Category: mental illness

How to manage defiance and oppositional defiant disorder

How to manage defiance and oppositional defiant disorder

Troubled children and teenagers who are pathologically defiant have a brain condition with many possible causes or diagnoses.  Whether they are overtly aggressive or “passive-aggressive,” parents have options for reducing defiance and limiting the stress they bring into the household.

anterior cingulate gyrus
In a healthy brain, the pink region doesn’t light up quite like this when a person is confronted with a limit or rule. A healthy child starts considering options and ways to work around.

If your child is defiant to a degree that affects their life functions, this is what it looks like in their brain.  The pink color of this curving central region indicates intense electrical activity.  This is the brain scan of a 13-year-old boy with severe oppositional defiant disorder (ODD).  Hyper-charged activity in this region can also be responsible for obsessive compulsive disorder (OCD), unstoppable rages, pathological gambling, chronic pain, and severe PMS.

It is called the anterior cingulate gyrus (ACG), which allows a person to shift attention to different subjects and think flexibly–something defiant kids don’t do well.  Nor do they regulate emotions, something the ACG also does.  Children with a hyper-charged ACG have “a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which 4 or more of the following are present:

  • Often loses temper
  • Often argues with adults.
  • Often actively defies or refuses to comply with adults’ requests or rules.
  • Often deliberately annoys people.
  • Often blames others for his or her mistakes or misbehavior.
  • Is often touchy or easily annoyed by others.
  • Is often angry and resentful.
  • Is often spiteful and vindictive.” 

–From the “Diagnostic and Statistical Manual of Mental Disorders, 4th Edition,” published by the American Psychiatric Association, 2000.

Typical traits of defiant children.

  • screaming teenage girlThey act younger than they are. Don’t expect them to mature quickly.
  • They live in the here and now, and can’t think about the past or future.  They don’t see how their actions result in a series of consequences.  They can learn sometimes, but only if it is pointed out immediately after an incident.
  • They don’t notice their effect on others.  Sometimes you can ask one of the others how they feel immediately after an incident, or you can gently report how it makes you feel.
  • Their brain is easily overloaded, and they have a hard time with changes.  And yet, you can use this overloading problem to your advantage (more below).
  • They cannot follow your reasoning, so don’t try.
  • Defiance may be a strength in their future. With mature skills, they’ll better resist negative things they’ll face in life.

Unrelenting defiance is a true disability that negatively affects a child’s life and future.  I’ve seen highly intelligent defiant or ODD diagnosed children experience academic failure or enough suspensions or expulsion to hold them back a grade.  This is a can’t-win-for-losing path that really sucks, doesn’t it?

Two different psychiatric approaches to defiant behavior and ODD

  • Treating it as a form of attention deficit disorder;
  • Treating it as form of depression and obsessive-compulsive disorder.

The attention deficit approach uses therapy in combination with medications, such as Straterra (chemical name is atomoxetine), Ritalin (methylphenidate), Risperdal (risperidone, an antipsychotic), and Depakote or divalproex (a mood stabilizer).  This is not a complete list because new compounds are being formulated to reduce side-effects.

The depression & obsessive-compulsive approach combines therapy in combination with serotonin-based antidepressants such as Prozac (fluoxetine) or Zoloft (sertaline), and Anafranil (clomipramine, for anxiety). Again, this is not a complete list.

Treatment must also include holistic or ‘lifestyle’ approaches.

These are absolutely essential.  No amount of medication or therapy will help a child whose physical body is in poor shape!  The brain is an organ too, like the heart or liver, and needs the right nutrients and oxygen delivered through the blood.

  • avocadoEat brain food that includes nutrients and minerals listed in these articles:  The best vitamins for your child’s brain, and The brain diet for troubled kids.
  • Avoid foods that cause mood extremes and limit cognitive functions (such as memory and processing speed) such as:  food fried in oils other than olive oil, refined sugars and starches (flour, white sugar), saturated and hydrogenated fats, diuretics like caffeine, and any other foods that have dyes or nutrients removed by processing (for example, apple filling in pastry instead of actual apples).
  • Get more sleep and exercise – these have an immediate and direct impact on brain health!  In even one day, a brain will under-perform if there’s been inadequate sleep or exercise.  Sleep restores brain function and memory, and exercise pumps oxygen to the brain and causes the release of positive hormones and neurotransmitters.
  • Drink water (sports drinks are OK too if they don’t have caffeine)

Defiance and ODD often include symptoms of other disorders

  • 50-65% of defiant children also have ADD or ADHD
  • 35% develop some form of depressive disorder
  • 20% have some form of mood disorder, such as bipolar disorder or anxiety
  • 15% develop some form of personality disorder
  • Many also have learning disorders

Anthony Kane, MD 

Other conditions can cause defiant and disruptive behavior

  1. Neurological disorders from brain injuries, left temporal lobe seizures (these do not cause convulsions, no one can tell these are happening), tumors, and vascular abnormalities
  2. Endocrine system problems such as a hyperactive thyroid
  3. Infections such as encephalitis and post-encephalitis syndromes
  4. Inability to regulate sugar, resulting in rapid ups and downs of sugar in the blood
  5. Systemic lupus erythematosus, Wilson’s disease
  6. Side-effects of some prescription medications:  Corticosteroids (anti-inflammatory and arthritis drugs such as Prednisone);  Beta-agonists (asthma drugs such as Advair and Symbicort)
    –From Peters and Josephson.  Psychiatric Times, 2009
  7. Autism spectrum disorders
  8. PANDAS – an acronym for a strep infection-caused disorder that can make a previously normal child violently resistant.  (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections)
  9. Dehydration

If your child has these traits, it will be easier to reduce defiant or ODD behavior

  • A normal IQ
  • A first-born child
  • An affectionate temperament
  • Positive interactions with friends their age
  • Nurturing parents who can consistently set clear behavioral limits

–From the Journal of American Academic Child and Adolescent Psychiatry, 2002.  Author J.D. Burke.

