1. Rationale for new diagnosis
Problems with Insurance reinbursement—mid-80’s
Books like “The Bipolar Child”
500% increase in BD in children and adolescents in past 20 years
Increase in antipsychotic prescriptions linked to these changes in diagnostic practices
Severe irritability without clear cut episodic mood change was being label with pediatric BD
Wozniak, J., Biederman, J., Kiely, K., Ablon,----from mass. General hospital—note only 2 of 43 kids had classic mania/
S., Faraone, S. V., Mundy, E., et al. (1995).
Mania-like symptoms suggestive of childhood
onset bipolar disorder in clinically
referred children. Journal of the American
Academy of Child and Adolescent Psychiatry,
34,
Papolos, D., & Papolos, J. (1999). The bipolar child. New York City: Broadway Books.
Clinical associate professor at albert einstein school of medicine
Althoff, R. R., Verhulst, F. C., Rettew, D.
C., Hudziak, J. J., & van der, E. J. (2010).
Adult outcomes of childhood dysregulation:
A 14-year follow-up study. Journal of the American Academy of Child and Adolescent
Psychiatry, 49,

2. Criteria Severe recurrent temper outbursts (TO’s)
Verbal or behavioral
Grossly out of proportion: Intensity or Duration
TO’s inconsistent with developmental level
TO’s 3x or more per week
Inter outburst mood irritability/anger**
12 mos. Duration, no 3 consecutive mos. period without
Present in at least 2 setting, severe in at least 1
Not diagnosed before age 6
Criteria A-E is before age 10
No mania or hypomania for duration of 1 day
Not exclusively occuring during MDD, not better explained by:
Autistic spectrum, PTSD, SAD, Dysthymia--
K. Not attributale to physical or substances or neurological
May coexist with ADHD, CD, and Substance Abuse
Cannot coexist with ODD or Intermittent explosive disorder or Bipolar Disorder

3. Secure Base Perceived Threat Felt security Safe Haven
Self-Confidence/Exploration
Felt security
Secure Base
Caregiver’s
Signal detection
Perceived Threat
Safe Haven
Attachment System
Signaling
Proximity Seeking

4. Relationship Components
IWM of Attachment and Caregiving
Based onHx of attachment experiences
IWM of Attachment and Caregiving
Based on Hx of attachment experiences
Relationship Specific
Cognitions
Relationship Specific
Cognitions P C
interactions

5. Sameroff’s three R’s of intervention
Re-education
Redefine
Remediate

6. Cognitive Flexibility
Compliance
Problem Solving
Language Processing
Cognitive Flexibility
Social Skills
Emotion Regulation

7. Redefine Motivation vs Skills

8. Remediation Identifying Compliance Interaction
Teaching Situation Analysis
Teaching Emotion Regulation and Collaborative Problem Solving Skills
Enhancing parents mentalization skills
Strengthening Attachment Relationship
Improve Child’s Neurocognitive/pyramid skills

9. Compliance Interactions
Preventing explosions while enhancing neuro-cognitive skill development

10. The Room Wrecker
Working on a school project in kitchen. I had drawn an outline of almost everything but said that if you want to use this for credit you’re going to need to do the rest. But he talked me into helping him with the coloring some and I agreed. He soon got side-tracked, playing with the dog.

11. The Room Wrecker (cont.)
I said, “I’m finished, I’m going into the other room. You are on your own.” After about two minutes, he got angry because he made a mistake and threw the marker on the table. It rolled onto the floor and I picked it up but ignored his little tantrum. He started coloring again and soon he did the same thing, throwing the marker. I stuck my head in the room and said, “This is your project.” As I walked away he mocked me by mumbling what I said under his breath. I told him if he doesn’t straighten up he’s going to be put into time out. He started cursing out loud and throwing markers across the room.

12. Room Wrecker (cont.)
I went back into the room and grabbed his arm and escorted him to the stairs and told him to go to his room. As he marched up the stairs he was cursing and name- calling. After each burst, I took more and more away, but it did nothing. He melted down, went to his room and wrecked it …a complete rage --we now have taken everything out of his room.
The pastor who’s daughter routinely call him asshole. “I wish I had more insulation in my house. When I walk outside I’m sure all the neighbors think, “there’s the pastor whose must be a real asshole.”

