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.

What is ADHD, really?

A few days ago, I was working with a mother who was concerned that her son had ADHD (Attention Deficit Hyperactivity Disorder).  She said that she knows “a little” about ADHD, but was not sure if ADHD explained some of the difficulties that her son was experiencing at home and at school.  So, I thought that I would write a little about what ADHD is and, most importantly, what it is NOT.

Here is a little history about ADHD before we discuss what it is.  ADHD is the newest label of a disorder that has been around for a long time.  It has had many different names and children with impulsivity and restlessness was described in writings since at least the 1700’s.  Prior to the 1960’s, many physicians believed that children with inattention, overactivity, impulsivity, and learning difficulties experienced some type of mild encephalopathy (which basically means a disease in the brain).   They said “mild,” because these people, usually kids, had average to above average intelligence and were not “severely” impaired. Further, there were no true clinical findings of brain damage.  As time passed, it became problematic to “suppose” that there was brain damage in these people.  Therefore, in the late 1960’s, things began to change when several labels began to emerge to describe this condition.  Clinicians began using labels such as “Minimal Brain Dysfunction,” or MDB, and “Hyperkinetic Reaction of Childhood” to diagnose individuals with average or above average IQ who experienced behavioral and learning difficulties.  In the mid to late 1970’s, however, the label changed yet again.  Around that time, there was a great deal of education reform occurring in the US.  In fact, it was not until the mid 1970’s that laws were passed that required public schools to educate all children (remember that, prior to these laws, many children were not educated in schools).  The passing of these laws necessitated a method for identifying children who had difficulties learning.  It was at that time that learning disabilities were first truly identified.  At the same time, the American Psychiatric Association was redefining “Hyperkinetic Reaction of Childhood” and first used the label “Attention Deficit Disorder with or without Hyperactivity.”  As the education system defined learning disabilities, and the American Psychiatric Association defined ADD, the group of children previously diagnosed with MBD or Hyperkinetic Reaction of Childhood were split into one of the two groups, ADD or learning disabled, based upon their symptoms.  ADD with or without Hyperactivity (which was typically abbreviated as ADD/H) was, again, relabeled in 1987, when the American Psychiatric Association referred to it as ADHD (Attention Deficit Hyperactivity Disorder).  ADHD has been the title used for this condition since that time.  ADHD has been around for a long time and has had many aliases over the years.

So, what makes up a diagnosis of ADHD?  Well, you can Google (or Bing) “ADHD diagnosis” and have millions of hits (I just Googled it and got 3,870,000).  Many of those hits will give you the criteria that professionals use to make the diagnosis.  Therefore, to reduce repetition, I will just give you a summary.  There are three subtypes of ADHD: Predominantly Inattentive Type, Predominantly Hyperactive/Impulsive Type, and Combined Type.  The inattentive type suggests that the person has multiple symptoms of inattention.  Typical symptoms of inattention include difficulty focusing, making careless mistakes, forgetfulness, misplacing things, etc.  To meet criteria, a person has to have at least 6 symptoms of inattention (as defined in the criteria).   The hyperactive/impulsive type suggests that the person has multiple symptoms of overactivity and impulsivity.  Typical symptoms include acting as if “driven by a motor,” difficulty sitting still, fidgetiness, interrupting others, and acting without considering the consequences.  To meet criteria for the hyperactive/impulsive type, a person must have 6 symptoms, as defined by the criteria.  If a person must have 6 inattentive symptoms AND 6 hyperactive/impulsive symptoms, then they meet criteria for ADHD, Combined type.

While the symptoms mentioned above are the primary behaviors of ADHD, there are several other things that have to be present before a true diagnosis of ADHD can be made.  First, there must be symptoms prior to the age of 7 years.  A person, based upon the current diagnostic criteria made by the American Psychiatric Association, cannot be diagnosed with ADHD unless symptoms were present early in life.  This, of course, creates some questions related to “Adult Onset ADHD.”  It is certainly possible that a person can make it through their childhood and adolescence without being diagnosed as ADHD, only to be diagnosed with ADHD as an adult.  However, to accurately make the diagnosis, the adult must report symptoms that existed before the age of 7.  This creates some challenges, as there are many conditions that create inattention and forgetfulness that are not ADHD (i.e., depression and anxiety).  Therefore, accurately diagnosing ADHD in adults is somewhat challenging.

