Saturday, October 6, 2012

The Explosive Child Book Review

The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, "Chronically Inflexible" Children Ross W. Greene, Ph.D.




Dr. Greene’s book presents a crisis that affects far more lives and families than most care to admit or experience. When a parent is presented with the challenge of parenting a child for whom logical, well planned, widely approved and successful parenting methods prove worthless. Parenting this child leaves the family in a constant state of crisis. This is the type of child presented in this book; the child that is inflexible to the point of explosiveness, verbally and even physically aggressive, presenting a danger to the family’s well being.

Dr. Greene goes into detailed explanation for the neurobiological causes and implications of such disability. He breaks down the labels of many of the disorders, describing the various attributes these carry and the deficits they present that cause the appearance of what many term behavioral problems, difficult children, manipulative, demanding, stubborn, attention seeking, coercive and defiant. Simply put, flexibility and frustration tolerance are critical developmental skills that some children fail to develop normally.
Dr. Greene outlines the stages leading to an explosion. Initially, when met with a need for transition or response, the inflexible child will enter what he describes as vapor lock, they are having difficulty processing and transitioning to the newly presented situation or request. When we persist on compliance, the child reaches a crossroads phase where there is still a chance to respond to their frustration, allowing communication and resolution. At this point, if we continue to persist rather than use specific directed responses to deescalate the situation, then detonation occurs. At this point, it is very likely that people and objects within the vicinity of the exploding child will become attacked by verbal or physical means. This places the child, family and personal property in danger. Following an explosion, these children are usually extremely embarrassed, remorseful for their actions, some with little recall of what actually occurred except knowing that it was NOT good.
The approach presented by Dr. Greene to address this type of child is one of prioritization. He describes using what he calls the ‘Basket Method’ to minimize the explosive nature of the child, giving the child the ability to develop this skill. He recommends three ‘baskets’ of priorities. One, things you will not and cannot compromise. Two holds things that are very important but not necessarily worth fighting over and thirdly, things that are wished for but not worth a second mention, if mentioned at all.
Basket one is surprisingly empty; safety comes first. Safety of self, others and personal property. It is quite difficult to reduce this basket to so little but he insists this is absolutely necessary. He recommends the second basket include things such as personal hygiene, homework, and things the child is capable of doing and requires little encouragement. The final basket is overflowing; these items are normally a part of the average child’s everyday realm. The normal child does not have to be more than mildly encouraged on these matters but for the inflexible-explosive child, they are beyond attainment.
As the child becomes accustomed to the routine, is given opportunity to practice finding ways to talk about or vent frustrations through modification of parental approaches to vapor lock situations; the child is able to develop this skill, tolerating more instances that are important to both the parents and more mature lives.
Having practiced these methods with an inflexible-explosive child, I find that this theory works quite well. He really explains everything very clearly and uses the science behind it all to explain the ‘whys’ for our children’s behaviors. Practice of these techniques removes the ‘eggshell’ sensitivity that is present with unmanaged explosive children, allowing the family to move out of the constant state of crisis.