Choose your battles
Let’s face it, consistently enforcing limits isn’t possible 24/7.  It’s exhausting.  Take a break; let some things go.

Parenting that works for ‘normal’ children does not work for defiant children or teenagers.

First, be kind to yourself; this is hard.  Get enough sleep, maintain your supportive relationships (spouse or partner, children, friends), schedule breaks and getaways, and guard your physical and emotional health.  Don’t expect quick results because success may take weeks or months. 

Address just one issue at a time, then strengthen yourself for running a marathon.

Find something positive to do together.  Your child needs for closeness and appreciation and joy, like everyone.  Ask your child what positive activity interests them most, or try new activities until one brings about a good chemistry between you and your child.

Praise is a powerful tool for managing disruptive behavior.  Make an effort to inject positive energy into your relationship with your child or teen.  It’s likely that this relationship has become mostly negative over time.   Caution: don’t expect thanks when you praise your child.  They are typically self-absorbed and not thinking about you.

Set limits – “Consistent limit setting and predictable responses from parents help give children a sense of stability and security.  Children and teens who feel a sense of security regarding the limits of their environment have less need to constantly test it.”
–Webster-Stratton and Hancock, Handbook for Parent Training, 1998

ignore childActively ignore – This works for best with children between the ages of 2 and 12.  It involves purposefully withdrawing your attention away from your child when they are misbehaving, such as a temper tantrum, whining or sulking, baiting or teasing, or making continuous demands or loud complaints.  Pretend you don’t care and even turn your back if possible.  Give attention only after their behavior is ending or over.

Make the behavior uncomfortable.

  • Example:  If your kid swears, test them, “C’mon, you can do better than that, be creative, I’ve heard all those things before.”  They can get frustrated when they aren’t getting the reaction they want from you, and defy you by giving up.
  • Another example:  Your teen refuses to get out of bed for school.  Don’t nag or repeat, repeat, repeat.  Remove the bed covers and set them far enough away that your child has to get out of bed to retrieve them.  (“Managing Resistance,” John W. Maag)

Give multiple instructions at once, where at least one of the instructions is what they want to do, and one is what you want them to do.  “Close the door while you’re yelling at your sister and don’t forget the light.”  Your child will be overloaded as they try to figure out which thing they’re supposed to defy.  Kids tend to get flustered by the mental effort and comply without knowing they’re doing it. (from “Managing Resistance,” Maag)

Use reverse psychology: it’s a good kind of manipulation.  Insist or pressure your child to do something they think you don’t want them to do, so they will defy you and do it… which is indeed what you wanted in the first place.  Pretend to agree or disagree with a behavior or choice so that you get the outcome you want.

A mother I know did this with her 14 year old daughter who’d threatened to cut off all her hair and self-tattoo her face.  The mother said she “went ballistic” over the idea of her beautiful hair being cut (even though she knew it would grow back, whereas a tattoo would be permanent).  The results were exactly what the mother wanted.  Her daughter totally butchered her hair, and the tattoo idea never came up again.

Offer unexpected rewards – On random occasions, reward appropriate behavior with something they like.  They are more likely to do a desired behavior if they expect something they want and aren’t sure when it will be offered.

Redirect their attention.  If you’re entering a situation where you know your child will become defiant, distract them.  Make yourself a list of actions or behaviors you can do that are distracting during times when their defiance should not be tolerated, such as when there’s a threat to safety.

Keep your power. Claim your throne as ultimate decision maker and boundary setter.

Don’t treat your home like a democracy or try to be fair and equal.  Be a benevolent dictator.  A troubled child should not have an equal say in how things are done.  To keep your authority and power in the household, tell your defiant child that you’ll listen and consider compromise, but make no promises.

Never justify your decision or provide reasons.  Reasoning does not work; it only promotes endless arguments. As your child ages into adulthood, an adult child will continue to require limits, and limits will still need enforcement. To a parent, it will feel like you’re treating your adult offspring as a child. YOU ARE and you should be, and this is the interesting part:  they won’t notice.

Allow some aggression.  When it’s appropriate and safe, ask your child to do more of what they’re already doing so that they turn around and defy you by stopping the behavior. Example: your child refuses to take a direction and throws a book on the floor in anger.

  • Parent:  “There’s only one book on the floor. Here is another one, now throw this on the floor.”  (Child throws book down.)
  • “Here’s another one. Throw this down too.”  (Child throws book down.)
  • “And here’s another, throw this down, too.”  (Child stops throwing books in defiance.)

Be a marshmallow.  Show no resistance.  Instead, listen and respond to how they feel, not what they say.  Show them you are open talk later when the stress dies down.

  • Teen:  “I hate you f- -king b- -ch!”
  • Parent:  “Sounds like you’re really angry.”
  • Teen:  “Shut up you stupid c – -t!”
  • Parent:  “Can you tell why me you’re angry so I can do something about it?”
  • Teen:  “Leave me alone f- -k face!  Stop patronizing me!”
  • Parent:  “OK, I hear you don’t want me to patronize you.  I feel this is stressful for both of us, so let’s take a break and talk about it later.”
  • Teen: F—k you!  I’m not talking to you ever.  (Well that’s not true, but they may ‘defy’ you by avoiding the behavior.) 

Call their bluff.

  • Child:  “I’m going to run away!”
  • Parent:  “OK, if you do, call me, and I’ll bring your stuff and maybe a snack.  Here’s the runaway hotline phone number if you don’t want to call directly.”  Then walk away.  If they do run and call, you’ll know where they are and can fetch them or call the police.
  • Child:  I’ll kill myself!  (This rarely true if shouted in anger and defiance. Your child may be throwing out threats to see how you react and get you to back down.)
  • Parent:  “If you really mean that, this is serious and means we need to get you to a hospital!  Let’s get ready and go because you need to get assessed.”

Warning, once you make progress regaining authority and reducing defiance, a honeymoon phase will be followed by a huge backlash… but this is a good sign! 

