Feb 28, 2010


Assessing Caregiver Reflective Capacity, Commitment, Insightfulness, and Sensitivity is a new DVD by Arthur Becker-Weidman, Ph.D. . This two DVD set provides a comprehensive approach for the assessment of important caregiver functions.

The first DVD begins with an overview of the factors associated with placement stability. The presentation, which includes lecture, PowerPoint slides and videoclips of actual sessions, goes on to present material about assessing parent state of mind with respect to attachment, insightfulness, and reflective abilities.

The second DVD discusses caregiver sensitivity, how to assess commitment, the Adult Attachment Interview, and related topics.

ISBN: 978-0-9822883-3-7.
The DVD can be ordered directly from The Center For Family Development or at Amazon.com

Feb 20, 2010

Temper Dysregulation Disorder & Bipolar Disorder


The proposed DSM-V will contain a new diagnosis, Temper Dysregulation Disorder (TDD). This new category was created to reflect a syndrome that has been labeled childhood bipolar disorder.
The creation of TDD does not deny the existence of bipolar disorder in childhood. That is, although extremely rare, bipolar disorder can occur in children and adolescents, and it is very similar to adult bipolar. TDD was created to capture a valid syndrome with characteristics and outcomes that are different than those of bipolar disorder. The available scientific data supports the position that the TDD syndrome is not simply the manifestation of bipolar disorder in childhood. This means that thousands of children that have been diagnosed with childhood bipolar disorder may not have bipolar and instead have a completely different syndrome now called Temper Dysregulation Disorder with Dysphoria.
So what is TDD?
Here is the proposed criteria for TDD: (from the DSM-V site see: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=397
A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.
1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.
2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation.
3. The responses are inconsistent with developmental level.
B. Frequency: The temper outbursts occur, on average, three or more times per week.
C. Mood between temper outbursts:
1. Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).
2. The negative mood is observable by others (e.g., parents, teachers, peers).
D. Duration: Criteria A-C have been present for at least 12 months. Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.
E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.
F. Chronological age is at least 6 years (or equivalent developmental level).
G. The onset is before age 10 years.
H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the “B” criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.
I. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.
The syndrome captured by section A-C (frequent and intense temper outbursts, happening several times per week in the context of negative emotionality) is the core of the symptoms that has been incorrectly interpreted as indicative of childhood bipolar disorder. Section H is very interesting. It states that this diagnosis is not appropriate if the person has experienced classic mania (e.g., bnormally elevated or expansive mood), as in such a case the diagnosis of bipolar is likely more accurate.
So why did the DSM-V decide that this syndrome is not simply bipolar disorder of childhood?
1. Lack of continuity to bipolar.
If TDD is simply the expression of bipolar disorder during childhood, then children diagnosed with this condition would eventually develop symptoms of classic bipolar disorder as they reach adulthood. The data do not support this hypothesis. That is, children who display the TDD syndrome in childhood (and are often incorrectly diagnosed as bipolar) are not more likely to develop classic bipolar disorder later in life as their peers (see Brotman et al., 2006; Leibenluft et al, 2006; Stringaris et al, 2009). Instead, these children are more likely to develop depression, not bipolar!
2. Different Biological Markets.
Youth who are diagnosed with classic bipolar differ significantly from those who have a TDD-like syndrome (see Brotman et al, 2010; Guyer et al, 2007; Rich et al, 2008). If TDD is simply bipolar, then the biomarkers of TDD should be similar to those of bipolar, but this is not the case.
3. Different Demographic Factors.
If TDD is simply bipolar, then the gender distribution of TDD should be similar to that of bipolar. This does not appear to be the case. Specifically, there is no gender differences in the rate of classic bipolar; male and females are equally likely to develop the condition. However, the TDD-like syndrome is disproportionately observed in boys rather than girls.
4. A need for a new category that would impact treatment and research.
In theory, the presence of TDD will educate clinicians, researchers, and the public that this syndrome is not simply a version of bipolar disorder. This would facilitate research on the causes, features, and treatments for this condition. This has major implications for treatment. For example, the standard treatment for bipolar disorder does NOT seem to work in children that have the TDD syndrome (Dickstein et al, 2009). By explicitly stating that TDD is not bipolar, researchers would be less likely to approach the search for treatments from a “bipolar framework”, which would potentially facilitate the discovery of more effective interventions.
I am actually glad about this change as it will have a clear impact on clinical practice and research that will most likely benefit the children affected with this condition.
Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, Egger HL, Angold A, Pine DS, & Leibenluft E (2006). Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biological psychiatry, 60 (9), 991-7 PMID: 17056393
Dickstein DP, Towbin KE, Van Der Veen JW, Rich BA, Brotman MA, Knopf L, Onelio L, Pine DS, Leibenluft E (2009): Randomized double-blind placebo-controlled trial of lithium in youth with severe mood dysregulation. J Child Adolesc Psychopharm 19: 61-73
Guyer AE, McClure EB, Adler AD, Brotman MA, Rich BA, Kimes AS, Pine DS, Ernst M, Leibenluft E (2007): Specificity of face emotion labeling deficits in childhood psychopathology. Journal of Child Psychiatry and Psychology, 48:863-71
Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS (2003): Defining clinical phenotypes of juvenile mania. Am J Psychiatry 160: 430-437
Rich BA, Grimley ME, Schmajuk M, Blair KS, Blair RJR, Leibenluft E (2008): Face emotion labeling deficits in children with bipolar disorder and severe mood dysregulation. Development and Psychopathology 20: 529-546
Stringaris A, Cohen P, Pine DS, Leibenluft E (2009): Adult outcomes of adolescent irritabilty: A 20-year community follow-up. Am J Psychiatry 166: 1048-54