Copyright © October 2002 by Crackerjack

Discipline vs. Punishment for BP Kids

Discipline vs. Punnishment
Discipline for Bpers, this is a dilema that we all have to face in raising our kids. Personally, I think the answer lies in the details.
Think *responsibility* instead *fault*.
Your child is not at fault for having BP, nor for having symptoms. No one would ever say he was *at fault* for vomiting if he had the stomach flu, and BP rages are very often like "brain barf".
However, each of us is *responsible* for our actions. As an adult, if I get the flu, although I am not at *fault*, I am still the one cleaning up any mess that I may make. I am a grown up and I am *responsible* for my messes, whatever the cause. I am trying to teach my boys that they are *responsible* for their illness. Being *responsible* includes not only careful behavior even when having symptoms, it includes taking care of things when they blow it, and it includes getting adequate rest, eating right, and taking their meds.
Instead of *punishment* think *discipline* or *training*
Punishment is punitive, it means the child is "paying" for his/her mistakes, and that's not really fair if the cause of the behavior was an illness. Our kids already pay too high of a cost in lost friendships, lost time, lost joy. *Discipline* or training is focused teaching better responses for the next time the problem situation comes around.
No kid (or adult for that matter) is going to be able to understand, process, and learn from *discipline* in the middle of a BP rage. If you wait til after the episode to talk about the problem, discuss alternatives, discuss restitution, then they can actually process what you are saying, rather than get into a huge confrontation that is fruitless. Sometimes if the child is very unstable, even between rages they are not able to process the *discipline*. Sometimes you have to wait for the meds to kick in, and that can be months, but eventually that time will come and you can begin to *discipline* you child so he/she can handle it out there in the adult world.
I love Ross Greens approach in the book Explosive Child. because it gives a concrete way for a parent to put these ideas into practice. It's important to remember to use "B" basket, as well as "A" and "C" though... or else all you are doing is ignoring the bad behavior, and that does not equip the child for his/her future.
It's hard to get the schools and others to understand that the process of being responsible for their own behavior is harder for our kids than for many others, and that often in has to be broken down into smaller chunks so it is more managable for them. It's a challenge as a parent to keep going and not grow weary when progrss in measured in milimeters and there are still kilometers yet to go.
For kids who are more stable, the book Parenting with Love and Logic by Foster Cline and Jim Fay can be very helpful in teaching them to function inthe world, and also to help reduce the power struggles that can so easily develop with our kids.
Expressed Emotion is another important key in helping our kids. If we do not allow the illness to consume our lives and  do not become overly emotional at the conflicts, we provide a handhold to help our kids climb back into a "normal" life.

Curlywhirly (copyright 4/29/03)

Is it ADHD or Bipolar?

ADHD vs. Bipolar Symptoms

It can sometimes be a challenge to try to discover if your children are suffereing from Bipolar Disorder Symptoms or from ADHD symptoms. It is possible to tell the difference over time, and careful charting can help. Why Chart?
 

Cardinal Symptoms of Bipolar that are *not* present in children who have ADHD are:
  •  grandiosity
  •  elated mood
  •  daredevil acts
  •  flight of ideas
  •  racing thoughts
  •  hypersexuality
  •  decreased need for sleep
  • suicidality with plan or intent

Here is another articles that discuss the difference between these two disorders:

Tuesday, October 2, 2012

How To: Mood Charts

Mood Charts

This mood chart is in Microsoft Word format. If your computer does not have Word installed, you can download a free viewer at Word 97/2000 Viewer.
To use this chart you simply print it off (you may want to save it to your hard drive first) and then fill in the Name and Date at the top. Fill in each symptom that you wish to track in the blanks going down the left hand side of the page (use the same symptoms every day) and at the end of the day rate the symptom on a scale of 0 to +5. Some possible symptoms would be mania, depression, aggression, anxiety or lethergy. There is plenty of space to note events on the chart that could be relevant, such as disturbed sleep, missed medication, or unusual or relevant comments the person has made.
If depression is a symptom you are tracking, marking +5 would indicate that the person was totally despondant and likely suicidal, a +2 would mean the person was down but somewhat functional, and a 0 would mean no depression.
These charts can be filled out as frequently as desired. You can fill them out every hour to catch rapid cycling, or once a day, or however you need to in order to get an accurate picture of what you are seeing in the symptoms. After compiling charts for some times (a day, a week or month etc.) if you wish you can then take graph paper and plot the ratings and make a graphic chart that can reaveal cycling and other clues not otherwise easily recognzable.
Please feel free to modify these charts to fit your need.
Curlywhirly's Mood Chart1
This second chart is similar to the first, but has a rating scale of -5 to +5 which is handy for charting such symptoms as mania (+5) vs. depression (-5) or high energy (+5) vs. lethergy (-5).
Curlywhirly's Mood Chart2 

Other Charts:

Massachusettes General Hospital Bipolar Clinic

Psychiatry24/7.com Mood Charts

Why Charting?