It’s proof your work is having an impact.  Extreme resistance to behavioral change is a common response called an “extinction burst;” see diagram below.  Pressure builds because it’s exhausting to try and control an urge to misbehave, and they eventually explode.  This as predictable so plan ahead.  The extreme “burst” is evidence the ingrained behavior is ending or going extinct.  There may be more bursts that test your resolve.  Eventually, your child likely stops defying at least one rule.  Pick the most critical behaviors that need extinguishing and keep up the effort.  Eventually, they back off again, and the pattern continues until it’s just not worth it to defy these rules anymore.

extinction burst

–From “Behavioral Interventions for Children with ADHD,” by Daniel T. Moore, Ph.D., © 2001, http://www.yourfamilyclinic.com/shareware/addbehavior.html .  The author requests a $2 donation through PayPal to distribute his article or receive printed copies.

Some rules for you

Don’t blame your child.  It’s easy to think they’re being bad on purpose because they’ll act like it, and show amusement when they’re bad or belittle you. Keep in mind that their behavior is no one’s fault, and your child would not choose to behave like they do if they understood what it meant.

Don’t ignore other challenges that might be responsible for their behavior.  They may face bullying at school, lack of sleep, or stress from things at home for example.

teenage mouse
Seriously, defiant teenagers think this way, and can’t see the obvious right in front of them.  I got this cartoon from a therapist who treats teenagers with criminal convictions, who are required by juvenile court to get counseling.

Always enforce your rules as immediately after the fact as possible.  Why:  If enforcement comes later or only occasionally, the child does not connect the broken rule with the punishment. They really don’t, even when you explain it quite clearly.

Don’t direct anger at your child.  If you do, apologize.

  • They can use your reaction against you, and tease or bait you to get you angry again
  • Don’t model that anger is an OK response to stress.
  • Do model that apologies are a proper response

Avoid explaining and justifying rules. Defiant children and teenagers are not able to reason once their emotions take control. They will only resist harder and pelt you with arguments. (What’s interesting is I’ve observed parents trying to reason with young children (4 or 5), too young to be reasonable in the first place, or with young adults (early 20’s) who have a long track record of being unreasonable.

Don’t interpret everything as pathological defiance or ODD.  Some rebelliousness is normal for children.  It’s especially so if parents are over-controlling.

Don’t keep trying the same things that still don’t work.  Like yelling or repeating yourself over and over (Don’t be embarrassed; we’ve all done this).

It helps to lower your expectations for your child’s behavior and progress.  What you want may be totally unrealistic, and more than you and your child can handle.

I once saw a bumper sticker that said “I feel much better now that I’ve given up hope,” and found it strangely comforting. 

Don’t jump to conclusions that demonize the child.  I often hear parents say:  “Why does he keep doing this?, or, “Why doesn’t she stop after I’ve told her not to, over and over again.”  Then they answer their own questions:  “It’s because he always wants his way,” or, “She’s doing this to get back at me.”  As they tell their story, I hear them taking things personally:  “He does this just to make me mad;” “She manipulates the situation because she wants more (something) and I won’t give it to her.”  Is this really what you want?

Two training approaches that help parents like you: 

Parent Management Training:  this is an intensive educational program that has been proven to help parents handle extremely difficult children, including those defiance and ODD.  PMT teaches parents precisely how to assert consistency, keep interactions predictable, and promote pro-social behavior in their child.  A good explanation can be found at this link: Encyclopedia of Mental Disorders.  Examples of parent management training include:  the Total Transformation and the Incredible Years.

Collaborative Problem Solving:  CPS teaches how to negotiate with a defiant or resistant child.  This may seem like giving in, but it depends on how one negotiates or comes to a compromise.  If defiance is a result of something the child needs but can’t express appropriately, a CPS approach helps the parents hone in on the  underlying need, which may be simple and easy to address.  A great place to find out more is on the Think:Kids website.

Find the energy and doggedness to be consistent, and the compassion and forgiveness to be nurturing.
This is a heroic endeavor.


If you would like to get ongoing updates on the latest news and research in child & adolescent mental health, follow my Facebook Page.

The best vitamins for your child’s brain

The best vitamins for your child’s brain

avocadoThe vitamins listed here are absolutely essential for your child’s brain, and it’s highly likely your child doesn’t have enough.  People with psychiatric disorders commonly have physical problems that are symptoms of vitamin deficiency.  Take digestive problems, for example–low levels of B vitamins cause digestive disorders, especially B12.

“One of the most common deficiencies seen in patients with mental disorders is B vitamins”*

B1 – Thiamine helps neurons to send electrical signals.  A proper level in the blood stream wards off depression. B1 is found in beans, asparagus, beef, oranges, sunflower seeds, oats, and green peas.

canteloupeB2 Riboflavin is also needed for neurons to send electrical signals.  B2 is found in sunflower seeds, fish, poultry, bananas, leafy greens, and sweet potatoes.

B6 prevents memory loss, improves memory, and helps reduce depression, and increase hemoglobin in the blood which supplies oxygen to the body and brain.  B6 is found in sunflower seeds, fish, poultry, bananas, leafy greens, sweet potato

B9 – Folic acid helps in formation of nerve tissue, or the neurons in the brain.  B9 is found in spinach, asparagus, beans, avocado, lentils, and broccoli.

kiwisB12 is needed for the myelin sheath that covers and protects neurons, and signs of deficiency are bowel and stomach problems. Probiotics for gut health are helpful, but so is sufficient B12.  It is found in seafood, eggs, cheese, leafy greens, milk, and red meat.

Vitamin CAscorbic acid regulates the production of neurotransmitters like dopamine, and protects the brain against oxidative stress, which is when there are too many “free radicals” (one kind of chemical), and too few “antioxidants” (another kind of chemical).  Vitamin C is found in citrus, tomato, kiwi, strawberry, mango, pineapple, cantaloupe, and green vegetables.

strawberry

Calcium is an actual nerve cell messenger.  It controls how signals pass between neurons.  Calcium is found in dairy (milk, hard cheese, and yogurt), sardines and salmon, beans and lentils, almonds, collard greens, tofu, and figs.

