Treatment of TDD (or Early Onset Bipolar Disorder)

ByDr. Berney

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