Why is charting beneficial for kids with Bipolar?
  • Easier to recognize when a specific medication is helping or making things worse. Through careful examination of the charts parents and doctors are able to pick up the first subtle clues of a problem brewing and connect it to starting or discontinue a med and make adjustments as needed.
  • Children and teens can begin to fill out their own charts and see their own patterns so they become more able to manage their illness. It can help them to begin to describe their feelings, to see the beginnings of problems, and to quantify feelings and symptoms. Those are all valuable handling difficult situations skills our kids will need as adults managing their own illness.
  • Charts graphically depict the cycling over time which can help the doctor with a treatment plan as well as the family planning (not a good idea to take a vacation during a time of year when commonly manic, for example).
  • Progress, however minute, can be seen when charts are kept over a longer period of time.
The method is less important than the ease of use and sticking to it long term. Charting provides a gold mine of information and tools to help beat the beast and get our kids lives back. Mood Charting is a skill every family of a Bipolar child needs to know, and every Bipolar child needs to learn for themselves.

Unwanted Advice

How do I handle all the unwanted parenting advice?

Let's face it, we've all been in an embarrassing situation where our children are raging or otherwise being symptomatic in public, only to have the situation compounded by some well meaning stranger that feels they have the answer to cure your problem child. Or worse, tell you what a horrible parent you are. What do you do?
There are a number of ways to handle these situations. Some things that parents have used include boundary setting statements, surprise tactics, ignoring the person, educating through a few short statements or a flyer/business card with critical information.
Boundary setting statements
"Just why do you feel you need to share that?"
"That would be your opinion, I'm sorry you feel that way."
The silent stare
"Today I'm here to purchase groceries. Thank you, but I do not care for any advice."
"I'm sure you mean well but I did not ask for advice."
"My child is under the care of a qualified physician and I am following his prescribed treatment plan."
Surprise tactics
"Well, I would never have thought of that, thank you so much!"
"You know how to fix him? That's wonderful! I appreciate your offer to take him for me. I sure need a break." (said with relief and excitement)
"I'm so glad to finally find someone who knows how to fix my child. I've been searching for years now!"
"Do you have any research studies to validate your claims?"
Ignoring
Simply pretend you don't hear or see them
Walk away while they are talking
Educating
"My child has a neurobiological brain disorder called Bipolar, this causes electrical 'storms' in his brain and results in this type of reaction."
"My child has an illness. To learn more about it you can visit (url or support group like NAMI)."
Business cards or flyers with information
A website url with information on PBPD
"My child has PBPD, thank you for understanding"
"Caring for my child's illness is very difficult, thank you for your understanding."
Sometimes one method of handling these intrusions is easier than another. Some days we just don't want to educate. Some days we have had it up to 'there' and the surprise tactics are more to our preferences and let off a little bit of steam in the process. It can be helpful to be familiar with more than one type of response. Choose what you are comfortable with. You may wish to rehearse some statements to become comfortable and familiar with them so they are easy to recall during that critical high stress moment.
Crackerjack (copyright 1/30/04)

Monday, October 1, 2012

Three Rules for Effective Medication Use for Ped Bipolar


There are 3 big rules that most experts recommend for using psych medications effectively.
 

  • Start low and go slow. Start low and go slow means to start with a very small dose of a medication and titrate up slowly to avoid un-necessary side effects.

     
  • Maximize each medication before adding another. Push doses to the max before discarding it as a failed med trial. Some people metabolize medications more quickly than others and even small changes can make a huge difference in weather the med works or not.

     
  • One change at a time. If you change more than one thing at a time you'll never be able to tell cause and effect if a med is helping or causing more problems. Make sure to allow enough time for improvements to manifest themselves. Some meds can take up to 8 weeks to show improvement and there are case reports of a first response to Lithium after two years of treatment.

