Lakeland Ledger article from Sunday 11/28/2010
Every other month or so I am asked to write a column for the Lakeland Ledger. This past Sunday, one of my columns was published in the Polk MD: Health for a New You magazine. The magazine is published on the last Sunday of every month. If you follow this link (http://www.mydigitalpublication.com/publication/?m=4954&l=1) it will take you to the magazine website. My column is on page 5.
Hope that it helps.
Dr. B
Marriage after the book, “Eat, Pray, Love” by Elizabeth Gilbert
I will start by saying that I have not yet read this book. I will read it, I just haven’t yet.
I heard that this book was very good. When the Julia Roberts movie came out, praise for Ms. Gilbert’s story permeated the web and conversations. Having heard the praise, I decided that I would purchase the book as a gift for my wife, not knowing anything about the story.
One day, about a week after purchasing the book, I was at work talking to a new patient. During my interview with the patient, he brought up the book, “Eat, Pray, Love.” My first thought was, “It is interesting that he mentioned this book. I don’t know much about it, but this could be great. I will hear more about the book so that I will be able to talk with my wife about it.” Unfortunately, the patient’s story had an interesting twist.
The gentleman reported that he, too, purchased the book for his wife. He felt that it would be a nice gift for her birthday. The man and his wife had been together since high school. They had kids right away and settled into a demanding “adult life” by the time they were 20 years old. While they both went to college, demands at home (i.e., kids, rent, etc.) forced them to attend part time, while they both carried full time jobs. Nonetheless, the man loves his wife and indicated that he would do anything for her.
So he bought his wife this book, believing that she would enjoy the story. He even planned to take her to see the movie. As his wife began reading the book, she seemed to delve into the story. Much of her free time over the next few days was taken up by the book. Over the subsequent weeks, she read the book… three times. Initially, he felt very good about himself, feeling as though this could bring him and his wife closer. You see, the man acknowledges that he and his wife were in a rut. They had the exact routine, day in and day out. Very little spontaneity, very little excitement. Looking back on their relationship, he cannot pinpoint the time when this happened. When did they change from exuberant, energetic lovers of life to … his parents? That was exactly how he felt, like a 60 year old couple, in 35 year old bodies.
Well, as his wife read through the book, he began noticing changes in her. Just subtle things at first. Not coming home right after work. She began to have “girl’s nights out,” which she had never done before. He did not believe that she was cheating on him, he simply recognized that things were different. He found himself alone more, as their children were now adolescents and spending most of their time out of the house. He felt… lonely. He tried to keep to his routine, but things felt wrong, as his wife was not there with him. Over the subsequent weeks and months, she changed more and more. What was happening?
As the story culminated in my office, with the man becoming tearful and sullen, we explored more of his and his wife’s life together. As we talked, he repeatedly used a very interesting phrase. He referred to him and his wife as “one.” Now, I know what you may be thinking. “Isn’t that what a marriage is, the joining of two into a new one?” I guess, as this story shows, the answer would be… sort of.
At its base, marriage is a joining, a union. As I have heard in many wedding ceremonies, “Marriage is when two lives become one.” This is, in many ways, absolutely true. A married couple shifts from individual progress, to unified goals. As a unified team, they decide to have children, buy a house, or move to a new town. Many decisions, big decisions, are made together.
In my experience, however, problems arise when the marriage results in loss of individuality, and I believe that is what happened to my patient and his wife. They became one, and forgot who they were. As his wife read the book, she yearned for individuality, excitement, and adventure. She missed that in her life, and began looking for it. Unfortunately, she began that search and left her husband behind. The couple is now getting a divorce.
While I know that this is an unfortunate story, I decided to share it with you to help married couples out there. To prevent this trend from reoccurring. You have to remember, as U2’s “One” says, “We’re one, but we’re not the same.” Even in a marriage, you have to accept the fact that you are still two people. Just because you say, “I do,” does not change who you are, what you enjoy, and what you don’t enjoy. Everyone should have hobbies that give them some individuality, time to themselves. This may take you by surprise, but you do NOT have to do everything with your spouse.
This is not to say that you can make unilateral decisions about those big life decisions or when that decision will affect your spouse. Rather, you communicate with one another and be truthful. It is OK to go to the movies alone. It is OK to hang out with friends. It is OK to go out with co-workers after work. But be honest, open, and faithful. Do not be deceptive, secretive, and selfish.
Life is so much better with excitement and adventure. Just because you are married does not mean you have to give those things up. Do not try to convince yourself that, “I am married now, I can’t have a girl’s night out.” That is ridiculous. Those things make you… well… you. They keep you connected, stable, and happy. That’s right. They make you happy. It is perfectly OK for someone, besides just your spouse, to make you happy. As a spouse, you too have to accept that about your significant other.
I firmly believe that when a couple accepts the fact that they are “unified individuals,” they are happier and enjoy their time together much more. Books don’t ruin marriages, that is a job for regret, unhappiness, and jealousy (sounds like the start of another blog).
I hope that this helps some of you out there. I am eager to hear your thoughts.
BTW, I am OK with my wife reading “Eat, Pray, Love.”
