Archive for the ‘ Questions ’ Category

Should Disruptive Mood Dysregulation Disorder Be In DSM-5?

Wednesday, May 29th, 2013

The biggest controversies that arise in diagnostic systems – like DSM-5 – come about when a previous diagnosis category is eliminated (as is the case with Asperger’s Disorder) or a new one is introduced. Such is the case with the new disorder Disruptive Mood Dysregulation Disorder (DMDD). Part of the rationale for including it was to prevent inappropriate use of a diagnosis of pediatric bipolar disorder. But that’s not a strong enough rationale to introduce a whole new diagnosis. So … should it be in the DSM-5? 

The answer is no. Here’s why.

The idea of the DSM is to represent not just current clinical thinking but sufficient evidence to support a diagnostic category. This process is already murky because DSM-5 operates by defining a disorder as a collection of symptoms. While this is necessary when known causes – and gold standard methods for identifying a disorder – are not available, we typically rely on a number of carefully designed studies that support diagnostic criteria. Simply put, that is what is lacking right now with respect to DMDD.

We are just starting see research studies that evaluate the utility of the diagnosis of DMDD. At best, they highlight the complexities involved in sorting through whether or not DMDD offers unique insight into the developmental profile of a specific subset of children who could profit from intervention.

And that’s the point. This research is important and will continue. But until it yields more clear guidelines – which will take some time – it’s just not time to include it in DSM-5. There is concern that kids with extreme temperamental traits – like those who are prone to tantrums – will get inappropriately labeled. It may be that many kids who will get the DMDD diagnosis can be better captured by other disorders with similar symptom profiles (like oppositional defiant disorder). Until we have better trials to evaluate these issues DMDD should not be in the manual. That’s how clinical science is supposed to work.

Question Mark via Shutterstock.com

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ADHD in the DSM-5 Era

Friday, May 24th, 2013

The new diagnostic criteria for ADHD in DSM-5 flag issues that deserve attention if you are a parent. These include:

1) Age doesn’t matter as much. In prior versions of the DSM, ADHD was represented as a disorder which starts in childhood – an onset prior to age 7 had to be established to make a diagnosis. This has changed – the age of onset has been extended to before 12 years of age. So parents should be aware that ADHD symptoms may now  be detected later in childhood. And parents too may be more likely to be diagnosed themselves, as the new criteria make it easier to recognize ADHD in adults.

2) Age does matter though. While it is legitimate to say that children, teens, and adults all can show symptoms of ADHD, applying the criteria to the different age groups requires much clinical skill. Keep in mind that the proper use of DSM-5 requires this. For example, a clinician must apply the same criteria to a 5-year-old, a 10-year-old, and a 15-year old. The symptoms of ADHD reflect behaviors that can be shown by any child – it’s typically the frequency of these behaviors (they occur much more often as compared to what’s expected developmentally), the pervasiveness of the behaviors (you see them at home and in school), and the consequences of the behaviors (e.g., a kid is having difficulties keeping up with school work, is getting in trouble in school). A clinician needs to have a reference point for each age in their head in order to properly apply the DSM-5 criteria. This means that they should have very solid training in developmental science as part of their overall expertise. This is particularly true given the controversies about diagnosing and treating ADHD in preschoolers.

3) Be careful who applies the criteria. The DSM series (we are now on the 5th edition) is a guidebook for clinicians. It represents current thinking on the most telling signs of a disorder. It does not say anything about how the information should be collected to come to a clinical decision. So, you need to beware of anyone who doesn’t do a full, comprehensive evaluation that includes observations of the child, interviews with the child, much discussion with parents, acquiring lots of information from parents via questionnaires, collecting information from teachers and school personnel, and ideally a range of tests (including neuropsychological exams) that can consider alternative issues (like underlying learning disorders). This kind of evaluation is required to prevent overdiagnosis of ADHD, which may be rampant these days.

