Bipolar, Reactive Attachment, and Oppositional Defiant

DisordersAn Introduction and Overview

Carrie Shapiro, PsychologistSchalmont Central School District

November 21, 2005

What is Bipolar Disorder?

• Bipolar disorder is a brain disorder that causes unusual shifts in a person’s mood, energy, and ability to function.

• Symptoms can range from mania to depression; severe symptoms as opposed to normal ups and downs.

• Bipolar disorder typically develops in late adolescence or early adulthood, however, some individuals may experience some symptoms as early as childhood.

Bipolar con’t

• Like most mental health disorders a person with bipolar will need to seek treatment for the rest of their life.

Bipolar: Children and Adolescents

• Although not common in children, both children and adolescents can develop bipolar disorder.

• Most likely to affect the children of parents who have the illness.

• Unlike may adults with bipolar disorder, whose episodes tend to be clearly defined, children and young adolescents with bipolar disorder often experience very fast mood swings between depression and mania may times within a day.

Children and adolescents con’t

• Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated.

• Bipolar disorder in children and adolescents can be hard to tell apart from other problems that may occur in these age groups.

• For example: While irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of attention deficit hyperactivity disorder, conduct disorder, or oppositional defiant disorder.

Bipolar disorder: Adults

• In adults, bipolar disorder can be mistaken for major depression or schizophrenia.

• Drug abuse may also lead to similar symptoms.

Bipolar disorder/ manic-depression

• Until recently, a diagnosis of the disorder was rarely made in childhood.

• Doctors now will recognize and treat the disorder in young children.

• Early intervention and treatment offer the best chance for children with emerging bipolar disorder to achieve stability and gain the best possible level of wellness.

Symptoms of Mania (manic episode)

• Increased energy, activity and restlessness.

• Excessively “high,” overly good, euphoric mood.

• Extreme irritability.

• Racing thoughts and talking very fast, jumping from one idea to another.

Symptoms Con’t

• Distractibility, can’t concentrate well.

• Little sleep needed.

• Unrealistic beliefs in one’s abilities/powers.

• Poor judgment.

• Substance abuse.

• Denial in regards to behavior.

Symptoms of Depression(depressive episode)

• Lasting sad, anxious, or empty mood.

• Feelings of hopelessness or excessive pessimism.

• Feelings of guilt, worthlessness, or helplessness.

• Decreased energy; fatigue.

• Difficulty concentrating, remembering, or making decisions.

Symptoms Con’t

• Sleeping too much; or insomnia.

• Change in appetite; fluctuation in weight.

• Chronic pain, or bodily symptoms with no medical foundation.

• Suicidal ideation; suicide attempts.

Diagnostic Criteria

• A manic episode is diagnosed if elevated mood occurs with 3 or more of the other symptoms, most of the day, nearly every day, for 1 week or longer.

• A depressive is diagnosed if 5 or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.

Other symptoms in young children may include :

• An expansive or irritable mood

• Depression

• Rapidly changing moods.

• Explosive, destructive rages

• Separation anxiety.

• Defiance of authority.

• Bed wetting and night terrors.

Types of Bipolar Disorders.

• Bipolar I: (6 Different Specifications)1. Single Manic Episode2. Most Recent Episode Hypo Manic

3. Most Recent Episode Manic 4. Most Recent Episode Mixed 5. Most Recent Episode Depressed 6. Most Recent Episode Unspecified• When an individual goes from one extreme

to another.

Types Con’t

• Bipolar II:– Recurrent Depression Episodes with at least

one Hypo manic Episode.– Symptoms are not as extreme as Bipolar I,

they go from hypomania (which is above normal in elation) to major depression.

• Bipolar NOS: A mix of symptoms without specific criteria to

allow for a specialized diagnosis.

Treatment

• Drug therapy – “mood stabilizers”

- Anticonvulsant medications (Depakote, Tegretol), most commonly, Lithium (used to alleviate manic episodes).

* Counseling: Individual cognitive-behavioral therapy; and family or group counseling also effective.