Magnesium is essential for many chemicals in the brain and body. It promotes the metabolism of B vitamins as well as signal transmission between neurons.  Magnesium calms people.  It is found in nuts, pumpkin seeds, black beans, avocado, brown rice, and leafy green vegetables.

Zinc helps regulate the electrical signals between neurons.  It is found in pumpkin seeds, beef, shrimp, nuts, chocolate, wheat germ, and oysters.

chardVitamin D is essential because it directs the production of neurotransmitters, nerve growth, and nerve connections.  Lack of Vitamin D is a common problem in people with psychiatric disorders.  The best form is from sunlight or the full sun spectrum.  Supplements have some benefit, but sun is best.

All vitamins are best obtained through food, not pills.

*“Essential Vitamins and Minerals for Brain Function”

See additional brain foods in this article, The Brain Diet for Troubled Kids.  Did you know that ~75% of individuals who are hospitalized for mental illness have very low Vitamin D?


Want a steady stream of useful information for parents like you?  Follow the Facebook page.

What hallucinations are like, from those who know

What hallucinations are like, from those who know

If you care for a child experiencing hallucinations but don’t know what it’s like, these first-hand accounts may help you better understand and support your child.


This writer is taking medications, which help, but do not fully eliminate the hallucinations.

hallucinations 1“The reason my thoughts inaccurately capture existence is because my understanding of existence is different insofar that I have to daily navigate through illusory experiences.

How hallucinations look/sound

“They look like I am looking into another dimension, their bodies fade into the background, but they sound real.  I can tell that it is from another dimension but cannot distinguish it from other normal people’s realities because my reality is all I know.

“In general I find my experience with hallucinations unfavourable because they make other people in this reality quite distant.  Learning complicated tasks is a hundred-fold more complicated for me to manage than regular people.  I literally am disadvantaged by the hallucinations in the academic sphere, but seem to thrive with the hallucinations in other ways such as long distance walking and jogging.  People should NOT interact with me when I am hallucinating because when I am hallucinating, it means I am being overpowered by another dimension and can’t understand what is going on anyway.

hallucinations 2“If family members and friends are concerned about my wellbeing they should encourage me in a positive way to do different projects on my own like reading books about subjects that interest me or go on long excursions like long distance walking and jogging.  Heavy exercise seems to alleviate paranoia and negative thought patterns like being suicidal or angry with others.”

–By Anonymous 1, who lives with schizoaffective disorder


This writer responded to questions I asked.

1. How would you describe visual/auditory hallucinations to someone who has never experienced these? What do you see/hear?

I often see people’s faces and gestures twist up and look and act angry. I hear my name a lot. I see people hiding and running to avoid me catching them and [people] watching me.

2. How do they look or sound? 

Angry, abnormal colored skin, and strange upsetting body language.

3. Can you tell when you are hallucinating while it is occurring?

Sometimes…I don’t always notice right away but there have been times when I knew it wasn’t real.

4. Do you like or dislike hallucinating?

I do, because I feel like God is reaching out to me to protect people from evil.

5. How should someone interact with you if you’re hallucinating?

Calmly, if the situation has highly intense feelings and reactions I could go into a panic attack lasting 1-3 days.

surreal leaves6. What should loved ones do or not do if you’re hallucinating but they are concerned about your welfare?

 

DON’T :

-> Never raise your voice or let yourself become agitated

-> Try to take control of the situation

-> Take anything personally

DO:

-> Hand me things I can hold in my hand for centering (leaves, rocks)

-> Remind me of the people who care about me

-> Be honest with me if I ask how realistic it was

–By Anonymous 2, who lives with schizoaffective disorder


This is a first-hand account drawn from the SARDAA newsletter (Schizophrenia and Related Disorders Alliance of America).

Somewhere around the age of 17 or 18, I noticed that I was not feeling quite right mentally.  Things were confusing, not making any sense, and I started losing my sense of connectedness.  I started drinking to cope and became an alcoholic when I entered college.

hallucination leaf dressAnyway, I got sober by entering treatment and Alcoholics Anonymous about a year later.  I was exhilarated, although things still didn’t seem to be quite right.  I felt lost.  About 14 months into my new life, I decided to find some meaning to my existence.  While on a trip with an acquaintance I noticed things were really quite different.  The leaves in the wind seemed to be talking to me.  Cloud formations had special meanings.  Television and radio shows were talking about my life.  And I thought I could read peoples’ minds and communicate with them without speaking.  I thought I had found what great spiritual leaders termed “being spiritual.”  I truly thought I had been blessed by God and that I had a direct pipeline to Him.  I felt happy and scared at the same time.  I was in a different world.

About one week later I decided to travel out to the West Coast to really find myself, given this new-found power.  While traveling, it seemed like God’s voice entered into my thoughts and told me to do something if I wanted real peace and power in my life.  That being, to run my car off the road and leave the rest to Him.  I did this only to find no peace, but a totaled car and a trip to the state mental hospital.

Since that time, I’ve been dealing with a disease called schizophrenia.  It has been an uphill struggle.  At the time of this writing, I believe I’ve found a way to pull myself out of psychosis and feel connected like before the alcoholism and schizophrenia.  Today I feel peace, own a thriving business and have a wonderful relationship with my wife.  We’re in the process of planning a family.  This has been accomplished by the philosophy of Schizophrenia Alliance, Alcoholics Anonymous, and a few special people in my life.


Readers, what does your child experience?

Do any readers have a child (of any age) who can describe what they’re experiencing when their mental health is poor?  Please share in the comments section, or if you wish to stay completely anonymous, please contact me and I will add your child’s story without any identifying information.

Unsettling: What psychosis looks like in children and young people

Unsettling: What psychosis looks like in children and young people

kill him street
This eerie painting is by a young woman of 22 diagnosed with schizophrenia. She is encountering a threat, real or imagined, and her paranoia is compounded by being watched from the window above. Note the symbolic references to communications links and satellites.

