Defiant Johnny

“Johnny is oppositional and defiant! He doesn’t listen… and when you tell him “no” or to do something, he explodes… he screams, hits, kicks… he used to bite… but now he generally just throws things and yells at me. We’ve been at this since he could walk (unspoken: “… and we are very tired”). I can’t even leave him at school (the respite center for most parents)… they call a couple times each week with more complaints… he doesn’t stay in his seat, he doesn’t listen, he hits other kids… plays too rough on the playground. He saw a couple counselors but nothing helps.” This scenario, in various terms by various parents, plays out during the initial screening about 200-300 times each year in our clinic (from among 400 referrals). Interesting (to us), but frustrating to the parents, Johnny sits stoically during the recitation of his “crimes” with nary a complaint nor hint of the symptoms that are tearing this parent (and usually family) apart. Occasionally a parent may go so far as to prod the child into a negative response simply to show that they (the parent) are not lying. Other parents support their argument with a recitation of the teachers, service providers, family, etc. that have been ravaged by their child’s behaviors and concluded the ominous diagnostic verdict, “Your child has oppositional defiant disorder.”

A child who is oppositional and defiant has “oppositional defiant disorder?!?” As professionals, we may need to guard the diagnostic secret that all we do is say “disorder” after the child’s symptoms! Given this line of reasoning, secondary diagnoses for this child could include “scream disorder and kick disorder.” Labeling the child’s symptoms as “oppositional defiant” does not advance understanding of the etiology of symptoms nor potential treatment avenues. Unfortunately, this scenario plays out millions of times each day for children across the country with similar conclusions. The primary cost of this labeling approach to diagnoses is that it tends to result in termination of the search for the underlying etiology or cause for the presenting symptoms. The solution… complete an evaluation or assessment to search for factors that may contribute to the symptoms.

Existing research irrespective of diagnosis indicates that outcomes are related to three factors including: (1) abilities (ie., “hardware” or central nervous system-based processing capacities), (2) skills (ie., acquired responses based on the environment including academic skills, daily living skills, social skills, etc.) and (3) coping resources (ie., “software” packages written by a child in response to the world in which they live). Given this background, a logical extension is that failures of positive outcome (ie., oppositional defiant behaviors) must similarly be related to limitations or deficits related to abilities, skills and coping resources.

What about Johnny? Test results showed strengths across measures of verbal (language), perceptual-motor, learning/memory and higher level reasoning abilities. In contrast, deficits were observed across measures of lower level executive or “conductor” functions including: (a) inhibition (b) rhythm/background tone and (c) “select” (ie., multi-tasking, shifting mental sets, etc.) functions. Deficits in inhibition (or disinhibition) were reflected across external stimuli (ie., short attention span, distractible, etc.), motor responses (ie., hyperactive, hurried, fidgeting, messy, etc.), behavior (ie., rule violations), mood/emotions (ie., irritable, anger, temper tantrums, etc.) and arousal level (ie., difficulties falling asleep, constant motion, broken sleep, etc.). Poor rhythm/background tone was reflected in low frustration tolerance and difficulties adapting to change. Deficient “select” functions were reflected in difficulties with respect to multi-tasking (ie., performing two tasks at once or in rapid/alternating succession) with a high frequency of off-task behaviors (ie., failure to complete assignments, requirements for re-direction and difficulties completing assignments on time). The conclusion…. Johnny’s collection of symptoms/problems (his “ODD”) was related to a breakdown in abilities that warranted a similarly biologically-based (central nervous system) intervention program foundation. Research suggests that an estimated 90% of children with this profile (who also meet ADHD criteria) show benefits to psychostimulant medications.

Mustard Seeds and the Two Poles

“My ten-year old son has dramatic mood swings. He can be happy one minute and another minute, he’s in a rage for no apparent reason.”

“What sets him off?”

“Mustard seeds.” (I love this one… an actual quote).

“He is irritable all the time, overly aggressive with his peers at school and defiant (ie. yells, curses at parents, etc.) to the point of belligerence towards us. We went to see a professional (ie. physician, psychiatrist, psychologist, etc.) who said that he has bi-polar disorder!! We’re terrified. Does this mean that he will have this the rest of his life?”

Bi-polar disorder implies that a child has two (bi) (polar) opposite emotions or behaviors with some implication that transitions from one pole (depression) to other pole (anger, mania, etc.) may occur rather abruptly and with minimal (mustard seeds) or no apparent cause. Does your child present with features of “bi-polar”? The answer is “yes” and most likely your child would meet the diagnostic criteria for bi-polar disorder. But, this diagnosis is a symptom-based diagnosis, it refers to a cluster of symptoms (such as “headache”) and does not actually have a defined etiology or cause (such as “trigeminal neuralgia, cervical neck strain, brain tumor”, etc.).