Kindling Theory in BP


Kindling Theory is the idea that one episode of unstable mood paves the way for more frequent and more severe episodes in the future. Kindling theory originally was related to epilepsy and the idea that seizures got more severe and frequent over time, and then observation seemed to indicate it was also a feature of Bipolar.
 Features associated with the delayed initiation of mood stabilizers at illness onset in bipolar disorder.Goldberg JF, Ernst CL. discusses how delaying treament for Bipolar symptoms can mean a worse outcome for treament. However, not everyone is sure that the Kindling Model is acurate. At this time, the only way I see to prove or disprove this fascinating theory is a large (very large) and very long study that follows a group of Bipolars for many years to see the outcome.

How to prevent kindling? Proper and timely diagnosis and appropriate treatment with medications that are effective is the only way to prevent kindling.
More articles on Kindling:

Frequently Asked Questions About Pediatric Bipolar Disorders

What Is Pediatric Bipolar Disorder? 
Bipolar Disorder is a neurobiological brain disorder. It was formerly called manic-depression. Until about 20 years ago, most doctors did not believe children could have Bipolar, and this is still an issue of some controversy. However, as more research is done and the information from that research is distributed, more and more doctors are becoming familiar with Pediatric Bipolar Disorder. Pediatric Bipolar is also known as EOBP (Early Onset Bipolar) and COBP (Childhood Onset Bipolar).
How Is It Different Than Adult Bipolar?
Pediatric Bipolar starts in childhood or infancy, whereas adult Bipolar can have an onset at any age, most commonly early 20s and 30s. Because Pediatric Bipolar has only recently come to the attention of clinicians and researchers, they are not entirely sure what will happen with a child who has BP... what they will be like as adults. "Classic" symptoms of Bipolar such as running up credit card debt do not apply, since most kids don't have credit cards. The symptoms express themselves in more age appropriate ways, such as insatiable urges to buy gifts for other people or other impulsive money handling. Also another possible expression of this would be the compulsive collection of every receipt, every paper, every bottle cap, every piece of trash. Many researchers believe that Pediatric Bipolar is a more severe form of illness than adult onset Bipolar
Where Does Pediatric Bipolar Disorder Come From?
Good Question! Geneticists have found many genes that have some effect on Bipolar and Schizophrenia, and there may be more yet undiscovered. It appears there is a genetic predisposition to Bipolar, yet some go on to develop the disease, and others do not. Stress and Other environmental factors also play a part, and can trigger onset or episodes, but the exact nature of the relationship to environment and genetics is yet to be defined. This is NOT to say Pediatric Bipolar is a parenting problem! It is a medical problem much like diabetes, with genetic and environmental factors which are not yet fully understood.
How Is Pediatric Bipolar Disorder Treated?
Bipolar Disorder is treated through the use of medications and environmental interventions. Medication is the first line of defense. Stress reduction is important, as is learning to recognize and manage symptoms appropriately, and therapy can at times be an asset. Each individual treatment won't work for everyone, so it's a process of trial and error to find what works for each person. Because there is still so much to learn about how and why Bipolar develops, there is no one "right answer" for treatment. Treatment guidelines can help decide the next best course of treatment. What's right is what works for your child.
How Can You Tell Pediatric Bipolar from Other Physical or Mental Illnesses?
It really takes a skilled practitioner and usually observation over time to make a firm diagnosis. Symptoms often develop over time, and it may be impossible to have a "firm" diagnosis for a child, but a working diagnosis can be developed and the child can be treated to improve quality of life. There is a significant body of research about the Kindling Theory that indicates that the more episodes a person has that are unchecked by interventions or treatment, the more difficult it is to treat.
Where Can I Find A Good Doctor?
It has been our experience that the best psychiatric evaluations for children and teens are usually found at major teaching universities.
Will My Child Get Well?
Of all the questions, this is the one for which  we wish we had a definitive answer, but unfortunately, we do not.  There are a portion of children and adults with Bipolar who do not respond to medication or environmental interventions enough to live the life they were expecting before the onset of symptoms or diagnosis. Many of these children do respond enough to be better, if not well. There is no cure yet for Bipolar, but most everyone can be helped to some degree. There is also new research all the time, and soon we may have a cure or at least more effective treatments  that help everyone not just some.

Crackerjack, Curlywhirly and Wickedpenmeister (2003)(2004)