teen and early adulthood although it is seen earlier than that in children and adolescents. Bipolar Disorder has a tendency to run in the family, as is the case for Ian Gallagher, whose mom also had the disease (Roberson, 2014).

Diagnosing “There are no blood assays or brain scans to diagnose the symptoms of Bipolar. The clinical workup may include testing for learning, thinking, speech and language. Other comorbid conditions may exist like substance abuse” (Roberson, 2014).

Medications Although there is no cure for Bipolar, medications and psychotherapy can help children and adolescents. Mood stabilizers such as Lithium carbonate (Lithium) can be used for children over 12.

Divalproex sodium (Depakote) and lamotrigine (Lamictal), which are anticonvulsants, are also used.

Atypical antipsychotic and antidepressants are useful for this age group as well (Roberson, 2014).

There are many types of psychotherapy that can be helpful. “Family Focused Therapy helps family coping by improving communication and problem solving” (Roberson, 2014).

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Culture/Religion Challenges: The neighborhood that the Gallaghers live in, the South side of Chicago, Illinois, is in a lower socioeconomic area with higher incidences of gang and illegal activity.

The Gallaghers are very poor, and barely scrape together enough money to keep the family afloat. The Gallaghers like to drink, smoke marijuana, do other drugs, and party. They frequently hosts parties and get togethers at the house. All the Gallagher children drink and do drugs, except 5 year old Liam and Debbie. Fiona frequently has caregiver role strain as she is not the parent of the children but an older sister.

The Gallagher family is not religious. They don’t go to church and they don’t have any particular spiritual beliefs.

Strengths: The family lives in a two story house that was inherited from Monica’s family.

Although Fiona is the main caregiver of the children, she is doing the best with the part of a role that was thrown onto her due to Frank and Monica’s neglect. The neighbors and friends of the Gallaghers are supportive of Fiona with raising the children. They help with babysitting, with emergencies, and other social support.

Communication practices The Gallagher children are very open with one another. They live in the same house and have breakfast and dinner together. They talk to each other about what is going on in their lives. They are a tight-knit family and they can sense when there is something going on with their siblings. They are concerned about each other’s well being. Frank and Monica, however, are both self-absorbed. Frank may appear to care or have interest in his children, but mostly only cares about himself. The Gallagher family frequently uses swear words and can have heated arguments when discord happens in the house. The children get very angry and frustrated when it comes to dealing with Frank. They often fight with Frank when he is around, and kick him out of the house. They will violently throw Frank out of the house at times. When referring to their mother, they call her by her name Monica. All the children do not get along with their mother at all. They don’t speak to her and would rather not have her around, which was a tough decision for them.

Assessment: Developmental stages Ian

Identity vs. Role Confusion/Diffu sion

Role confusion. Ian is in denial about his diagnoses and what he is experiencing.

Fiona

Intimacy vs.

Isolation

Intimacy. Fiona, who is 25 years old, is very committed to the family.

Phillip

Intimacy vs.

Isolation

Intimacy. Phillip, who is 21 years old, is also very well connected with the family and is concerned about Ian’s well being.

Carl

Industry vs.

Inferiority

Industry. Carl, 14, is very industrious and has many skills and talents along with caring for his family.

Debbie

Industry vs.

Inferiority

Industry. Debbie, 16, is smart and responsible and has a good sense of self.

Liam

Trust vs.

Mistrust

Liam, 5, doesn’t talk much but nonverbally appears trusting of the family that takes care of him.

Frank (dad)

Generativity vs.

Stagnation/SelfAbsorbtion)

Stagnation. Frank has a long history of substance abuse and neglecting his family. He does not think about others only himself.

Monica (mom)

Generativity vs.

Stagnation/SelfAbsorbtion)

Stagnation. Just like Frank, Monica is self-absorbed and has always been reluctant to get help for her substance abuse issues and her Bipolar Disorder. She does not care about her family and only cares about herself.

Applying the Bioecological Systems Theory Bioecological Systems Theory was developed by Urie Bronfenbrenner who “contributed greatly to the ecological theory of human development, which concentrated on the interaction and interdependence of humans-as biological and social entities-with the environment” (Kaakinen, 2015). Looking through the “lens” of Bioecological Systems Theory, we can look at the “human ecology” and how the environment of the family, and society at large contribute to development of the life course of a person from childhood to adulthood (Kaakinen, 2015).