4) DSM-5 does not dictate what treatment will work best. DSM-5 is designed to facilitate the diagnostic process. It does not dictate the treatment strategy. A diagnosis of ADHD does not mean that a child necessarily needs Ritalin or other similar medications to control the symptoms. That’s a whole different discussion with a clinician who is trained to consider a range of treatment strategies. It is always wise to consider first behavioral treatments for ADHD and determine, after a sufficient amount of time, how much improvement can be gained by them before thinking about medication. Do not believe a practitioner who only endorses medication after a diagnosis is made.

The bottom line is the the DSM-5 is not intended to be used in a simplistic way to quickly diagnose ADHD and immediately promote medication. It is a tool that helps clinicians come to a determination of where a child is at developmentally with respect to ADHD. This is a complex process that requires lots of clinical insight. Having DSM-5 in hand doesn’t change that.

ADHD via Shutterstock.com

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DSM-5: Why (and What) Parents Should Know About It

Tuesday, May 21st, 2013

As a parent, you may be wondering why such a fuss is being made about the release of the DSM-5 (the 5th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association). Here is a brief overview of why it may be (0r become) relevant to you – and why it’s important to learn about the issues that are being debated.

Many Kids Will Experience A Mental Disorder

The primary reason parents need to know about DSM-5 is that many psychiatric disorders that originate in childhood are not uncommon. Consider some rough numbers:

  • Around 1 in 50 kids are being diagnosed with Autism Spectrum Disorder
  • Around 1 in 10 kids are being diagnosed with Attention Deficit Hyperactivity Disorder
  • Around 1 in 10 kids are being diagnosed with Conduct Disorder
  • Around 1 in 10 kids are being diagnosed  with an Anxiety Disorder
  • Around 1 in 10 kids are being diagnosed with a Mood Disorder
  • Around 1 in 2 teens have reported meeting diagnostic criteria for at least 1 disorder in their lifetime

Having a good look at these numbers means that lots of parents will be faced at some point in time with the possibility of having their child evaluated for a disorder – and will need to consider treatment options. That’s where the DSM-5 comes in.

DSM-5 Is The Primary Guide For Clinical Diagnosis

The DSM-5 is the handbook used by a broad range of health care professionals who evaluate individuals (youth and adults) for potential psychiatric disorders. It’s an authoritative guide that reflects a consensus statement on the best way to categorize disorders along with the specific symptoms and rules to be used to make a diagnosis. The intention is to make it reflect current clinical thinking that is supported by research. It is not perfect, it reflects a particular point of view by those charged with generating the guidelines, and there is much debate (and criticism) of the diagnostic approach taken by the DSM-5.

All that said, the fact remains that the DSM-5 will be used if you bring your child to a health care professional for evaluation. The clinician will consider lots of information during this process – the DSM-5 does not dictate what information they use and how they get it. It’s intended to serve as a guide to the endpoint of making (or not making) a diagnosis. And it serves as the template for a health care provider to request reimbursement from insurance companies to support treatment.

Why All The Controversy Now?

The DSM-5 is a revision of the prior version which was released in 2000. As such, it includes a number of changes – some of which are minor, some of which are major. Beyond the more general discussions about what’s “normal” and what isn’t, the key things that parents need to know are the practical implications of the changes. As a parent, you should be aware of the changes to disorders that are especially relevant for youth. Here’s a brief overview:

Autism Spectrum Disorder: Major changes have occurred. In the prior version, a spectrum of disorders were available to clinicians, reflecting important variations in symptom profile. Four disorders were listed: Autistic Disorder, Asperger’s Disorder, Childhood Disintegration Disorder, and Pervasive Developmental Disorder Not Otherwise Specified. The key change is that there is now just one diagnosis made of Autism Spectrum Disorder (ASD) – and the other diagnostic categories will no longer be used. Proponents of this change suggest that it is more accurate by defining the core features of ASD that were common to all of the disorders in the spectrum and allowing for differences in severity level under one diagnostic umbrella. Critics suggest that a number of youth who require diagnosis and treatment will not be diagnosed – and that the reliance on severity levels may make it harder for kids with more mild symptoms to receive treatments they need. There’s no answer to these issues yet – they will unfold over time as data are collected. But if your child is evaluated for ASD, it’s in your best interests to be up on the debates and have informed discussions with your clinician in order to make sure you are advocating for the best care for your child.