Odd, eccentric, a little weird:  people experiencing psychosis are living in dream space.  If you haven’t experienced psychosis yourself, it’s a little like the period just before you awake, when you’re in a dream but also aware of your surroundings.  Your dream and emerging consciousness weave together in a wonderful or horrible or simply odd narrative.  If you try to explain it someone, you realize it makes no sense, yet it made a lot of sense while you were dreaming.

To a parent watching a psychotic child, you may observe that they see, feel, hear, move about, and respond to you as if fully conscious, but it’s important to know that they simultaneously inhabit the subconscious. As a result, they don’t notice that what they do and think is any different from anyone else.  The term “anosognosia” refers to their inability to recognize this, and it explains why so many resent being told they have a problem and need treatment.  They simply aren’t aware that anything is different about them.

Evidence of psychotic behavior

Parents of a child who was eventually diagnosed with a psychotic disorder often report that their child was always a bit different from their peers–slightly eccentric, a unique individual who had an interesting way of looking at the world. Parents have also reported the following behaviors when their child was exhibiting psychosis.  (Not all of these are present in each child.)

  • A belief in something that isn’t rational, and the belief is unusual or unreal or impossible.  The person cannot be talked out of the belief.  And rational, logical reason only increases resistance to reason.
    • If the psychotic episode is positive or magical, the person may have powerful religious feelings and a sense of omnipotence or clairvoyance. They may believe they have been instructed to give a message to save the world, for example.
    • If the episode is negative and paranoid, they can become very agitated, fearful, or they may panic.  They may act negatively on irrational beliefs.  They are attracted to paranoid or extremist views, especially those with high emotional content.
  • Smiling or laughing at nothing in particular and for no apparent reason. It’s as if someone has just told them a joke.
  • Yelling or ranting, this could be at an object or at someone or at nothing apparent. The ranting can happen online.  The ranting has repeated themes, and the themes are unique to each person.
  • Intense, crushing anxiety, irritability, accusations, and obsessive troubling thoughts.
  • Talking and gesturing as if they’re in a conversation with an invisible someone. (Normal people also gesture they think, but they are aware they are not literally communicating with someone.)
  • Wandering eyes and shifting body language as if they are seeing or feeling things that aren’t there.
  • Abrupt personality change from seemingly normal behavior.  Often, a child’s eyes will have a disquieting faraway ‘look’, as if the child is not in their body, and a they’ve been overtaken by a demon.
  • Fear, anxiety, and paranoia–they feel watched, trapped, and controlled in some way. They stop trusting people.  They hide or try to block experiences to protect themselves.
  • Intense obsessions with ideas, things, or events (even if they occurred long past). Themes emerge which often refer to actual events that elicited strong emotions.
  • Seeing patterns and connections in events that aren’t connected.
  • Unusual and confusing responses when communicating with others—a comment that doesn’t seem to apply, or a a string of words that defy interpretation.
  • A preference for solitude and closing themselves off from others.  This is for self-protection.
  • Loss of interest in self-care: not wearing clean clothes, bathing, or organizing their surroundings.

The most common diagnoses that have psychotic features are schizophrenia, schizoaffective disorder, bipolar disorder, and depression.  This story about schizoaffective disorder gives some real world examples of psychosis:  “Life with a Schizoaffective Teen.”

Psychotic behavior can have a long slow onset

brain degeneration in schizophrenia
The image on the left is of a 15-year-old boy with early onset schizophrenia. The purple regions have normal neuron density, red regions have low neuron density. In the 2nd image, the red area at the top of the brain is in the cerebral cortex, the region of executive function and rational thought.

It’s easy to miss signs of early psychosis!  Sometimes a child or young person starts showing eccentric behaviors that aren’t serious or are easy to interpret as something else: creativity and imagination; immaturity; puberty; influences from immature friends; too much video gaming…  Your child may have been experiencing mild visual or aural hallucinations for some time, even a couple of years, and just assumed it happened to everyone so they never reported it.  As psychosis emerges in the early teens, their thoughts and behaviors start affecting friendships or school work.  The child stops doing things they once enjoyed.  Someone might assume they’re experimenting with drugs.  They seem so much like other difficult, distracted, or defiant teens that a parent can be lulled into thinking they are not seriously mentally ill… but psychosis is very serious.

If this describes your child, immediately (and I mean immediately) find a psychiatrist and get an assessment.  The earlier you can treat psychosis, the better the outcome for your child.  Psychosis is degenerative.  The longer a brain stays in a state of psychosis, the more neurons it loses.  Early treatment via therapies, medication, diet, and other physical supports can literally prevent neuron loss and future psychotic breaks that require hospitalization.

Psychosis can emerge abruptly

For disorders on the schizophrenic spectrum, this is common in young men in the late teens and early 20’s.  However, adults in their 30’s and 40’s have also been known to have sudden onset of psychosis.  It’s tragic, you witness this young person launching into adulthood, studying in college or starting employment, and suddenly his or her personality changes.  Their behavior worsens, and it becomes evident they’ll never be able to have the future they planned.  They need immediate treatment, possibly hospitalization if the psychotic break reaches a crisis point.  If this is your child and they are past age 18, use every means possible to get help for them!

Kendall art
Self-portrait by a 24-year-old woman diagnosed with schizoaffective disorder. Her image is a modified mug shot photo taken of her after an arrest.

What worsens psychosis and what you can do to relieve it

  • Poor sleep and reduced sleep.

Help your child get enough hours of sound sleep. The best sleep environment is a cool very dark room.  Once my child became unable to attend high school, I allowed her to nap any time of the day.

  • Closing themselves off from the world.

Your child needs mental and sensory stimulation to keep their mind from spinning out on their obsessions, hallucinations, and paranoia, but the amount must be tolerable.   Stimulus must come from the tangible, sensory world (e.g. not screen time, videos, books).  Concrete interaction with reality diverts their attention from obsessive thoughts or voices.  They will benefit from regular (perhaps limited) social interaction*, an undemanding therapy animal, creative work (such as art and music), and being out in nature.