13. SAT Meltdown I woke Jeremy up to go take his SAT on Saturday morning.
As soon as he woke up he said, “I don’t want to go.”
I told him he has to go take the test, no questions ask.
He pulled the covers over is head and said, “No you can’t make me. I don’t feel like it.
I told him we paid a lot of money for him to take that test and that he was going to get his tale-end out of bed

14. SAT meltdown (cont)
I still refused to get up so I told him that he was going to lose all his privileges if he did not get up and get downstairs.
He rolled over in his bed and I picked up his laptop and said, this is mine now and you won’t be getting it back for a long time.
He jumped out of bed screaming and yelling, threatening to hit me. He was shaking with anger

15. Exploding in the Backseat
Jason came home from school and I asked him what he wanted for snack. He said he wanted the tuna fish salad and cracker he had picked out from the store.
I told him he could have something else, either an apple or other kind of fruit and milk. He said, “I don’t want anything, just forget it.” So I said, lets go we have to go pick daddy up from work today.
As we pulled out of the driveway he started complaining about being hungry

16. I told him he had his chance to eat something but he passed it up
I told him he had his chance to eat something but he passed it up. Now he has to wait for dinner.
He started crying, saying “I wanted my crackers and tuna fish.”
I told him he could have had fruit and milk.
He started yelling “I want my crackers” and kicking the back of my seat.

17. A Compliance Interaction
A situation where adult wants child to do something that child doesn’t want to do.
Or a situation where a child wants adult to do something that adult doesn’t want to do
An emotionally charged interaction, with no clear wants or needs are verbally expressed by child

18. Goals: Pursue adults unmet expectations
Address child’s concerns. Solve the problems precipitating child’s challenging episodes
Reduce Challenging Behaviors, especially Reduce Melt-Downs
Destructive child’s nervous system
Conditioned Emotional Responses
Reinforces insecure relationship models
Work on Pyramid Skills
Improve Secure Base Use—establish a helping relationships

19. Using the Whole Brain Left-Right Hemisphere Brain Stem Limbic System
Avoid Amygdala Hijacking
Septal Rages
Prefrontal Cortex—engaging Executive Functions
See siegel and the whole brain child

20. Three Pathways Pathway A Pathway B Compliance Interaction Pathway C
Force parent Concern
Pathway B
Work on Pyramid Skills
Compliance Interaction
Bed time
Brushing teath
Bath time
Dinner time
Path B—connect and redirect
Pathway C
Temporarily Drop Concern/Punt

21. Goals: Take parent concerns seriously Take child concerns seriously
Reduce Challenging Behaviors, especially Reduce Melt-Downs
Destructive child’s nervous system
Conditioned Emotional Responses (CERs)
Reinforces insecure relationship models (attachment)
Work on Neuro-Cognitive Skills—Whole Brain Child
Improve Secure Base

22. Using the Whole Brain Left-Right Hemisphere Brain Stem Limbic System
Avoid Amygdala Hijacking
Septal Rages
Prefrontal Cortex

23. Secure Base Effects Powerful influence on Neurobiology
Emotion-Regulation and Sensory Integration
Language Development
Executive skills—
Frustration tolerance
Shifting
Monitoring
Labeling
Problem-solving

24. Compliance Interaction
Three Pathways
Pathway A
Compliance Interaction
Pathway B
Pathway C

25. Three Pathways Compliance Interactions
Pathway A—Force Adult Concern
Advantages
Disadvantages
Pathway B—Collaborative Problem Solving
Pathway C—Temporarily Dropping Concern

26. Collaborative Problem Solving:
E—empathy—
A—Assert—
R—Respect—
I—Invite--
C—Collaboration—

27. Empathy Listening and understanding child concerns
Helping child articulate concerns what the concern
Taking concerns seriously
Empathy is a reciprocal process, so you may try to empathize but if the child does not believe you understand then you have not empathized

28. Assert-- Define Problem, expressing concern or expectation
Don’t mistake your solutions for concerns or expectation
Appeal to rules as important principles to follow

29. Respect
Work at monitoring and managing your own emotion regulation—if too upset, go to pathway C
Non-contingent respect
Never use disrespect as a form of punishment
Avoid global, negative attributions
Remain warm—avoid triggering CER’s

30. Invite asking child to generate possible solutions
Avoid forcing solutions
Think out loud

31. Collaboration Working with child to come up with workable solutions
Help child use foresight and hindsight
Model flexibility
Model regulation
Model respect
Maintain warmth

32. Qualities of Good Solutions
Mutually satisfactory
Do-able
Durable

33. Back to the pathways When to use A When to use C
Different kinds of C’s, some are better than others
Two kinds of B’s
Emergence
Proactive—timing is everything

34. Parenting and Mentalization
The use parent-child interaction questionnaire
Describe situation: beginning, middle, end
Describe behavior
Interpretations
Actual outcome
Desired outcome
Question: did you get DO?
Remediation Phase

35. Engaging the Repair Cycle
Turning conflict into learning

36. Treatments
Only randomized controlled treatment found lithium did not beat placebo, but open label trial, risperidone was effective from pre-to-post
Parent training, with emphasis on emotion regulation skills seems to have most promise

37. Shorter episodes of mania (BD, NOS): up to 40% convert to classic BD-I.

38. The Movement