Attention Deficit Hyperactivity Disorder (ADHD): Minor changes have occurred. In the past, there had to be evidence that a child showed symptoms of ADHD before age 7. That has been extended to age 12 in the DSM-5. There is also more attention to making diagnoses in adults more manageable. All of these changes mean that if you have an older child who has never been diagnosed with ADHD, they might now be evaluated differently. It’s also important to know what isn’t in the DSM-5 – a lower limit on age. That is, there are no guidelines in terms of how young a child may be when making a diagnosis. This is relevant as there have been (controversial) suggestions that kids as young as 4 years of age could be diagnosed (and many in fact have). Know that DSM-5 does not offer guidance here and you will need to make up your own mind if this makes sense for your child –  hopefully with the appropriate guidance of a well-trained clinician. Overall, the worry here is that kids of all ages may be overdiagnosed.

Conduct Disorder (CD): Minor changes have occurred. Conduct disorder represents a persistent pattern of rule breaking behavior and behavior that violates the rights of others. It can be diagnosed in young children as well as teens. The primary change has been to incorporate symptoms indicating a callous and unemotional interpersonal style. The thinking here is kids with this profile may be especially prone to experience problems in the future – and require more intensive management and treatment. Be aware that these symptoms will receive more attention now in the diagnostic process.

Disruptive Mood Dysregulation Disorder (DMDD): This diagnosis reflects a major change – it is a new diagnostic category. The idea was to provide a diagnostic option for kids who show persistent irritability and extreme emotional and behavioral outbursts. The rationale for developing the DMDD criteria was to make sure kids who show these symptoms do not get mislabeled as having pediatric bipolar disorder – but still may qualify for treatment. The controversy is that many feel that there is not sufficient evidence to support this new diagnosis – and in the worst case scenario kids who do not have psychiatric problems will be diagnosed with a disorder and get treatment that they don’t need.

Over the next few days, I will publish blog posts that consider each of these four disorders in greater detail, and provide some guidance for parents to help sort through these complex issues. There are no straightforward answers to be found – rather parents need to know about DSM-5 so they can be prepared to navigate the best decisions for their child.

 

 

 

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Why Playfulness Is More Important Than Play

Thursday, May 9th, 2013

We all know that it is critical for kids of all ages to play. And we know that play can take many forms. But there’s a deeper idea about the importance for kids to learn how to be playful – and how that spirit should permeate their development.

Such is the advice given by Steve Gross, Executive Director – and Chief Playmaker – of The Life is good Playmakers, the action arm of The Life is good Kids Foundation, a nonprofit organization established by Life is good to raise money to help kids in need. Life is good is a company with a positive purpose and is committed to spreading the power of optimism and donating 10% of its net profits to helping kids in need through The Life is good Kids Foundation.

Steve Gross, Chief Playmaker, Life is good Playmakers

The Life is good Kids Foundation directly funds the Life is good Playmakers program. The Life is good Playmakers provide training and support to childcare professionals, who use these tools to ensure that children grow up feeling safe, loved and joyful.

Steve certainly champions the essential nature of play in a kid’s life  (“Children need food and water to survive, but to truly live, they’ve gotta play”). But he points out that we often get the message that play happens in a designated time and space and includes specific activities – which means much of the time we don’t harness the power of playfulness in the majority of moments in a kid’s everyday life. He suggests that we want kids to develop the trait of playfulness as a style they bring to everything they do. Steve defines playfulness as “the motivation to freely and joyfully engage with, connect with, and explore the surrounding world.” It’s an attitude, and a style, that provides a cognitive and emotional platform for kids to embrace themselves and fuel for them to bring themselves to the world in a positive way.