Feb 17, 2010

Stockholm Syndrome: what it is

In August 2009, when Jaycee Dugard, a woman kidnapped 18 years ago, was found, the media reported that she displayed symptoms of the psychological disorder known as Stockholm Syndrome, so named after a famous Swedish robbery in which hostages sympathized with their captors. Housed in a shed in her captor’s backyard, Dugard was repeatedly raped since she was eleven years old. But when investigators questioned her, Dugard reported that her captor was a “great person.”

Dugard’s case is only one of the many news stories that have received worldwide media attention. The public is fascinated by victims’ seemingly inexplicable positive responses after having suffered physical, emotional, and sexual abuse.

In her groundbreaking book, Loving to Survive: Sexual Terror, Men’s Violence, and Women’s Lives, Dr. Dee Graham, one of the earliest Stockholm Syndrome researchers, identified four characteristics that typify those suffering from the syndrome:

1. Perceived threat to survival, and belief that the captor is able to carry out the threat at any time.
2. A captor carries out a small act of kindness, and the captive perceives it as redemptive.
3. The captive is isolated for a significant amount of time, such that the victim can only see through the captor’s perspective.
4. Perceived impossibility of escape.

Shirley Julich, a professor at the Auckland University of Technology in New Zealand, focuses her research on child sexual abuse. In 2005, she wrote a comprehensive report analyzing interviews with 21 survivors of childhood sexual abuse. In her attempt to understand her interviewers’ initial reticence to report abuse, she turned to Graham’s research, concluding that Stockholm Syndrome was indeed a major culprit, in effect contradicting an earlier child sexual abuse study conducted by the Otago Women’s Health Survey.

Shirley Julich’s full report is available here.

To read a more in-depth description of Stockholm Syndrome symptoms, read Dr. Joseph Carver’s Mental Health Matters blog post .

To get a brief history of major news stories featuring victims suffering from Stockholm Syndrome, read this recent Time magazine article.

Feb 14, 2010

Overview of Proposed DSM-V Changes


There are no proposed changes to the diagnosis of Reactive Attachment Disorder. In addition, the proposals to add Developmental Trauma Disorder of Complex Trauma have been rejected, which is most unfortunate. Many children who have experienced chronic early maltreatment within a caregiving relationship exhibit a range of symptoms across several domains. Without a diagnostic category of Developmental Trauma Disorder that captures the range and depth of dysfunction, we are left giving children a basket of different diagnoses. This can lead to treating a range of symptoms and not the underlying causative factors.