For more information…

• National Institute of Mental Health (NIMH)

Office of Communications

Information Resources and Inquiries Branch

6001 Executive Blvd., Rm. 8184, MSC 9663

Bethesda, MD 20892-9663

Phone: (301) 443-4513 Fax: (301) 443-4279

email: nimhinfo@nih.gov;

website: http://www.nimh.nih.gov

• Child and Adolescent Bipolar Foundation

1187 Wilmette Ave., PMB #331

Wilmette, IL 60091

Phone: (847) 256-8525

website: http://www.bpkids.org

What is Reactive-Attachment Disorder?

• Individuals who show a nearly complete lack of ability to be genuinely affectionate with others. They typically fail to develop a conscience and do not learn to trust.

Children with healthy attachments to a loving caregiver...

• Feel secure and loved.

• Can attain their potential.

• Can develop reciprocal relationships.

• Can develop a conscience.

• Can cope with stress and anxiety.

• Become self-reliant.

Children who do not have healthy attachments with caregivers…

• Do not trust caregivers or adults in authority.• Have extreme control problems, manifested in

covertly manipulative or overtly hostile ways.• Do not develop a moral foundation: no empathy,

no remorse, no conscience, no compassion for others.

• Lack the ability to give and receive genuine affection or love.

• Resist all efforts to nurture or guide them.

Con’t

• Lack cause and effect thinking.

• Act out negatively, provoking anger in others.

• Lie, steal, cheat, manipulate.

• Are destructive, cruel, argumentative and hostile.

• Lack self-control – are impulsive.

• Are superficially charming and engaging.

Common causes

• Abuse/neglect in the first 3 years of life.

• Multiple primary caregivers.

• Separation from birthmother due to hospitalization, incubator, etc.

• Many placements foster care.

• Unresolved pain (e.g., ear infections, colic, etc.)

• Maternal alcohol/drug use.

Causes Con’t

• Maternal depression.

• Lack of attunement between mother and child.

• Young or inexperienced mother with poor parenting skills.

Symptoms of RAD

• Severe need for control.• Toileting issues.• Poor eye contact.• Lack of cause and effect thinking.• Accident prone.• Homework problems.• Poor peer relationships/poor social skills.• Forgetfulness.

Con’t

• No conscience – shows no remorse.

• Speech and Language problems.

• Developmental Delays.

• Food issues.

• Sleep problems.

• Parents appear hostile and angry.

Behaviors associated with RAD

• Purposely destructive to self, others, and material things.

• Argumentative.• Demanding/clingy.• Extremely emotionally reactive (e.g.

episodes of rage) OR apparently totally unemotional (“dead eyes”).

• Very poor impulse control.• Chemical self-medicating.

Con’t

• Phoniness/ theatrical displays.• Stealing behaviors.• Poor self-soothing techniques (e.g. head banging).• Sexual behaviors excessive or inappropriate to age.• Acts confused.• Indiscriminate affection.• Hypervigilant/hyperactive.• Pathological lying and/or “crazy lying.”• Cruelty to animals and/or people.• Fascination with fire, blood, weapons, or evil.

Teaching Teachers about RAD

1. Establish Eye Contact: Insist that the child maintain normal eye contact during the conversation.

2. Establish Who Is Boss: When a child tries to manipulate, remind them in a calm, firm, controlled voice that you are the boss.

3. Recognize the Child’s subtle attempts to control: Unattached children often deliberately omit parts of an assignment, letters, words, sentences, problem numbers or their names. Ask the child to continue working until they produce adequate and acceptable work.

Teaching con’t

4. Win all control battles: Structure all of the child’s choices so that the teacher remains in control. (e.g.: “Do you want to wear your coat or carry it.”)

5. Recognize good and poor decisions:Recognize good decisions as if you expected this behavior all along (e.g. “I see you made a good decision to finish your math.” Recognize poor decisions with a similar suitable statement such as, “I see you chose to have incomplete work today. You may finish it at recess.”

Teaching con’t

6. Allow the child to accept responsibility: look for creative ways to allow the child to experience the natural consequences of their actions.

7. Be consistent: Do not allow the child any slack. Confront each misbehavior and support each good behavior.

8. Remain calm: A child who manages to upset the teacher is in control of the situation. Model and verbalize desired behavior.