Four ingredients make up Steve’s recipe for playfulness:

AFFECT: Kids need to experience joyfulness in their everyday moments – not just the time that’s “reserved” for play. Most of the opportunities for “play” happen in real time. Steve gives a wonderful example of how getting a kid ready to go to play is an ideal time to promote joyfulness – and also a moment that often turns in the other direction for parents. Rather than getting stressed about making sure a toddler has their shoes on and their coat ready, how about treating THAT time as the time to get silly and experience joy and anticipation. It may be even more fun than when you actually get outside to “play.” It’s these little moments that define the affective climate for a child – and bringing anticipation, lightness, joy, and overt silliness to the everyday tasks infuses a kid with a playful spirit that makes most of the day feel like play rather than the other way around.

SOCIAL CONNECTION: Interacting with people is play. It’s as important – if not more important – that your kid is looking at you and seeing you laugh and smile and express joy when you are playing than being engaged in the play itself. Think about all the moments you have to simply talk to your kid – especially babies and toddlers. Don’t underestimate how fun and rewarding (at a very deep level) it is for your kid to explore your face and your emotions and your tone of voice. It’s a constant stream of engaging content for them that they could never find in a toy or a device. So Steve proposes that treating the everyday interaction moments as opportunities to cultivate joyfulness helps a kid discover the power of social connection.

INTERNAL CONTROL: Steve suggests that kids need to feel like they are in control of themselves, and that the world is a safe place for them. They need to feel like they can explore without fear of bad consequences. Sure, you need to keep your kid safe. But a constant stream of “No No No” communicates two things to a little one: the world isn’t safe to explore, and your little one is not competent enough to explore it. One of the tricks of the trade is to practice redirection: rather than saying “Don’t do that!” focus on saying, “Do this instead!” Cultivate the curiosity and direct it in a safe way. That way, you are following Steve’s advice by showing your kid how to explore the world in a safe manner and you are making them feel like they can – and should – follow their instincts to do that.

ACTIVE ENGAGEMENT: One of the wonderful deliverables of playfulness is the ability to be focused and get in the flow of an activity – whatever that activity happens to be. Steve’s conception of active engagement is a core part of what we think of as creativity. Kids need to get lost in the moment, block out everything else, and just follow where the experience takes them. As Steve points out, this doesn’t just happen during what we think of as “play” (although those are of course opportune times to witness this). For younger kids, it can be looking at rocks, following a bug, watching mom put on lipstick, or playing with a zipper on a pocketbook. For older kids, “play” can involve math, English, science, music – whatever turns them on. This all goes to Steve’s overriding message – it’s all about kids bringing a sense of playfulness to everything they do.

In the busy world we live in, we often think it is difficult to find time to play with our kids and give our kids opportunities to play. But if we embrace the philosophy of Steve Gross – Executive Director AND Chief Playmaker of the Life is good Playmakers– we see that we actually have more than enough time to infuse our kids with a sense of playfulness, and a trait that will serve them well for their entire lifetime.

Steve in Haiti

Images courtesy of Life is good

 

 

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“Life is good”: 4 Ways to Nurture Optimism In Your Kids

Monday, May 6th, 2013

One of the most important traits you can nurture in your child is optimism. The roots of optimism take hold early in life, and contrary to popular opinion, are primarily the result of experience, rather than genetics (or put another way, optimism can most definitely be taught even though some may be prone to be more optimistic than others). Optimistic kids have an edge – they are protected from depression and show much more resiliency when faced with challenges. And by optimism, I’m talking about the realistic kind – not the Pollyannaish brand. The core of optimism is to perceive the realities of a situation and focus on the things you can do to help make things better. It’s a motivational fuel that propels behaviors necessary for success, as discussed in Paul Tough’s recent book How Children Succeed: Grit, Curiosity, and the Hidden Power of Character.