There are substantial changes proposed for the Diagnostic and Statistical Manual of Mental Disorders.
The American Psychiatric Association (APA) has posted the draft of DSM-V on a special Web site, www.dsm5.org, to obtain comments.
A few of the proposed major changes:
• Recategorizing learning disorders, including creation of a single diagnostic category for autism and other socialization disorders, and replacing the controversial term "mental retardation" with "intellectual disability"
• Eliminating "substance abuse" and "substance dependence" as disorders, to be replaced with a single "addiction and related disorders" category
• Creating a "behavioral addictions" category that will include addictions to gambling but not to the Internet or sex
• Offering a new assessment tool for suicide risk
• Including a category of "risk syndromes" for psychosis and cognitive impairment, intended to capture mild versions of these conditions that do not always progress to full-blown psychotic disorders or dementia, but often do
• Adding a new disorder in children, "temper dysregulation with dysphoria," for persistent negative mood with bursts of rage
• Revising criteria for some eating disorders, including creation of a separate "binge eating disorder" distinct from bulimia
• Using "dimensional assessments" to account for severity of symptoms, especially those that appear in multiple diagnostic categories
The draft diagnostic criteria will then undergo two years of field testing. The final DSM-V is scheduled for release in May 2013, a year later than originally planned.
New Categories for Dyslexia, Autism
In the area of neurodevelopmental disorders, DSM-V will put dyslexia and dyscalculia -- reflecting disabilities of reading and mathematics, respectively -- into a new category of learning disabilities.
Autism, Asperger's syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified will make up the new "autism and related disorders" category.
The head of the APA's work group on substance-related disorders, Charles O'Brien, MD, PhD, of the University of Pennsylvania, told reporters on a press call that substance dependence and abuse had no basis in the research on addictions.
"We unanimously agreed that . . . there really isn't evidence for an intermediate stage [short of addiction] that is now known as abuse," he said. Instead, there will be substance use disorders for each of the major types of drugs that cause problems, such as alcohol.
He added that the term "dependence" was problematic as a psychiatric diagnosis because some types of physical dependence are "completely normal" for some medications, such as opioid painkillers. The draft, DSM-V will include "discontinuation syndromes" to allow for the proper assessment of symptoms of withdrawal from psychoactive substances, including caffeine.
Dimensional and Risk Assessments
There are two new suicide risk assessment scales planned for DSM-V, one for adolescents and one for adults. The new risk assessment tools focus on risk factors such as impulsive behavior, heavy drinking, and chronic severe pain and illness. In DSM-IV, suicidal ideation is treated as a symptom of major depression and certain other disorders.
Temper Dysregulation Disorder to be used in some cases instead of Bipolar Disorder
There is a proposed new diagnosis. The proposed new childhood disorder, temper dysregulation with dysphoria (TDD). It is reported that about 40% to 60% of the cases seen will be children who are doing things that other people don't want them to do. Many of these are children who are "stubborn and resistant and disobedient and moody, according to David Shaffer, MD, of Columbia University. There is currently a recognized syndrome known as oppositional defiant disorder, but some children also display severe aggression and negative moods that go beyond mere stubbornness.
Such children are often tagged as having juvenile bipolar disorder, but research has shown that the label is often inappropriate, since they usually do not qualify for a bipolar disorder diagnosis when they reach adulthood, although they remain dysfunctional. More often, these children are diagnosed as depressed when they become adults, according to Dr. Shaffer. He said the addition of TDD would better describe the severity and frequency of irritable behavior while also recognizing the mood disorder that goes with it.
Dimensional Assessment
Another innovation in DSM-V will be the extensive use of so-called dimensional assessments. Whereas DSM-IV relied heavily on present-absent symptom checklists, the new edition will include severity scales for symptoms, such as anxiety or insomnia, that may appear to larger or smaller degrees in many different mental illnesses.
Gender Identity Disorder Stays
A closely watched issue in the DSM-V revision has been whether to change or do away with gender identity disorder, now listed in DSM-IV. In the draft, APA leaders are proposing to rename the condition "gender incongruence" for adults and children.
People who consider themselves "transgendered" have long criticized DSM-IV and previous editions for labeling them with a mental disease when their problems, they believe, are purely somatic -- that is, they have the wrong genitalia and hormonal balance.
At the APA's annual meeting last May, members of the transgender community made a case for dropping gender identity disorder from DSM-V, but keeping some kind of "gender variance" diagnosis as a medical condition. Such an approach would eliminate the stigma of a psychiatric diagnosis while leaving a pathway for third-party payment for gender transition treatments, they said.
APA officials said the organization planned more discussions with members of the transgender community.
Kupfer, the DSM-V task force chairman, stressed that further changes in many diagnostic categories are likely following the comment period and field trials.
Final revisions will be submitted in 2012 for approval by the APA's two governing bodies, the Assembly and the board of trustees.