Dr. B
Parenting in Broken Homes
Divorce is almost as common as marriage. While I think that there are a number of reasons for the increased divorce rate (people getting married too young, the fall of the economy, and the growth of social networking, just to name a few), the casualties of divorce extend well beyond the husbands and wives. The children of divorce are often left in the wake of turmoil, without a life raft. Now don’t get me wrong, I firmly believe that divorce is the right decision in many cases, even when children are involved. I do not believe that parents should stay together, “for the sake of the children.” Children thrive in loving, stable homes. When parents “tolerate” one another for the “sake of the children,” it is rarely, if ever, loving and stable. In fact, I have seen situations in which the best thing that happened to the family was divorce.
Unfortunately, the strife and problems between parents often extend well beyond the final Dissolution of Marriage. The arguments continue, and often escalates as time passes. When this is the case, attorneys and judges often call for the involvement of a parent coordinator, which is one of the most difficult roles I play as a psychologist. Trying to help two adults, both of which harbor deep seeded anger and hurt about the other, is challenging and requires considerable time and effort, on everyone’s part. Nonetheless, through my experience I have found at least five pitfalls that tend to make parenting in broken homes problematic. Therefore, while I will save a discussion of healthy divorces for another post, I want to uncover the common pitfalls and give you a new route to avoid the problems that tend to accompany them.
Pitfall 1 – More time does not always mean better relationship. Parents often assume that they need more time with the child, as though this is the only way that they can have a true relationship with their child. This is definitely not the case. In fact, it can often harm the relationship. Let me say right off, parents need to spend time with their child. It is imperative that both parents have weekly time with the child. However, when time in your home becomes more important than the child’s needs, it can damage your relationship. This becomes especially salient as the child has extracurricular activities. Let me give you a real example.
An 8-year-old boy, who lives primarily with his mother, has signed up for soccer. The father, who lives in the next town over, is upset because games are on Saturdays, which will take time away from his visitation weekend. Unfortunately, this father is more focused on the “time” with his son than on their “relationship.” As such, the father refuses to take his son to his soccer games. From the father’s perspective, his time is limited and he does not want to take time away from visiting with his son. Unfortunately, this places the child is a very bad situation. While he certainly wants to spend time with his father, the boy begins feeling frustrated with his father and resists visits. He does not want to go to his father’s house because it takes him away from other important things in his life (social relationships). As you can imagine, the father subsequently blames the mother for this (“She is trying to keep him away from me!”). We will talk more about this with Pitfall 3, but the father is certainly not thinking about the child’s perspective in this situation. All he is focused on is time. As I hope you can see, the emphasis on “more time” caused damage to the father-son relationship.
Pitfall 2 – Visitation has to be “Fair.” Related to Pitfall 1 is the issue of visitation time being “fair.” Minute by minute is counted and any time “missed” in visitation must be made up, because it is “fair.” Many parents, when dealing with the issue of “fairness,” talk about 50/50 time share. I am not a proponent of this type of arrangement. As you have seen in some of my other posts, children need consistency and predictability. If they are changing homes every few days or so (or even every other week), kids must keep adjusting to new expectations and routines. This is very difficult, especially during the school year when they are expected to use most of their mental and emotional energy to learn. It is my opinion that a child should sleep in one bed, most of the time. Now I know the argument, “Well if we switch every other week (i.e., one week with dad, one week with mom, etc.), isn’t that consistent?” The simple answer is, no. Consistently being inconsistent is not consistency. Most parents that I talk to admit that it takes the child a few days to readjust back to their home after visits with the other parent. If you do this every week, the child is spending 25% of their life readjusting to where they are living. There is no way to argue that this is consistency. In my experience, the issue of “fairness” has less to do with the child and more to do with issues between the parents. One parent does not want the other parent to “win.” We will delve farther into this issue in Pitfall 4. In the meantime, let’s look at an example that I hope will illustrate that “fair” has nothing to do with accounting for the amount of time in each home.
Let’s go back to when the parents were together. Think back to when the parents were married and everyone lived together. On a typical week day, how much time each night did you spend, one-on-one with the child? Probably not a lot of time, unless you were helping him/her with homework or eating dinner together. Most of the time, the child is playing (outside or with video games) or doing homework between the time they get home from school and begin preparing for bed. I have never met a parent who spends 4 hours of one-on-one time, each night with their child. It just does not happen. If that is the case, why is it “fair,” once you are divorced, to insist that you have to have a specific amount of time with the child each night? The parent that the child lives with primarily does not spend 4-hours each night with the child, so why do we, when trying to be “fair,” imply that they do? By and large, if the “non-primary” parent has dinner with the child, they have spent about as much time with the kid as the “primary” parent. Trying to think of what is “fair” for the child as opposed to what is “fair” for the parent would likely make things much better for the child. They would be able to better stick with their week-day routine, improving their ability to meet expectations at school and learn.
Pitfall 3 – Change your perspective to that of your child. During the struggles of a divorce and the subsequent battles with visitation, parents tend to omit the perspective of the child. Of course, every parent says that they want “what is best” for their child. However, what they view as “best” tends to be what the parent feels is “best.” They fail to step back and really examine what the child may be experiencing.