The issue of age creates a similar problem when trying to diagnose children.  It is becoming more common that I will have parents bring young children, 3-5 years old, to my office for an ADHD evaluation.  I often resist making a diagnosis of ADHD in individuals that young, though there are some children who obviously have difficulties.  For the remaining young children, however, ADHD-like symptoms is a way of life.  Have you ever seen a kindergarten classroom?  I am awed by those teachers!  They must frequently change activities, keep the children engaged, and be entertaining for 7 and a half hours a day.  Why?  Because most of those children would easily lose their attention to task and become overactive if they were not constantly stimulated.  It is not until children are 8 or 9 years old that we expect them to have calmed down and have the ability to focus on a task for more than a few minutes.  Isn’t it interesting that it is around that time (2 and 3 grade) that we expect kids to be able to read chapter books and answer questions about what they have read?  It is because most of them are not able to focus long enough until they are that old.  It does not mean that they had ADHD!

The second issue that must be addressed before an accurate diagnosis of ADHD can be made is the need for the individual to have symptom related problems in more than one setting.  The majority of patients that I see are self-referred.  That means that they were not referred by another professional or by the school.  In children, that means that I am seeing them because their parents feel as though there is a problem.  I have often begun an ADHD evaluation with a child, only to find that the teacher has no concerns with the child’s behavior.  The teacher indicates that the child can sit and focus, attend to task, and never gets into trouble for being out of his seat.  Situations such as this rarely qualifies a child as being ADHD.  Think about it this way.  If a child has ADHD, it means that they CANNOT focus and attend.  They have significant difficulty sitting still and resisting impulsive responses.  If these are things that they CANNOT do, how is it that they can do it at school if they really have ADHD?  The answer, they do not really have ADHD.  Now I should note that I said it “rarely” qualifies for a diagnosis of ADHD.  There are times when a fabulous teacher (there are a lot of them out there) is able to create a classroom setting that effectively manages children with mild ADHD.  So, of course, this must be taken into consideration.  Nonetheless, 9 times out of 10, if a child has behavioral issues at home, and there are no issues at school, it is not ADHD.  It is something else.

The other scenario is when the child has problems at school and no issues at home.  This one is a little more challenging.  Sometimes children do not have any problems at home because there are no demands placed upon them.  They do not have chores or homework.  They do not have to do things that they do not want to do.  In these situations, ADHD is still a possibility and further testing is needed.

This brings me to the last section to discuss, testing for ADHD.  Today, ADHD is a condition that is diagnosed based upon clinical findings.  Although there are researchers searching for some type of laboratory test to identify ADHD, it remains that the only way to test for ADHD is through neuropsychological testing and observations.  In my clinic, I perform multiple tests to assess intellectual ability, academic achievement, executive functioning (a big topic I will discuss in a different thread. Just note here that ADHD is considered a disorder of executive function), and attention.  In addition, I provide forms to parents and teachers to complete to assess ADHD behaviors at home and at school.  For adults, I perform a similar battery of tests and provide them with self-report questionnaires (questionnaires that they fill out about themselves) and encourage them to have one of their parents help them complete a questionnaire that asks about their childhood.

ADHD is the most common psychological/psychiatric diagnosis made in children.  Further, I believe that the number of ADHD diagnoses will continue to rise.  Though I will save it for a different post, I believe that there are many things happening in education these days that are “causing” ADHD symptoms in children.  As educational expectations rise, and fourth grade students continue to be asked to learn algebra and geometry, students are going to have ever more difficulty focusing and concentrating in school.  Behavioral issues will continue to rise, not because more kids have ADHD, but because we are creating a setting that is not appropriate for them, developmentally.  At many schools, kids can’t even talk at lunch any more!  Wow, I will save that soap box for later …

Autism and Parent Training

I was not sure what I wanted to discuss for my first, truly mental health related post.  There are many “hot topics” out there right now and there is so much to say about them all.  Nonetheless, as I was making my decision, I was reading in the Journal of the American Academy of Child and Adolescent Psychiatry, which is THE JOURNAL for child and adolescent psychiatry.  In the Journal’s December 2010 issue (yes, you will have somewhat of a jump start by reading this post) there is an article written by researchers at the NIMH Research Units on Pediatric Psychopharmacology (RUPP) Autism Network.  In this article, the authors describe the results of a study meant to compare the benefits of medication alone to medication plus parent training in reducing the behavioral issues associated with Autism, PDD-NOS, and Asperger’s Disorder (if you do not know the differences between these diagnoses, keep checking this site, as I will be posting other threads to describe them in more detail).  In this post I will review the article as well as give you my own impressions and views.