Does he have bi-polar disorder? Hmmmm… From a process perspective, bi-polar disorder symptoms may be related to the presence of primitive limbic system-driven “fight or flight” activation (ie., gas pedal for emotions, drives, instincts, etc.) that is not adequately or effectively modulated by higher level frontal lobe inhibitory systems (ie., brakes, social rules, etc.). In other words, symptoms of bi-polar disorder are related to limbic system activation and/or frontal lobe dysfunction.

• Limbic system activation may be causally related to biological/genetic factors (possibly “true” bi-polar disorder with a higher state of background arousal) or in response to environmental factors including trauma, unmet needs for safety or security, abuse, neglect, etc. (possibly post-traumatic stress disorder).
  
• Frontal lobe dysfunction may be related to biological/genetic factors with associated failure to establish limbic-frontal lobe subcortical connections (possibly Fragile-X syndrome, Asperger’s Syndrome, prematurity, etc.) or environmental factors including neglect, deprivation, etc. (possibly Reactive Attachment Disorder).

The solution?, consider completion of a comprehensive evaluation that may facilitate identification of etiological factors contributing to your child’s symptoms/problems so that subsequent treatment interventions may focus on treating the cause, not medical management of superficial symptoms!

My Lazy Kid

“Teachers have been telling me that my child is lazy and that if only she just worked harder, was more motivated, etc., then she could do very well. We have responded by setting aside daily study times, requiring her to complete all homework before going out to play, providing her with stars for success, taking away all video games and grounding her for poor grades. Our interventions have resulted in study times that take all night, angry outbursts, depression (“I just wish I was dead”), loss of friends, no free time and… poor grades. Help!” The parent saying these words generally looks the part of the beleaguered parent with the wear and tear of endless nights of battles over homework and being the target of child anger being etched in their face.

Hmmm….. First, a quiz. Which would be easier? To put in forty-five minutes of study time, go out and play, be the recipient of parental praise and have extended free time… or… take four hours to complete a homework assignment while having your parents relentlessly harass you, lose privileges, have your videogames taken away, lose friends and have no free time to play? I’m thinking that it would be much easier to just do the work in the shortest amount of time and receive the benefits… and so would every child. Present to each child in school (through about age 12 years) a request that “Who ever wants an “A” in all their classes for this year, just raise your hand” and you will see 100% compliance or agreement. If the ante was raised slightly, “Who ever wants an “A” in all their classes for this year, raise your hand and walk around the track one time (400 meters)” and you may see a slight reduction in compliance. How about “Raise your hand, walk around the track one time and run the 100 yard dash in under 11 seconds” and you will begin to lose some more hands.

The point?…. everyone wants success, but at some point the child may not have the tools to achieve that success. For the child that is working four hours while screaming and crying, losing privileges and enduring parental harassment, these conditions are obviously more readily available than success by studying 45 minutes. I see about 350 children each year… and during the past 20 years, I believe that I have seen about three “lazy” children (and each of these were adolescents with psychopathic features). The rest? The rest were children with undiagnosed learning disorders that have variously included deficits in attention, visual-spatial processing, visual-motor integration, auditory processing disorders… or children that were the victims of significant life stressors, neglect, deprivation, etc. that undermined their capacity to translate abilities into “real world” performance on a consistent basis.

Your child has been labeled “lazy”? Consider the probability that your child has an undiagnosed learning disorder or other stress-related disorder. The solution… consider having a formal evaluation completed to rule out this potential.

Generic Treatment - Sex Offenders are not all Created Equal

I just finished reading a March 6, 2007 New York Times article on adult sex offenders that indicates dismal outcomes (high recidivism or repeat offending) among individuals who participate in sex offender programs. The article appears to relate this failure (in part) to our failure to complete research on treatment programs and effective interventions (when I thought that the major cause of sex offending was due to the presence of perpetrators). Sometimes I feel like a broken record... but my belief is that one of the major problems in the area of sex offender treatment programs is that the programs tend to treat "sex offenders" using "programs". There is not a thing that is a "sex offender"... only individuals who engage in sexually inappropriate behaviors... and a as a result, any “program” that treats sex offenders is bound to be associated with limited results.

About twenty years ago, I had the wonderful opportunity to experience and be mentored by Dr. Jan van Eys in the Dept. of Pediatrics at M.D. Anderson Hospital and Tumor Institute (who mentored everyone who had the good fortune to be near him). During one of our discussions, he indicated that existing treatments for ALL (acute lymphocytic leukemia) were not 60% effective (which is what I recall the literature stated at that time), but that the existing treatment was probably 100% effective for 60% of the children and 0% effective among 40% of the children. Wow… the thought changed my life. The task in cancer treatment… like ADHD treatment… like sex offender interventions… is to learn to identify those individuals who benefit from specific treatments and to develop alternative interventions among individuals who do not respond to specific treatments. The critical factor to this type of undertaking? …perform evaluations that provide data to allow us to differentiate among responders and non-responders for treatment.