Microsystems: The Gallagher family is a broken nuclear family with a mom, dad, and six children. Since Frank the dad does not work but drinks and does drugs all day and Monica the mom ran away, is also a drug addict and has Bipolar Disorder, they are not much support for Ian. Fiona, Ian’s 25 year old eldest sister, works, pays the bills, and feeds the children.

Ian’s brothers and sisters are very supportive of one another. They are his strongest support system, along with his boyfriend, Mickey. The Gallagher children experienced the traumatic impact of their mom being Bipolar and don’t want the same for Ian. Ian’s mom did not take medications and it resulted in her being very unstable.

Mesosystem: Ian used to like going to school but has become increasingly uninterested in going. His other brothers and sisters do attend school except Fiona, who had to drop out of High School to take care of the family. Ian works at a convenience store part time after school. The family relies on social support from the neighborhood, which is a tight-knit community of people in a lower socioeconomic part of town. Ian has a boyfriend who at first was very against the idea of Ian going to getting psychiatric help saying that he would take care of Ian. After Ian’s brothers and sisters spoke to him, he also was convinced it is the right thing for Ian to do.

Exosystem: Ian lives in a “bad” neighborhood in a economically depressed area. Many of his friends and neighbors have substance issues and also engage in illegal activity. Ian is greatly influenced by his peers and his neighborhood culture. The family is not religious and do not attend church or hold any particular spiritual belief. There is a free clinic that Ian in the neighborhood that his sister will take him to go. Ian has gone a couple times but is refusing to go back saying that he “is OK.” Macrosystem: Ian and his family ares Caucasian and in the lower-class. He lives in Chicago, Illinois.

Chronosystem: Ian’s recent diagnosis of Bipolar disorder is a stressor on the family who already has many problems and challenges to face.

The Problem: Ian Gallagher does not want to get psychiatric help and take medications for his Bipolar disorder. He is in denial about what is happening to him. His family is his strongest support system, and they can help Ian get the help he needs. Using the strengths of the family will help Ian ultimately.

Outcome 1: The Gallagher family, including at least one of Ian’s biological parents, will attend a series of Family Group Conferences.

Intervention 1: The nurse will set a Family Group Conference either in the clinic or at the family’s home. The nurse’s role in the conference is to allow autonomy for the family to be involved in Ian’s health plan, to help navigate the plan and provide information (de Jong, Schout & Tineke Abma, 2014).

Outcome 2: The family will identify the signs and symptoms of Bipolar Disorder.

Intervention 2: The nurse will educate the family about the signs and symptoms of Bipolar Disorder and when to call for help when appropriate, ie if Ian displays suicidal thoughts or ideation. It is important that the family be educated and aware of Ian’s disease. Signs include periods of mania and depression, which can be so severe that it results in suicide (Carson & Yambor, 2012).

Outcome 3: The family will be referred to family therapy.

Intervention 3: The nurse will provide a referral for the family to begin family therapy.

Rationale: Because the Gallagher’s chaotic social dynamic plays a major role in Ian’s mental health and outcome, family therapy can be useful for the family to address communication issues and work on the strengths and weakness of the family dynamics.

Family therapy derives from the knowledge that assessing “family process probe and uncover processes in families. Treatment methods largely are developed and refined in relation to those processes, and treatments are then studied to help us discern the most effective means of treatment” (Lebow, 2016). If the family can work their issues out together, they will feel more unified and Ian treatment can be more prone to success for the long term.

References Carson, V. B. and Yambor, S. L. (2012). Managing Patients with Bipolar Disorder at Home: A Family Affair and A Psychiatric Challenge in Home Healthcare. Home Health Nurse, 30(5).

De Jong, G., Schout, G., Abma, T. (2014). Prevention of involuntary admission through Family Group Conferencing: a qualitative case study in community mental health nursing. Journal of Advanced Nursing 70(11), 2651–2662. doi:10.1111/jan.12445 Kaakinen, J., Padgett Coehlo, D., Steele, R., Tabacco, A., & Harmon Hanson, S. M. (2015).

Family health care nursing: Theory, practice, and research (5th ed.). F.A. Davis: Philadelphia.

Lebow, J. L. (2016). Editorial: Family Research and the Practice of Family Therapy. Family Process 55(1). doi: 10.1111/famp.12209 Roberson, C. (2014). Pediatric & Adolescent Bipolar. The Alabama Nurse.

Wells, A. (Writer). (2011-2017). Shameless. Chicago, IL: Showtime