How can you encourage optimism in your kids? Well, the easy answer is to say being optimistic yourself. That said we all know that parenting is hard, and the realities of the daily grind can wear down even the most optimistic parent. To that end, I spoke with John Jacobs – co-founder with his brother Bert of the Life is good Company – to get his insights on the role optimism has played throughout his life. Why John Jacobs? He and Bert spent five years selling homemade tee shirts without much success. One of their ideas, though, caught fire – a drawing of a face with an infectious grin and the slogan “Life is good.” Turns out that deceptively simple expression of optimism resonated with lots of folks, and now “Life is good” is a hugely successful lifestyle brand, as well as an ambassador for the power of optimism in people’s lives. Today, Life is good’s mission is to spread the power of optimism and help kids in need, which they accomplish by donating 10% of their net profits to the Life is good Kids Foundation.

The Jacobs brothers selling tee shirts

John is well positioned to talk about optimism for many reasons. In addition to his successful career and the central role that optimism plays in the “Life is good” story, he credits many experiences he had growing up with optimistic parents. And, as John is a dad to a four-year-old, a two-year-old, and a baby not yet six months old, he lives the life of a parent who brings optimism into his kids’ lives on a daily basis. John articulated a number of  important take-home messages for parents drawn from his many experiences – which I share here as 4 things you can do right now, everyday, to cultivate optimism in your kids.

LAUGH MORE, COMPLAIN LESS

John did not grow up with many traditional advantages. He was one of six kids growing up in a small house. Yet the emotional climate of the house was very positive:

“There was plenty to complain about if you wanted to, yet it seemed like when we woke up in our bunk beds, we’d hear our mom singing or cracking up over something. She just decided to focus on things that made her laugh or things that would be exciting to her kids. There was no dwelling on the fact that the toast was burning again or one the kids was wearing cleats to school because they couldn’t find their shoes.”

The bunkbed from John’s childhood

John summed up his mom’s parenting strategy as “keep the circus moving forward.” Yes, life with kids can be chaotic, stressful, and a little crazy sometimes. It can wear you down. But, making the decision to laugh (at least some of the time) rather than complain or dwell leads to a positive emotional climate in the home – and the foundation for an optimistic attitude in kids which doesn’t deny reality, but makes the best of it.

FRAME THE DAY

John recalls that there was something especially powerful about waking up each day to the sound of his mother’s happy, joyous singing. He, too, suggests that parents “frame the day” by setting a positive tone:

“I love the word ‘excited.’ It can be used every day when you wake up! You can talk in an excited voice about the color of the trees today or what the sky looks like. You can generate enthusiasm about what you’re planning to do that day, or who you’re going to see. It’s not a trick. You can fuel a kid’s excitement so that they get pumped up about playing with an empty box and they end up turning it into a rocket ship or an airplane or a clubhouse. It’s a decision you make on how you are going to frame your day from morning to night.”

This advice resonates strongly with clinical experience. Many families who express lots of negativity and interpersonal stress start off their day this way. There are usually triggers that gets parents and kids started with a negative attitude first thing in the morning – whether it involves issues with eating breakfast, getting dressed. These little things might not sound like a big deal – but it drags the energy level down and can turn into a way of seeing the day’s tasks as a burden.

John’s idea is so powerful because it covers the entire day – he also suggests you try to “frame the day” at night as well. How? Simply put, instead of everyone talking about all the lousy things that happened during the day (and we know there are usually a few every day), you make a concentrated effort to also talk about the good things that happened. John’s family has a habit of everyone (even the toddler) taking a turn at the dinner table and talking about one good thing that happened that day:

“Before dinner every person at our table shares what they are grateful for. Our four-year-old has taken over the leadoff slot. He likes to start the conversation and usually he just keeps going – it’s good stuff! He’ll say things like, ‘I’m grateful for the floor, for the ceiling, for the lights, the ocean, and the color green.’ We love hearing that and seeing the smile on his face makes it hard to cut him off. The food might get cold but you’re thrilled to see a kid that young frame the world in that way.”