Following a divorce, the child is, in essence, being pulled between the parents. There are some parents who do a wonderful job of avoiding these problems. Unfortunately, most parents fall head first into this pitfall and have a hard time finding their way out. Let’s return to the example from Pitfall 1. The father, whose perspective is that the best thing for the child is to spend more time with him, fails to understand the child’s perspective. Soccer and social relationships is important to the child. It is not that the child does not want to spend time with him, it is simply that as children age, they tend to want to spend more time with their friends. In any home (united homes or broken homes), all children spend less time with their parents as they age. As such, the best thing for the child, from the child’s perspective, may be less time with his/her parents, regardless of visitation schedules.
Another big issue I see with broken families is when a child desires to primarily live with the other parent. This tends to mean that the child, at some point, tells mom that they want to live with dad. This is an extremely difficult thing for the mom to hear. However, let’s look at it from the child’s perspective. If the child primarily lives with mom, that means that he/she has more expectations in her home. They tend to have more chores, more homework time, earlier bed times (due to being with you on school nights), and less “free time.” With the dad, however, there are far fewer expectations. If a kid is visiting the dad every other weekend, he has the opportunity to give the child much more attention and can spend a lot more “fun time” with the child. What kid would not be attracted to that? Should it really be surprising that the child, from their perspective, would want to live in that environment all of the time? This leaves mom with a decision. If she says no, she is looking at battling the kid’s frustration and irritability with not being able to live with dad. He/She will blame mom for keeping him/her from dad. I have even seen kids run away in these situations. What happens, however, if the mom says yes? From my experience (personal and professional), the change in living situation is relatively temporary. Look again at the situation I painted above. As soon as the child switches to live primarily with dad, what do you think happens? I’ll tell you… The child is surprised that it is not all fun and games with dad any more. Dad’s house is going to begin to look like mom’s house. The child will have more homework time, more chores, more expectations, etc. More times than not, the changes that occur at dad’s house tend to result in the child wanting to switch back to the way things were. This is not to say that anyone was wrong. All kids push limits and test hypotheses to see what is in their “best interest.” Nine times out of 10, when things do not work out the way we expect, we return to the norm. this is true for adults and children. As a result of this tendency, I typically encourage a trial period, allowing the child the opportunity to experiment with the change, with the option to return. Parents tend to be better off if they do not fight this battle (that is of course unless there are valid reasons to restrict a change).
Pitfall 4 – Not Friends, but allies. Despite the interpersonal problems that led to the divorce, being parents mean that you will always be connected to one another. You will be involved with one another for the rest of your lives. School functions, graduations, weddings, etc. will bring you together, despite your feelings for one another. Unfortunately, people tend to harbor so much unnecessary anger and even hatred for one another. Once the divorce is over, the issues that led to the divorce is also over. You do not have to deal with his irritating habits or her “nagging.” That part of your relationship is done. Rarely, if ever, to parents divorce because of the child, yet the child is the only reason that they have to maintain any connection. As such, why is it necessary to maintain so much animosity towards one another when the only thing that keeps you connected is the one thing that had nothing to do with the divorce? Regardless of your feelings for the other person, he or she is going to be a part of your child’s life, period.
What I try to help parents recognize is that the nature of their relationship is now different. No longer should you think that you and your “ex” must be friends and “get along.” Rather, consider him or her as an “ally.” Being an “ally” implies that you are coming together strictly for a common goal. There are no other motives. Outside of the “common goal,” he will do what he is gonna do and she will do what she is gonna do. Unless the other parent’s actions will directly affect the “common goal,” why should it matter to you what they do with their time and life? When the actions do affect the “common goal,” you should discuss (ideally with a mediator) and resolve the issue. Then, move on with your life. There is no reason to allow your life (e.g., your emotional stability, choices, relationships, etc.) to be negatively affected by the choices of the other person that you chose to divorce.
Pitfall 5 – Co-parenting. Related to being allies, co-parenting is often a challenge for divorced parents. What I mean by co-parenting is attempting to work together to ensure consistent expectations for your child. Too often, parents say that they “do not care” what the other parent expects of the child. “I don’t care what your dad [mom] lets you do, in my home…” This perspective is almost as ridiculous as parents believing that it is “the teacher’s responsibility” to teach the child all that they need to know. This segregation of expectations is not healthy for the child. In fact, it can create two problematic trends. First, the child will begin to pit one parent against the other. “Well dad lets me do… ” “Mom lets me stay up later.” This further increases strife between the two homes, making them more and more different and increasing negative feelings between the parents. Second, the child could develop internalizing conditions, such as anxiety or depression. As I mentioned many times on my blog, kids need consistency and predictability. If the expectations of the two homes are so different, children can develop symptoms of anxiety that could interfere with healthy emotional development.
