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.