  • Marijuana use–specifically the THC in marijuana

CBD in marijuana has many medical benefits and is considered safe, but the THC is not.  THC is also addictive, and available in very highly concentrated oils… extremely dangerous.  Like THC, any addictive substance, from alcohol to methamphetamine, will interfere with treatment for psychosis.  The drug’s influence trumps everything.  Drugs are literally self-induced psychosis.  See:  “Marijuana is Uniquely Harmful to Troubled Teens”;  “Marijuana is Dangerous.”

  • Continual exposure to things they already obsess on or that make them paranoid, angry, or anxious.

In every way possible, keep your child away from any material, people, or messages that upsets them.  These only add gasoline to the fire and increase the likelihood of future psychotic breaks.  They may obsess on the same things for the rest of their lives.  If someone who’s psychotic is exposed to intense emotional experiences that feed their obsessions and paranoia, people have been known to do to horrible things to themselves or others.  An example at the time of this writing is of a young woman with psychotic bipolar mania who tragically pulled out her own eyes.

Find ways to redirect your child’s attention elsewhere and help them get a grasp on the reality.  Help them calm down (“deescalate” them) and help them learn ways to calm themselves down.

A diagnosis of an illness that includes psychosis is devastating

Face to facePsychosis and/or a psychotic crisis in a child who previously led a normal healthy life blindsides everyone, especially the family.  Allow yourself to go through the stages of grief as you would after any death…  because it can feel like the ‘death’ of your child and their future and your hopes for them.  Get help from others as you would after any death.  Here you are, grieving, but your child needs you to be strong!  Get help for your own mental health.

Reason for hope

Children who receive regular social support from family and loved ones do well over the decades.  They can avoid homelessness, hospitalizations, harm.  They can get advanced education, keep strong relationships, maintain employment.  They get a life of wellbeing.  This has happened with my adult child after years of horrendous experiences.

Cognitive Enhancement Therapy

A relatively new therapy has been developed and tested that meaningfully helps people with chronic psychotic disorders.  “CET attempts to increase mental stamina, active information processing, and the spontaneous negotiation of unrehearsed social challenges. It does so with a focus on enhancing perspective taking, social context appraisal, and other components of social cognition… CET has been shown to have remarkable and enduring effects in a study of persons with schizophrenia or schizoaffective disorder…”
–CET Training LLC, “approved and recognized by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) as an evidence-based practice.

What are your experiences?  Have you found anything that helps?

–Margaret

 

*Social Interaction Increases Survival by 50%
Psychiatric Times. July 30, 2010

Theoretical models have suggested that social relationships influence health through stress reduction and by more direct protective effects that promote healthy behavior. A recent study confirms this concept.  Findings from a meta-analysis published in PLoS Medicine indicate that social interaction is a key to living longer. Julianne Holt-Lunstadt, PhD of Brigham Young University and colleagues analyzed data from 148 published studies (1979 through 2006) that comprised more than 300,000 individuals who had been followed for an average of 7.5 years. Not all the interactions in the reports were positive, yet the researchers found that the benefits of social contact are comparable to quitting smoking, and exceed those of losing weight or increasing physical activity.

Results of studies that showed increased rates of mortality in infants in custodial care who lacked human contact were the impetus for changes in social and medical practice and policy. Once the changes were in place, there was a significant decrease in mortality rates. Holt-Lundstadt and colleagues conclude that similar benefits would be seen in the health outcomes of adults: Social relationship-based interventions represent a major opportunity to enhance not only the quality of life but also of survival.”


If you would like to get ongoing updates on the latest news and research in child & adolescent mental health, follow my Facebook Page.

Welcome to the 911 Club for Parents of Troubled Kids

Welcome to the 911 Club for Parents of Troubled Kids

Let’s start a 911 Club, a community for parents who depend on emergency services for managing their mentally ill child. Our T-shirts would be black and blue like bruises. Only people raising a mentally ill child or young adult could join. Club rules would be simple:  1. No one is ever judged. 2. We keep things confidential. 3. Everyone is made to feel like a hero. 4. Everyone accepts that they are not guilty or failures, and neither are their children.

Every day, an emergency is just around the corner.

Parents with troubled children, no matter the age or diagnosis, are forced to make difficult decisions and take extreme actions… like calling 911.  It’s not something they choose, and they’ll avoid it if possible.  They are like any other parent with a severely disabled or physically ill child—they will do anything to help their child, but instead of wheelchairs or chemotherapy, they need emergency responders.

Most parents with normal children will never need to do the following 10 things that parents of troubled children often do:

  1. Call police
  2. Call an ambulance
  3. Or call a crisis line repeatedly
  4. Search a child’s room, especially if the child is a teenager or may be suicidal
  5. Spy on their child: read their email, texts, social media or search histories, read their journals
  6. File criminal charges or get a restraining order
  7. Lock up common household items (matches, knives, scissors, fuel, and anything conceivably dangerous in the wrong hands)
  8. Participate in endless meetings, appointments, and therapy sessions. Complete dozens of forms and continually pursue financial or community mental health resources
  9. Block out people who used to be friends
  10. Never share our stories with ‘normal’ people lest we get bombarded with uninformed and unsolicited opinions.


Parents can see an emergency coming, but can do little to prevent it.

All parents of troubled children have barriers to getting help, even when it’s blatantly obvious that the child needs it.  Why?  The aftermath of a recent high school shooting in Florida by provides details:

  1. The tragedy has to happen first: “A neighbor warned the sheriff’s office …and begged them to intervene. She was told there was nothing deputies could do until Cruz actually did something.”
  2. Mental health professionals don’t take history into account; and they are ignorant that children can behave well in their presence: “An investigator … spoke to Cruz, and advised that he was “not currently a threat to himself or others” and did not need to be committed.
  3. Family and other eyewitnesses are ignored by the people and institutions they depend on. “Lynda Cruz’s cousin warned deputies Cruz had rifles and pleaded for them to “recover these weapons.”