To help with co-parenting, I work with parents (often as a mediator) to develop similar expectations, rules, and schedules between the homes. I am not naive to believe that the two homes will become identical. Rather, it is my hopes to make them similar enough so that the child knows that “x, y, and z” is expected of them no matter where they are. It is a challenge for some parents (for many of the reasons mentioned above), but when divorced parents can co-parent in this way, the outcomes for the child (academic, emotional, etc.) tend to be far better.
I hope that this helps some of you out there. Please feel free to post questions.
Dr. B
Child and Adolescent Bipolar Disorder
Just a quick note to give you a link to the American Academy of Child and Adolescent Psychiatry (http://www.aacap.org). Today they published a paper about diagnosis and treatment of Bipolar Disorder in children and adolescents. The PDF can be found here (http://www.aacap.org/galleries/default-file/aacap_bipolar_medication_guide.pdf).
Hope it is helpful and please feel free to post any questions or comments here.
Dr. B
Structure vs. Punishment
The other day, I was working with a patient and we began to venture down a very interesting path. As a result of that discussion, I decided that I would break from my talks about TDD and Bipolar Disorder, and talk a little about the difference between structure and punishment.
As you can tell from some of my previous posts, I am a firm believer in structure. I often work with parents to build firm boundaries and strategies for managing their children. What structure does is provide consistency and predictability. Let’s begin with a concrete example… actual concrete. If you build a concrete wall (a structure), that wall becomes relatively permanent. It will look the same, feel the same, and “react” the same way every time. If you run into the wall today, it will feel the same way as when you ran into the wall yesterday. It is always the same… a constant.
Structured parenting is very similar. I encourage parents to be a constant. The rules today, are the rules tomorrow. The expectations today, are the expectations tomorrow. And, when needed, the consequences today, are the consequences tomorrow. The importance of consistency is that it leads to predictability. Predictability implies learning. Let’s go back to our concrete wall example, if you are running, and without warning, run into the wall, you will quickly learn (hopefully) that the wall is impassable. You cannot go through it. It cannot be manipulated. You learn that, every time you run into the wall, you will be stopped. Predictability in parenting should create the same scenario (aside from the bruises caused by the concrete wall). The more consistent you are, the faster your child will “learn” the boundaries of your structure. Sure they may test the stability of your structure from time to time, just to make sure that the wall has not weakened. But in general, they learn what is expected of them and understand that those expectations do not waiver. This structure makes for a healthy developmental environment for your child.
Overall, structure (in the form of consistency and predictability) helps your child learn what to do, instead of just what not to do. So often parents tell their children to “Stop this” and “Don’t do that.” Consistency and predictability encourages a scenario where parents do not just tell their child what NOT to do, but what they should be doing. It may be time for a simple example. Let’s say that your child is coloring a wonderful masterpiece… on the wall. Most parents will respond (maybe in a loud voice), “What are you doing? Don’t color on the walls!” I am not sure why, but situations like these tend to evoke loud and somewhat urgent responses from parents even though the damage is done and the child is likely to stop as soon as you say the first word. Why do we act as though it is an emergency? It is not getting any worse once the child stops drawing. Emergencies lead to impulsivity (which we will talk about in a few minutes). In any event, responding in this way, of course, tells the child what they are not to do, but does not tell the child what is expected of them… that is, what they should be doing.
Good structure would lead the parent to respond differently. With our example, the parent may respond by saying, “Remember Konor (my son’s name because, of course, this is an example from my life), coloring is for paper, not walls. Let’s go sit at the table and I will get you some more paper.” You may even have the child help you clean the walls. This will teach what is expected and applies an APPROPRIATE consequence (helping to clean the walls) for the action. Most importantly, the child knows what is expected (coloring on paper, not walls), as well as the consequences of the action (cleaning the walls). Notice how the consequence makes sense (for example, it would not make sense to take away his video games because he colored on the walls). This response to your child’s behavior is not, as I hope you can tell, punitive. No yelling. No imposed fear. No demeaning words. Just loving responses that educate.
Punishment, well that is a different story. Research has demonstrated, time and time again, that punishment is an ineffective way to teach expectations and redirect behaviors. Just the word evokes negative feelings and fear. Punishment.
The primary problem with punishment is that it is, by its very nature, punitive. There is little to no education involved. In my practice I see many families who use punishment. Invariably, they say, “He (the child) does it over and over again, no matter what. I can spank him five times a day, but it seems like he just doesn’t care.” When parents feel this way, they begin to incorporate emotion into the punishment (“I will make him care.”). This observation is exactly what the research predicts. Punishment based upon the perspective that children should do what I say, “because I am the adult,” has not worked for decades. Children today are VERY different than we were as kids. They know more, are exposed to more, and are much more savvy than we were. As a part of our culture, we look for “loop holes” and exceptions to the rule. Children are no different. Think about it, how many times have you said, “If I would have done/said that, I would have been in SO much trouble.”
For all of these reasons, and this is important (so I will use all caps), PUNISHMENT DOES NOT LEAD TO RESPECT. At best, use of punishment leads to fear, anger, and resentment; none of which is part of good parenting. The times are different, and different times call for different approaches to parenting.