My experience with child & adolescent sex offenders has really been enlightening, maybe 30-40% (I'm making up these numbers... but an estimate) are Asperger's Syndrome / Nonverbal Learning Disabled adolescent males who are unable to engage peers in social (or sexual) relationships and, as a result, tend to drop down to engage with younger children (i.e. the 16 year-old Asperger's male who cannot "get" the 16 year-old girl and drops down to engage with 10-12 year old females and proceeds to act out 16 year old sexual behaviors with a 10-12 year old female); another 20-30% may be low IQ - low frontal lobe processing - very disorganized, poor planning, failure to perceive consequences of actions, failure to identify with the victim or see the world from the perspective of others and violations of social rules/norms in the service of personal needs/wants and as a result act out more primitive drives; maybe 30-40% have a history of early sexual experiences and abuse that results in early sexualization, sort of like they "taste" sexual experiences/pleasures before they are in a position to appropriately channel it, they often attach sexual drives to children (since they were sexualized as a child) and subsequently as they become older repeat the attachment. They also tend to internalize or identify with their perpetrators and act out the sexual abuse they experienced. For another maybe 10%, sexual offending is about dominance, same-sex offending to dominate other males. This group tends to have high scores on the Psychopathy Checklist - YV. Generally "scary" to the community… repeat offenders who will use other means of domination including bullying, aggression, threats, etc. While I recognize that children / adolescents who are sexual predators have a high rate of exposure to sexual abuse, this exposure does not affect each child the same. Some become sexual offenders (maybe if they have other risk factors like Asperger's Syndrome, limited frontal lobe processing, etc.) some do not.

I’m not sure about the percentages (above), but in our practice, we have some prototypes that we tend to see as recurring and the interesting fact is that each group (and each child) is different and requires an equally individualized treatment plan that addresses their specific needs. I don't mean to criticize others for classification of all sex offenders in one group, and then embark on my own classification that simply has several groups, but I thought I would share some of my experiences & perceptions (since if I reviewed each individual child that we have seen, this blog would be even more cumbersome than I already have made it). Anyway, I feel like we embark on interventions, treatments or programs for individual children & adolescents before we have completed the evaluation to identify the cause…and the result?… catch the NY Times article… read your own local papers…

Pharmaceutical Guinea Pigs

You enter your physician’s office… once again you are greeted by a smiling nurse that escorts you quickly into an examination room where moments later the physician enters the room. She nods pleasantly and greets you with a smile. You inform her that you are experiencing abdominal pain. The smile does not leave her face as she begins to write vigorously on a prescription pad. After a few minutes, you are greeted with the product of her efforts…. a prescription for gall bladder surgery. You gulp… “Surgery???” you ask imploring a different response, “… but how do you know?… couldn’t it be something different?” Your physician smiles and unveils the explanation, “We have found that statistically speaking, the highest base rate disorder to account for your somatic distress is a gall bladder problem and the definitive treatment for gall bladder problems is surgery… so we’ll do the surgery first… if you still have the symptoms one month after surgery, then we may consider doing some testing.” Ludicrous?!? I hope you are nodding “yes”.

Unfortunately, many parents who present their children to professionals (physicians, psychologists, etc.) with symptoms of inattention and hyperactivity receive psychostimulant therapy since statistically speaking it is the most common childhood disorder associated with inattention and the definitive treatment for inattention is psychostimulants. The parents are subsequently informed that if the child fails the psychostimulant trial (ie., meaning the child develops insomnia, crying spells, shakiness, emotional lability, tremors, tics, etc.), then an evaluation may be considered. Ludicrous?!?! I hope you are still nodding. Managed care organizations (HMO) and insurance carriers support this approach by encouraging treatment of children but denying or limiting insurance coverage for evaluations. In other words, you (the consumer) are actually paying for and supporting the strategy of using medications to rule out or rule in a diagnosis. While the American Medical Association and its various branches decry this strategy, the reality is that medications, and psychostimulants in particular, are commonly used as a tool in diagnosing attention deficit and attention deficit hyperactivity disorders (ie. “Let’s give this a try… if its ADD/ADHD, then the medication will work…”). The Solution… ask “…and what will happen if it does not work?… adverse symptoms? delays in treatment? child perceptions of being a guinea pig. Parents need to be empowered to say “no” to medical testing on their children and request evaluations prior to treatment.

Hmmm… let’s open up the skull and see if there is a tumor or just nothing.