Policymakers, mental health professionals, and emergency responders out there:  fix this!

Part of the reason parents or family of the mentally ill person can’t get timely help is because of civil rights laws.  To those in the mental health community, start talking about how to handle this.  The present situation is unacceptable!  Stop protecting an acknowledged dangerous person’s rights over those of innocent victims.  It’s not OK.  This is just like some gun advocates who think it’s more important to sell assault rifles to protect their personal rights over those of innocent victims.

True Story

An upsetting thing happened in my city about 10 years ago that could have been my story. A man took his grown son to the emergency room because the son had been insisting he was going to stab someone—he suffered from untreated schizophrenia. When there, the staff found no reason to hold the son despite his history of violence and his father’s testimony. The father pleaded with them to put his son in a 72-hour hold and they refused.

Within minutes, the son ran off into the surrounding neighborhood, and within an hour, had stolen a steak knife from a restaurant, and ran out and stabbed a man walking on the sidewalk. (The victim lived, fortunately.) The father told the reporter that he’d been trying every possible means to stop this from happening in the hours before the event. Getting the son to go with him to the ER was an extraordinary feat in and of itself. He was beside himself with frustration and sadness and anger.  Now his son had aggravated assault and attempted homicide charges, and faced prison instead of a hospital.

–Margaret

 

U.K. needs to be a “999 Club”; Germany needs a “112” Club; a “110 Club” in China…

Your child’s ADHD diagnosis could be wrong, leaving other issues untreated

Your child’s ADHD diagnosis could be wrong, leaving other issues untreated

Inattention and distractibility are caused by many medical conditions and life situations.  You child may not have ADHD or ADD if they didn’t show signs when they were young.

Children don’t just catch ADHD or ADD

If your child has a behavioral change you haven’t seen before, there may be an underlying medical or co-occurring mental disorder that’s causing ADHD symptoms… especially if they’re on ADHD-ADD medications which are not working well.

“It is vital not to mistake another medical or psychiatric condition as ADHD.”
Richa Bhatia, MD, Fellow of the American Psychiatric Association

The medical conditions listed below produce ADHD and/or ADD symptoms such as slow processing speed, impulsive behavior, and limited attention and focus.

  • Epileptic seizures: some types cause a brief freeze in thinking–the child’s brain goes blank for a few moments (“absence seizures”)
  • Diseases of the brain: Lyme disease, HIV infection, parasitic and viral infections, brain tumors
  • Brain damage from head injury or toxins (e.g. narcotics)
  • Chemotherapy side-effects, “stupor”
  • Hypothyroidism.  Too little thyroid hormone results in memory, attention, and concentration problems. It decreases blood flow in brain regions that mediate attention and executive functioning (the hippocampus and cerebral cortexes).
  • Hyperthyroidism. At the other extreme, too much thyroid hormone causes anxiety and tension, irritability and impatience, and hyperactivity and distraction.
  • Sleep apnea. A condition where a child stops breathing during sleep, for a few seconds to a few minutes several times per night.  The following day, the child can’t pay attention, remember, or follow a sequence of steps.  It also causes hyperactivity and belligerence.


Mental health disorders with ADHD-like symptoms:

Anxiety disorders are common to most other mental health conditions, and create problems with concentration.  The chronic stress from anxiety affects the brain regions responsible for memory and cognitive functions.   If a child does not have a history of ADHD symptoms, than significant and pervasive anxiety may be the cause of inattention and distraction.

Abuse or trauma. Difficulty concentrating is one of the core symptoms of post-traumatic stress disorder (PTSD), and recent abuse or trauma can cause agitation, restlessness, and behavioral disturbance—symptoms that mimic ADHD.

Depression – Difficulty concentrating also is a criterion for major depressive disorder.

Bipolar disorder – ADHD symptoms are apparent in children with suspected bipolar disorder. Both disorders can cause distractibility, increased energy, and instant mood swings. (Some children are eventually diagnosed with both disorders.)

Drug abuse using marijuana, cocaine, ecstasy, produce similar symptoms of ADHD because they affect the same brain regions affected by anxiety.  MRI scans of the brain were taken of young children who were exposed to cocaine in the womb. The scans revealed frontal lobe malformations which predicted long-term problems with attention and impulse control.

Common stimulant foods and beverages with excess caffeine or sugar

Insomnia from medical conditions. Sleep plays a huge role in memory and attention. Sleep disorders (e.g., sleep apnea, restless legs syndrome) can produce chronic tiredness and significantly reduce attention, concentration, and cognitive functioning in children, adolescents, and adults.

Plain old lack of sleep in healthy children can cause inattention and reduce academic achievement.  There are many causes of sleep loss:  early school hours; screen time at least an hour before bed (because the blue light suppresses sleepiness); or allowing the use of technology in the bedroom at nighttime.  What helps getting to sleep and staying asleep:

  • A cool, dark room
  • Thirty minutes of reading or drawing on paper before lights out.
  • Removing phones, laptops, or desktops from the bedroom at night.


Learning disorders:
Children with an undiagnosed learning disorder often present with ADHD symptoms. An undiagnosed reading or mathematics disorder (dyslexia), or an autism spectrum disorder that’s not yet diagnosed, can have a significant impact on classroom behavior.  The child might not be paying attention because of his (her) restricted ability to grasp the subject matter, or because they are frustrated and irritated with the struggle to keep up.

Caution:  Teachers often report a student’s inattention and confused thinking to parents, and suggest a diagnosis of ADHD when the real problem may be lack of sleep or something else.  It’s useful to hear classroom observations of your child, but teachers are not trained in mental health diagnosis—get a second opinion from a professional!

More on the consequences of untreated ADHD or another underlying disorder is in this article:  “ADHD kids become troubled adults.”

–Margaret


Subject matter was drawn from this article by psychiatrist Dr. Richa Bhatia.