Another problem with punishment is that it is usually impulsive. Your child does something and you respond impulsively. As such, there is no forethought and your punishments (consequences) are often different (inconsistent). For example, when your child makes a poor choice one day, you may spank him. The next time he does the same thing, you may send him to his room (“timeout”). The third time he does it, you may take away his video game privileges. This inconsistency does not help the child learn your expectations. He cannot learn cause and effect, “If I do ‘X,’ ‘Y’ will happen.” Structure, as we discussed above, remedies the typical problems seen with the use of punishment.
As parents, we have to shift away from punitive, impulsive responses. We have to have a plan, which is implemented consistently and predictably, and with the goal of educating. Education reduces the likelihood of errors (in the form of misbehavior). While there will always be mistakes (on your and your child’s part), we must work hard to maintain our expectations and ensure that we educate our children instead of simply applying haphazard consequences.
Dr. B
Treatment of TDD (or Early Onset Bipolar Disorder)
In my last blog on Temper Dysregulation Disorder with Dysphoria (TDD), I promised that I would write about treatment options for TDD. As I previously wrote, TDD is a diagnosis that will be unveiled in 2013, with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Currently, most children who will meet criteria for TDD are diagnosed with Bipolar Disorder. Therefore, to differentiate between the treatment for true Bipolar Disorder and TDD, I will use TDD to describe these children within this blog.
To begin a discussion of treatment, it is important to first talk about what I believe is happening in the brain. Here is a quick lesson in neurophysiology (brain function). Whenever we perceive something, signals are sent to our brain. When I say “perceive,” I mean see, hear, feel, taste, or otherwise experience. Those signals go from our sensory organs (eyes, ears, etc.) to our brain. Most perceptions go through the “grand central station” of our brain, the thalamus. Typically, the thalamus receives those signals from our sensory organs and shuttles them off to the appropriate brain region (e.g., visual cortex for sight). Well, there are some situations in which we do not want this to happen. For example, if you are walking through the woods and see a bear, you would want to respond as fast as possible to get away. You really do not have any decisions to make in that situation. To address this, our body has developed (evolutionarily) a mechanism to override our typical brain function. In these life or death situations, our thalamus receives the information from the sensory organ and, in essence, says “holy cow! That is dangerous!” When the thalamus does this, it does not send the information to the typical brain region (i.e., visual cortex). Instead, it triggers another area in our brain, called the limbic system. We call this “fight or flight.”
When our brain goes into fight or flight, several important things happen. Right away, our body decides that survival is more important than making complex decisions. To survive, our muscles need more food so that we can run fast (flight) or defend our self (fight). How do our muscles get more food? Blood. Blood carries food in the form of glucose and oxygen to our muscles. This is why mothers can lift cars off of their children and we can run faster than that dog chasing us.
While survival is extremely important in these situations, it comes at a cost. Typically speaking, our brain consumes most of the food in our blood. In fact, more blood goes to our brain than any other place in our body (except our heart, of course). As such, when our body goes into fight or flight, most of the blood that would go to our brain, is detoured to our muscles. Our brain gets very little blood at this time. This is typically a good thing. Think about it, when you are running from a bear, you don’t want to be trying to solve an algebra equation or thinking about what you are going to have for dinner.
Once we are safe, our body works to correct the fight or flight system. Several hormones (for those of you wondering, the main one is cortisol) are released in our body to get everything back to normal. for most of us, our body goes through this entire process at the right times and smoothly returns to normalcy.
It is at this point we get to a hypothesis about TDD. Children with TDD seem to trip into fight or flight very easily. It seems that rather small triggers (e.g., the word “no”) are perceived as a “threat” to their thalamus. In response, their body enters fight or flight and they begin to defend themselves in any way they can. They may use words, objects around them, or their own body to get rid of the threat. Unfortunately, the perceived threat is usually mom, dad, sibling, or some other unsuspecting person in their environment. If we use this theory, there are two extremely important things to think about as it relates to treatment.
First, this process happens without the child making a choice. Just as you would involuntarily go into fight or flight when you see a large snake or a bear, they go into fight or flight when their body perceives a threat. This an important point. The brains of these children perceive a threat, whether the threat is real or not doesn’t matter. Parents typically say, “He exploded over nothing” or “His anger comes out of nowhere.” While we may not have seen a trigger, the child’s brain does. As a result, my perspective of this condition is that these children respond with explosions and outbursts involuntarily. Their brain functions in such a way as to make them hypersensitive to things around them and it responds very easily.
Second, as I described earlier, people in fight or flight cannot think or make decisions. The area of their brain that is used for decision making is not getting any food. As a result, parents’ attempt to remind the child of consequences or punishments (i.e., “if you do that again I am taking away your Playstation”) are not registered. In fact, they are often perceived as continued threats, prolonging the “fight or flight” episode.
So we have finally arrived at the treatment discussion of this blog. I guess I take the long road sometimes…
Treatment – Medication
Treatment of TDD will take two forms. As I described above, the brains of these children are hypersensitive. They respond outside of the child’s consciousness. As such, the first treatment form is medication. Medication is used to “calm the storm” in the child’s brain, making them less sensitive to what is happening around them. I am often asked, “Why is medication necessary to keep them from exploding? Why can’t they just stop?” My response is based upon the fact that 99% of children want to be good. They want to make the right decision and make their parents happy. Therefore, if the child could manage these explosions, they would. If they could choose to make the right decision, they would not have any problems. The issue is that they cannot usually make this choice. As such, medication is used to help the child do what they otherwise couldn’t do.