Teaching con’t

9. Document interactions and observations of the child: Unattached children can inflict injury upon themselves and claim abuse. They can easily assume the role of an abused child and manipulate outsiders to rescue them. Documentation is necessary to help the educator remain objective if the child accuses parents or classmates of abuse.

Teaching con’t

10. Request help: Administrators, psychologists, and social workers can be good resources in your building. These supports are invaluable for teachers of unattached children.

Oppositional Defiant Disorder313.81 Diagnostic Criteria

A. A pattern of negative, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:1. Often loses temper.2. Often argues with adults.3. Often actively defies or refuses to

comply with adults’ requests or rules.4. Often deliberately annoys people.

Diagnostic Criteria Con’t

5. Often blames others for his or her mistakes or misbehavior.

6. Is often touchy or easily annoyed by others.7. Is often angry and resentful.8. Is often spiteful or vindictive.

NOTE: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

Criteria con’t

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood disorder.

D. Criteria are not met for Conduct Disorder, and if the individual is 19 or older, criteria are not met for Antisocial Personality Disorder.

Possible causes

• Biological – inherited predisposition, neurological, or chemical imbalance.

• Parenting/environmental – runs in families of alcoholic parents and family history of incarceration.

• Abuse is positively correlated with the likelihood of ODD occurrence.

Prevention?

• Modeling of appropriate behaviors by adults.

• Consistent rules.

• Fair consequences.

• Punishment used when reasonable.

• Consistency among caregivers.

General Intervention Strategies

• Individual Therapy: Should focus on understanding the reasons for child’s frustration, and defining concrete ways to address and reduce behavioral issues. Also, social skill training.

• Family Therapy: Provide parents with educational materials about the problem behaviors and spend time discussing possible parental issues that may be contributing to the problem behaviors.

Interventions con’t

• Behavior Modification: Parents and teachers are taught to reward cooperative behavior consistently and to ignore or punish oppositional behavior. (e.g. token economy). Criteria:– Target a few important behaviors.– Operationally define behavior.– It must be consistent.– Gear rewards/punishment toward individual.– Rewards should not be tangible, but rather activities.– A mix of positive and negative reinforcement.– Written contract.Note: Does not work for everyone. Very time consuming in that it

requires constant and multiple revisions.

Controlling AntecedentsAlternative strategy, focus on prevention

of behaviorAntecedents to avoid

• Sharply worded directives (e.g. “Tony, stop playing with your crayons!”)

• Unexpected and unannounced deviation in routine (utilize presets for transitions).

• Tasks that are beyond the child’s ability.

• Gestures, or body language suggesting disapproval.

Antecedents that promote appropriate behavior

• Choices: Giving the child with ODD choices allows them to gain a sense of control over a particular situation.

• Routines: Often children with ODD can not cope with verbal directives or unexpected requests. Possible solutions could include posting the child’s schedule where he/she can see it.

Antecedents…pos. beh. con’t

• Foreshadowing: Using a cueing system to let the student know that they should be getting ready to transition to the next activity.

• Classroom rules: Modify classroom rules in order to allow students with ODD to experience success.

• “Take a break”: A plan for students to voluntarily leave the classroom and enter a safe location where he/she can calm down.

Social Skills Training

• Children with ODD have problems relating to adults, and they often fight with, bully and annoy their peers. These children will usually benefit from social skill training, (individually or in groups) focusing on relating and interacting with others.

Parenting Skills Training

• One of the most well-established methods for treating children with ODD is parent training. There are two highly recommended parent training programs:1. Parent training programs based on Patterson and Gullion’s (1968) manual Living with Children; and2. Webster-Stratton’s parent-training program, which includes a videotape series of parent-training lessons.

Note: Parents receiving this type of training have rated their children as having fewer problems and as having better attitudes toward their children and greater self-confidence regarding their parenting role.

Prognosis for children with ODD

• Depends greatly on the timing and the child and family’s response. In general, 4 possible outcomes:

1. The child will grow out of it. 2. ODD may turn into something else (e.g. ADHD, Conduct disorder, etc.)3. Continue to have ODD without the presence of any

additional disorders.4. Continue ODD, but comorbid with anxiety disorder,

ADHD, or Depressive disorder. Also possible mood disorder or anxiety issues that are disabling.