It’s a powerful way of making sure that the good doesn’t get lost in the bad – and that your kids develop the habit of framing their day with realistic positives, including both expectations of things to come and appreciation for things that came.

DISCOURAGE BOREDOM

We’ve all heard our young (and not-so-young) children complain about how bored they are. Such boredom often comes hand in hand with a dreary, enervated experience of the world. Don’t tolerate it! And certainly don’t mitigate it by allowing your children to watch television. John has a powerful recollection from his childhood days:

“I remember distinctly my mom saying to us ‘The only people who get bored are boring people.’ That was the last time I used the word ‘bored’ – when I was maybe six years old.”

Part of boredom is to shoot down ideas – to find the negative in anything. You know the drill – I don’t wanna do that ‘cause it’s boring. Blah blah blah. But this kind of pessimism doesn’t serve kids well. Check out John’s perception based on his career as an entrepreneur:

“Pessimism closes doors and squashes ideas before they have a chance to breathe, grow and develop. If you have a naysayer who’s squashing things, who focuses on why something won’t work, you’ll never have an innovative idea. Negativity sucks the energy out of a meeting; it sucks the life out of it. That’s why optimism is a trait we look for when hiring people.”

Give your kids the message that it’s up to them to make life interesting. It’s up to them to find ways to make themselves happy. It’s up to them to find ways to engage themselves. This is a fundamental aspect of optimism that you don’t necessarily hear that much about. Try it. You will be very surprised and pleased to see how creative your kids will be when left to their own devices.

ENCOURAGE MISTAKES

If you don’t try something new, you won’t succeed. It’s that simple. A primary reason kids become reluctant to try new things is that they are afraid of failure. John – like many entrepreneurs – has always embraced mistakes as a key way to learn:

“Even though you know you’re going to ‘fail,’ one of the biggest lessons we learned was that when you try, you either succeed, or you learn. These are both positive things. My business partner and I made so many – hundreds! – of mistakes, yet the power of the message and mission of our company, which is to spread optimism, just carried us through. We learned to try to keep trying, to stay nimble enough to try out new things, to make mistakes, to fall down, and to learn from all of that ‘failure.’ That’s how you get smarter. If you fold your arms and tuck away and get defensive, it’s not a good recipe to grow and develop.”

John strongly encourages his kids to try new things, even if they don’t know whether they will be good at it. As he tells them, they don’t have to do something perfect the first time:

“The most tangible example for me was teaching my oldest son to ride a bike. It was so exciting! We had the brief little protest of ‘I don’t have the training wheels’ and ‘I needthe training wheels’ – that kind of thing. But he got focused on what was in front of him and started to push down that front pedal. Twenty minutes later, he had a big smile on his face. It was a metaphor for so many stages in life. There are so many of those situations growing up when a kid is not sure and nervous about trying something. Then you go for it a little bit and maybe you stumble once or twice but eventually you have a positive experience.”

John Jacobs

If your kids don’t learn how to learn – that “mistakes” are a part of the learning curve – they will deprive themselves of the chance to get good at something. The optimist knows that they will get better if they really pay attention to all those mistakes and use them as a platform for improvement – one small step at a time. Those small steps add up when you take them.

PUTTING IT ALL TOGETHER

As John reflects:

“This idea of what you choose to focus on is one of the most basic foundations for a happy life for you and your kids. Do you want your child growing up thinking how lucky he or she is and how incredible this world is—and how many opportunities there are every day to do things that are new, and to grow as a person? This isn’t corny to me.  It’s what I truly believe.”

If you make these kinds of choices, your kids will also believe that “Life is good.” The will know how to ride out the bad times and learn from them. And they will have the skills to ensure that good things will come. 

 

 

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