Unfortunately, medications needed to address these issues are from two classes that are not typically approved for use in children, but are used for their “mood stabilizing” properties. The first family of medications is antipsychotics. I know, it is very scary to think about giving a child an antipsychotic medication. However, generally speaking, these medications help with irritability and agitation. The more common medications include Risperdal, Abilify, Seroquel, Zyprexa, and Geodon, though there are many others that could be used. Generally speaking, there are several side effects that you should be aware of. Most of these medications result in weight gain, some more than others. They tend to cause drowsiness. More significant is the risk for what is called extrapyramidal side-effects (EPS), which may cause some unusual, involuntary movements. If these effects are seen, it is important to talk with the physician.
The other type of medication is a broad class simply referred to as mood stabilizers. In addition to some antipsychotic medications, this class is comprised of medications used for seizures (Depakote, Tegretol, Trileptal, and others) and Lithium (the traditional medication used for Bipolar Disorder). Similar to what I described above, these medications work to “calm the storm.” They reduce extra brain activity, making the brain less reactive to what is happening in the child’s environment. Many of the seizure medications are approved for use in children with seizures, though not for TDD or Bipolar Disorder. Lithium is approved for adults with Bipolar Disorder, but not for children.
Treatment – Non-Medication
While medication is often needed initially to “calm the storm” and make the child available (cognitively) to learn new strategies for managing their behaviors, there are other things that I work on with parents to also reduce outbursts. The main goals are to reduce perceived triggers and consistency.
Reducing triggers can be difficult. Again, sometimes the child’s brain is triggered by something that we do not see. Our best hope at preventing most triggers is to reduce confrontation. As parents, we have to remove confrontation from our interactions. What does that mean? My first recommendation is to get rid of the word “no.” For most children, that one little word can set off an outburst that can ruin an entire day. While I am not saying that the child should have what ever he/she wants, I believe that “no” is an unnecessary definitive, most of the time. In fact, there are very few definitives in the world. Here is an example. Child says, “Mom, can I have some ice cream?” Mom responds, “No, you have not had dinner yet.” Child explodes. I firmly believe that the child’s brain perceives the mother’s response as, “No, you can never have ice cream. You do not deserve ice cream. I cannot believe that you would even ask something that ridiculous.” So, how does a mom not give-in by allowing the child to have ice cream without using the word “no?” The short answer, use a few more words. Here is that same example without “no.” Child says, “Mom, can I have some ice cream?” Mom responds, “That is a great idea. I am almost finished making dinner and you can have ice cream for dessert.” What happens now is the mother validated the child’s interest in ice-cream and made the child feel like their idea was a good one. She also set a limit and identified when ice-cream would be appropriate (“for dessert”). Now, the child knows that ice-cream is in his/her future, a realization that was not made available in the first scenario. This strategy can be used in most situations. I would not say that this will eliminate outbursts everytime, but it will definitely reduce the likelihood.
The last point about reducing confrontation is learning to walk away. When the child has an explosion or outburst, you have to walk away. DO NOT try to reason with or otherwise apply consequences when the child is having an outburst. It will only prolong the episode. As soon as an outburst begins, walk into the other room. Don’t get pulled into the ridiculous perspective that kids should obey simply because you are the parent. Also, recognize that the child’s brain is making the decisions, not the child. this does not mean that the child gets away with the outburst, but it does mean that we change our view from a “bad kid” to a kid whose brain crashes sometimes.
The second strategy is consistency. You have to say what you mean and mean what you say. Parents often “give in” to keep the peace or prevent outbursts. What that means is they will say “no,” the child will explode, then the parent will decide that it was not worth it and give the child what he/she wants. This is a HUGE problem. While most of the child’s explosions are out of their control, kids are not stupid. If they figure out that all they have to do is raise their voice to get what they want, guess what they will do to get what they want. These are learned behaviors that we have to prevent. To do so, you have to consistently hold your ground. You have to do a lot of thinking. Before you respond or say anything to your child, you have to consider how far you want this to go. If you think ahead of time and decide that it is not worth an explosion, respond accordingly, from the beginning. If it is something that you are willing to fight over, respond accordingly. Either way, you must stick with what you say. Even if you make a mistake (e.g., said no to something that really does not matter), you must hold fast to what you said. Overall, choose your battles wisely, but once you make a decision, you must follow through.
I know that this was a very long blog, but I hope that it is helpful. Please feel free to ask questions or post comments.
Dr. B
Temper Dysregulation Disorder with Dysphoria
Well, it is a little late, but here is my post about a new, proposed disorder entitled Temper Dysregulation Disorder with Dysphoria, or TDD for short. I guess that best way to present this disorder will be with a little history, at least as I understand it. As many of you probably know, the past 10-20 years has seen a HUGE increase in the number of children diagnosed with Bipolar Disorder. This is somewhat of a big deal for three reasons.