“Rule out these causes of inattention before diagnosing ADHD”
Richa Bhatia, MD, FAPA, Current Psychiatry. 2016 October; 15(10):32-C3

How to pick the ideal therapy pet for your child or teen

How to pick the ideal therapy pet for your child or teen

“A pet is an island of sanity in what appears to be an insane world. Whether a dog, cat, bird, fish, turtle, or what have you, one can rely upon the fact that one’s pet will always remain a faithful, intimate, non-competitive friend, regardless of the good or ill fortune life brings us.”
–Boris Levinson, PsyD, Child Psychologist

Any animal can be a therapy pet, but put thought into finding the ideal pet

therapy catIt depends on your child’s individual needs and his or her innate appreciation of or connection with the creature.  Parents often think of furry animals like dogs or cats or “pocket pets” as the best therapy animals.  Dogs and cats are the most common, but they are not the only effective options.  (And some are problematic:  perhaps a family dog or cat is of no interest to your child, or is stressful because its behavior–easily agitated cats and chronically fussy dogs aren’t therapeutic!

What fascinates your child? What do they want–what creature(s) are they drawn to?  And are you willing to take care of this pet?  Your child’s therapy pet is not a lesson in responsibility… though that may be an outcome someday.  The pet is a therapist first, not a teaching tool.  Since you may be the responsible one, the pet must work for your needs and household too.

The right creature will reduce your child’s stress and continually delight them in some way.

Dogs and cats

Under the best circumstances, the right dog or cat will choose your child, calming them down or drawing them out of their shell. Dogs and cats are ideal for symptoms of anxiety, autism spectrum disorders, or depression. The right dog or cat is calm, loyal, and patient, and helps an insecure child or one who can’t handle emotional demands. Dogs also support physical exercise, and provide opportunities for significant life lessons.

True story – Some juvenile prison systems have dog programs, where the inmate is assigned a troubled shelter dog to train and teach appropriate dog behavior. Young inmates often empathize with a dog’s abuse history, and training the dog helps them learn patience, forbearance, and anger management.  The trained dogs are them adopted out to the community.  A program I personally know about has had very positive outcomes.

Pocket pets

Pocket pets help children who like touch, and bring out a child’s nurturing side. Small animals can also be playful and amusing–ferrets have especially silly antics.  It’s important the pet likes to be held, but it’s also important to prevent it from escaping and hiding. Their small size and habitat needs are better for small living spaces, and they can go anywhere with the child in a small carrier.  A concern may be their shorter lifespans. Is your child able to handle loss and learn from it?

Birds

Birds are smart ‘pocket pets’ and very loyal to the person they bond with.  A bird that’s purchased young or been hand-fed as a chick is tame and will readily perch on a child’s shoulder or finger… or happily hide out in a pocket.  Most birds can be taught words, whistles, or even songs in human language.  They are pretty, charming, highly interactive, and long-lived.  Birds are good for depressed children who need energy and stimulation, and children with ADHD who need attention and interaction.  Like a pocket pet, a bird can also travel with a child in a small carrier.

Reptiles

Reptiles aren’t often considered as therapy pets, but reptile lovers will tell you that they are indeed therapeutic and have inidividual personalities. Most are quite beautiful. Many like to be held and carried.

“She fell asleep in my shirt and nobody saw her. I noticed I was able to communicate with other people without problems. When I started to feel anxiety I put my hand over her and it calmed me downI was able to go in [a store], do what I needed to do and get out without a panic attack.”
–Teen with social anxiety disorder speaking about her Bearded Dragon.

Ask if a pet store will allow your child to hold one of their reptiles for sale.  Common pet store lizards that are good for children are:  leopard geckos, bearded dragons, and iguanas (which need lots of handling at first).  Like other small animals, reptiles can escape. Turtles are usually easy to find, but not lizards or snakes.  There are lizard leashes on the market for this reason.  Most snakes available on the market like to be held, or will accept it if handled often.

Fish

Beautiful calming aquariums are excellent sources of visual delight and serenity. There is a reason aquariums are placed in waiting rooms and in psychiatric hospital settings.  They provide gentle entrancing movement in a miniature natural world—they are healing like Nature is healing.  An aquarium is good for children with intense anxiety they can’t express, often with schizophrenic or autistic symptoms.  The soft bubbling sound can be calming because it is steady and hides noises that may overstimulate a child who’s grappling with a stream of upsetting thoughts.  Read more about “calming rooms” and how visual and audio environments help children with tantrums, “Calming room ideas to prevent tantrums in autism and other disorders.”

Insects (yes, insects)

I have two stories about therapy with insects

True story – A depressed 9-year-old boy was regularly teased at school, then came home to a single mother who was always too distracted by dating concerns to spend time with him. His father found a second wife and started a new family and showed little interest in him.  The boy was smart and very interested in science.  He befriended a neighbor who kept hissing cockroaches to feed her lizards, and he would visit often and ask to hold a roach and pet it to make it hiss.  The neighbor allowed the boy to borrow one to take to school for show-and-tell, which he brought along in a plastic container.  The students were both fearful and intensely curious about this giant roach.  Except for the squeamish, everyone wanted to pet it to make it hiss.  He became the coolest kid in class.  His teacher was impressed because he told the story about hissing cockroaches, where they were from, and how they were part of a forest ecosystem.  He stopped being teased, and his teacher gave him more attention with science studies… all thanks to a lowly roach.

True story – An 11–year-old boy with ADHD found a praying mantis in his backyard and picked it up. He knew from school it wouldn’t bite, and that it caught and ate other insects.  He wandered around nearby homes looking for bugs to feed it.  When he caught something, he enjoyed watching the mantis snatch the bug from his finger and eat it with gross crunching sounds and goo…. awesome for a kid like him. He was allowed to keep the mantis in an empty aquarium. As Nature has it, it died in the Fall. His parents, however, purchased mantis eggs from a nursery to populate the yard the next summer. When they hatched, the boy spent hours amusing himself by finding and feeding the baby mantis population,and watching them grow to adulthood.  It reduced the hours he’d spend indoors on video games,and connected him with nature outdoors.

 

–Margaret