In the article, the authors reported that there has been a significant increase in the use of medication in children with Autism and Autistic Spectrum Disorders (ASD) over the past few years.  In fact, research suggests that 45 to 83% of individuals with ASD are prescribed medications.  The most common medications prescribed are selective serotonin reuptake inhibitors (SSRI; e.g., Prozac), antipsychotics (e.g., Risperdal and Abilify), alpha 2 adrenergic agonists (e.g., Clonidine), psychostimulants (e.g., Ritalin), and anticonvulsants (i.e., Depakote).  While most of these medications are used “off label” (meaning that they are not FDA approved for children with ASD), in October 2006, the FDA has approved the use of Risperdal (risperidone) for use in children with ASD who exhibit maladaptive and aggressive behaviors.  Further, in November 2009 (just a few weeks ago) the FDA approved Abilify (aripiprazole) for use in ASD related irritability.  Unfortunately, while these medications to be beneficial, research has shown that there are no lasting benefits once the medication is discontinued.

<<I want to add a brief note here.  The last statement I made, regarding the lack of continued benefit once the medication is discontinued, should not be surprising to anyone.  Medications do not teach skills.  Medications do not teach right from wrong.  All that medication does is make you “available.”  I will spend more time on this issue in another post, but the primary purpose of medication is to stop a particular behavior or set of behaviors.  Medication, in and of itself, does not teach appropriate behaviors!>>

Because medication has no long lasting gains once it is stopped, the researchers at RUPP Autism Network conducted a study to determine the benefits of adding a Parent Training (PT) program to the treatment of children with ASD.  In this study, 124 children between the ages of 4 and 13 years participated.  To be included in the study, the children had to have a diagnosis of Autism, PDD-NOS, or Asperger’s Disorder.  In addition to other inclusion and exclusion criteria, the participants had to demonstrate clinically significant behavior problems.

As part of the 24-week study, all of the children were prescribed risperidone (though a few were changed to Abilify during the study as a result of poor response), but only a portion of the participants also received PT.  This design allows for comparisons between two groups; the group where the children were just getting medication (MED) and the combination group where the children were getting medication and the parents were receiving PT (COMB).  The researchers used multiple rating scales to assess behavioral issues, which were administered throughout the study to measure changes in the severity of the child’s behavior.  Through this research study, the researchers hoped to demonstrate that risperidone treatment coupled with PT would be superior to risperidone treatment alone in reducing serious behavior problems in children with ASD.

The results of this study are very promising.  Children in both groups demonstrated improved compliance, as reported by their parents.  However, the COMB group reported greater improvements in compliance than those seen in the MED group.  That is, although all of the children demonstrated improvement, children whose parents were in the PT program demonstrated greater improvement.  Even more exciting was the fact that the children in the COMB group showed greater reduction in irritability.  Again, although all of the children demonstrated less irritability, the children whose parents received the PT demonstrated the greatest improvement.

This study demonstrated, yet again, the benefits of behavioral and psychological treatments in the management of challenging behaviors.  While medication is a useful tool for treating troublesome behaviors and emotions, the addition of psychological treatment (in the form of parent training, behavioral support, and therapy) results in greater, longer-lasting benefits.  I frequently recommend my patients to prescribing physicians to determine if medication could be helpful for them.  While I do not believe that medication is a “cure-all,” it has its place in helping the patient become “available” to the treatment I am providing.  Once the patient has benefitted from my treatment, there is the potential that the medication can be reduced or even completely stopped.  While all patients cannot be taken off of their medications, the additional benefits of psychological support are clear and well worth the additional treatment.  Now, if only we could get the insurance companies to agree…

Here is the reference for those of you who would like to see the full article:

Aman, MG; McDougle, CJ; Scahill, L; Handen, B; Arnold, LE; Johnson, C; et.al. (2009). Medication and Parent Training in Children with Pervasive Developmental Disorders and Serious Behavior Problems: Results From a Randomized Clinical Trial. Journal of the American Academy of Child & Adolescent Psychiatry. 48 (12), p. 1143-1154.