First, there are no specified diagnostic criteria for Bipolar Disorder in children. The criteria typically used to diagnose kids are the adult criteria delineated in the DSM-IV-TR, the diagnostic “bible” for mental health conditions.
Second, although the adult criteria are used to make the diagnosis of Bipolar Disorder in children, most children do not meet the criteria. For example, in the DSM-IV-TR, manic episodes (the hallmark feature of Bipolar Disorder Type I) must last for up to a week. Similarly, hypomanic episodes (symptoms similar to manic episodes only not as impairing and are necessary for a diagnosis of Bipolar Disorder Type II) has to be present for at least four days. “Manic” episodes in children tend to last a few hours at a time. Because of this, researchers and clinicians began using words such as “ultra-rapid cycling” to describe bipolar mood swings in children as a way to make the symptoms in children “fit” the adult criteria.
Third, because researchers and clinicians use the diagnosis of Bipolar Disorder for these children, they tend to use medications for Bipolar Disorder. These include heavy psychotropic drugs designed and tested in adults, and rarely approved by the FDA for use in children. As a result, we have a growing population of children on antipsychotic and other mood stabilizing medications that may have unknown affects on development.
[Let me add a quick caveat here before I go any further. As you know, I am not a medical doctor and I do not prescribe medication. However, I do think that medications are needed in many situations. I often refer my patients to psychiatrists to explore the need for medication when behavioral approaches are not successful. I say this to make sure that you are aware that I am not anti-medication. Rather, I am a proponent of research and safety and feel as though a balance between clinical efficacy and safety must be evaluated in most of the medications used in children. Now, back to the blog.]
Because of some of our early work, a colleague (Dr. Richard Marshall, a co-administrator on this blog) and I have conducted lectures up and down the east coast of the US on Early Onset Bipolar Disorder for about 7 years. Since the beginning, we have been adamant that Bipolar Disorder is a label being used to identify children with a particular set of behaviors. We do not know if it really is Bipolar Disorder. Rather, Bipolar Disorder is the label given so that clinicians discussing these children have a common frame of reference. That said, let me describe these children.
Overall, these children can be characterized with one word… Irritable. These children are irritable from the time they wake up until they go to bed. Parents use statements such as “walking on egg shells” to describe their household. Everyone in the home works to prevent the child’s irritability from exploding into a rage that could last up to an hour, if not longer. While there may be times where the child is pleasant and loving, those time periods usually last as long as they are getting what they want. As soon as demands are placed upon them, the irritability returns in full force. These children are often aggressive (physically and verbally) to people, toys and other objects. They tend to express violent themes in play and conversation. They are drawn to aggression and violence in movies and video games. Another difficult characteristic of these children is that they do not sleep well. These children take a long time to fall asleep, are restless throughout the night, and wake up in the morning in a very bad mood. Finally, their behaviors and “attitude” tend to result in poor social skills and the lack of friends and relationships.
Presented in this way, these children do not really sound Bipolar. There are no clear and persisting “manic” behaviors. Rather, most of these children have persistent irritability that affects their ability to regulate their emotions. They “fly off the handle” with very little (and sometimes no) provocation. All that is required for these children to “explode” is a “perceived threat.” Perceived meaning that the child believes it to be the case (even if not real). Threat meaning that things are not going the way in which the child wants.
As time has passed, researchers and some clinicians have moved away from a diagnosis of Bipolar Disorder and are moving towards the more descriptive label of “Emotional Dysregulation.” This label seems to more accurately describe the child’s presenting behaviors and is somewhat less stigmatizing than Bipolar Disorder.
In the upcoming revision of the DSM (in 2013, the DSM-V will be published) the committee is proposing to include a diagnosis that formally identifies children with the behaviors described above. To do so, they are recognizing that Bipolar Disorder is a poor label for the condition and moving in a direction that may lead to alternative treatment ideas. Currently, the proposed diagnosis is TDD, though there are some that would prefer to replace “Temper” with “Emotional”. Some information about this condition, including diagnostic criteria, can already be found on the DSM-V website (www.dsm5.org).
In my next blog, I will continue to talk about TDD, but plan to focus on treatment ideas. I will touch on medications used as well as other methods for working with these children at home and at school.
Dr. B.
Long time no see/write
Wow, has it been a long time since I posted anything! I will try to post something this week. I think that I will write about Temper Dysregulation Disorder with Dysphoria (aka, Early Onset Bipolar Disorder).
Chapter 4 excerpt from my upcoming book “Handbook for Raising an Emotionally Healthy Child”
As I mentioned in previous blogs, I have been writing a parenting book. Well, I am about four chapters into it now and am feeling great about it. In fact, I have sent a query letter to a literary agent with hopes of representation. Because I am always eager to have feedback, I have decided to post an excerpt from the chapter that I just recently finished. So, enjoy and I look forward to you feedback.
Chapter 4: Adolescence
Adolescence (11 to 18 years)
Looking back over the last decade, you have successfully developed routines and you have managed transitions. You even survived temper tantrums and the influence of peers. But you ain’t seen nothing yet. I welcome you to adolescence.
Adolescence is best described by the opening line from the Charles Dickens classic, “A Tale of Two Cities.”
“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way…”
Although Dickens was talking about London and Paris prior to the French Revolution, the words certainly hold true to adolescence. The relationship that you have developed thus far with your child will be put to the test, on a daily basis. There will be times when you look at your child and cry because they are so mature and adult-like. At other times, your adolescent will act so much like a toddler that you will cry, wondering how he or she will ever make it as an adult. There will be other times that your relationship with your child will be so strained, that you will cry because of what he or she said to you or did “just to spite” you. In other words, buy a lot of tissues and get that calming bath ready, because you need to be prepared for frustration and emotion like you have not yet seen.
Now, I am sure that there are those of you reading this who will say that I am exaggerating or being over dramatic. But there will be others who would say that I have said so far is not giving the turbulence justice. As a result, be aware that, like all other areas of development, there is some variability. As such, I will be speaking about adolescents in general, with a few examples, just to help with the points.
Globally speaking, adolescents present a set of challenges that many parents find difficult to tolerate. Parents are often torn between several potential roles. While they want to hold onto their historic roles of parent, authority, and decision-maker, they also find themselves wanting to befriend, bend, and let-go of their child. Many parents will swing between these roles, making them feel as though they are being ripped apart by their own decisions. As such, this may be the first time that you find yourself unsure as to what to say or do. Hopefully, you will find some comfort in knowing that most parents of adolescents are experiencing the same feelings. You should also be comforted in knowing that your adolescent is feeling exactly the same way. In fact, when I work with adolescents and their parents, one of the most common phrases I hear (from adolescents and parents alike) is, “I feel like I am bipolar.” Most of them do not truly mean that they are manic-depressive. Rather, they describe themselves as swinging between happiness to sadness, calmness to hostility, and enjoyment to anger. So, before we talk about some specific strategies for parents, let’s take a few minutes to talk about why this is such a turbulent time for everyone.
Piaget described adolescence as the Formal Operational Stage of development. During this time frame, adolescents continue to develop many of the cognitive skills that began in the Concrete Operational Stage. They begin to have the ability to think abstractly, logically, and in an organized manner, allowing them to think beyond the world of concrete reality and consider symbolism and abstraction. While some adolescents will have completely mastered this new perspective by the age of 15 years, others take longer to become fully able to utilize these skills consistently.
Some of you are probably flipping back to the beginning of this chapter. How can teenagers be capable of such advanced thought and consideration, but behave the way they do? Good question. Here is what I think causes all of the problems, emotion. Let me explain what I mean.
During adolescence, teenagers are attempting to create their own identity. They are developing their independent identities, which means that they must separate from you, their parent, and gravitate towards those who resemble what they see as their own ideal selves (their peers). While this sounds obvious, it is not so clear cut. On one hand, adolescents have their parents. Supports who have always been there for them and love them unconditionally. On the other hand, they have the wax and wane of friendships, relationships that they have to work on. Relationships that are very fragile and inconsistent.
Imagine standing at the base of a rocky cliff at the edge of the ocean. On one side you have the strength of immovable rocks and on the other, you have the ebb and flow of the powerful ocean. When the ocean is calm, you are able to stand with no problem. You can easily manage the rocks and the ocean. As such, you are calm. However, when the oceans are rough. As storms rage. When waves relentlessly crash against you, you find yourself drowning in the water, while your body pounds against the jagged and hard cliffs. You are anything but calm. You begin to panic, because now, everything around you is an enemy. You are unable to problem solve. You are unable to think about consequences. You simply want to survive.
In this analogy, the cliffs did not change, as a parent, you do not change. The ocean, your child’s friends, are ever changing, creating frustration and fear. Creating emotion. It is that emotion, the fear of losing those with whom they identify, that makes it impossible for them to consistently make appropriate decisions. This is the reason why you and your teenager can be getting along wonderfully one minute, but be screaming at one another the next. They are just trying to survive.
So as the winds of adolescence blow, we as parents have a choice. We can continue to be immovable and allow our children to crash against us, or we can be a solid foundation, while finding some flexibility in our expectations. Either way, parents must learn tolerance. You must be able to look beyond the immediate and remember that this is a marathon, not a sprint.
Update
I have not posted a blog in the last few weeks for several reasons. First, the holidays made it difficult to keep up with posts. I tried to cut back on “work” and just spend time with my family. It was great and we had loads of fun, but I am glad to be back at work.
The other big reason for my absence is that I have been working on a book. I am actively writing a parenting book that I hope to finish and have published within the year. It has taken a considerable amount of time, but it has been a great process. I have considered posting excerpts of it on this site, but I am cautious because I do not want anyone to take my ideas before I can get them published. As I continue to fight with myself about this, I will keep you posted.
Anyway, I will post more when I can. I am considering a few specific topics for my next real post, but I have not decided on one yet. If you have any requests, please feel free to ask.
Hope your New Year has been great,
Dr. B