Feb 3, 2010

How does Attachment Develop?

The attachment system evolved over time to ensure the survival of the infant. The attachment system is a biologically based system found in nearly all mammals. The attachment system operates in a manner similar to your home heating and cooling system. If the temperature is just right, nothing happens. Only when the temperature goes outside of preset bounds does your heating and cooling system turn on. The same type “homeostatic” process is at the core of the attachment system.
In its most simple form, the attachment system is a proximity seeking system. When the child feels some threat, the child gravitates toward the preferred caregiver, who is most likely to care for and protect the child. This is how the attachment system evolved as a means of ensuring the survival of the vulnerable infant and child. The attachment system and the exploration system operate like a see-saw. If one is activated, the other is deactivated. When the child feels safe and secure, the exploration system is active. When threatened, fearful, anxious, the attachment system is active.
Attachment behavior, which is proximity seeking behavior, is exhibited throughout the life cycle. The toddler, when threatened, will go to the parent, maybe grab the parent’s leg, hide behind the parent, or in some other way make contact with the parent. Once the child feels safe, the child will then go about exploring the environment (playing). An example of attachment behavior in a young adult can be seen in the actions of a young student away at college on 9/ll 2001. On that day the student called home several times during the day to give her parents “news updates” about the unfolding events. Her first call was to, “turn on the TV Dad, a plane just hit the world trade center.” Her second call was, “Mom, did you see, a second plane hit….” And so it went throughout that awful day. Something terrible was happening that was a threat to the girl, and so she felt the need to make contact with her primary attachment figures. For a young adult, the telephone worked fine; while for a toddler, physical contract may be necessary.
So, then, how does this system develop? Remember Erik Erikson’s stages of development? The first stage, Trust vs. Mistrust? During this stage the foundation of attachment and patterns of attachment emerge. Infants cannot easily regulate themselves and they need a caregiver to regulate them. The normally sensitive parent responds to the child’s cries, figures out what is wrong, and then responds to meet the need. When this happens is a fairly regular and consistent manner the child learns, experientially, several important things. The child learns that the world is largely a benign place. The child learns that discomfort will be remedied before it gets too bad; this forms the basis for impulse control. The child learns that its needs will be met in a timely manner. The infant learns that caregivers are largely reliable, good, and helpful. And the child learns that the child is valued, valuable, loved, and loveable.
During the toddler years, which are about shame, the child is ambulatory, exploring the world, and “getting into trouble,” largely because the child does not recognize dangers. As a result, the caring parent is saying “NO!” a lot; to protect the child. When the parent sets this sort of limit, the child experiences shame. The child may cry, hide, cover the child’s face, or in some other manner evidence shame. Shame is about who you are and when we feel shame, we hide. The normally sensitive parent responds by comforting the child while setting the limit. “It’s ok, sweetie, I don’t want you to grab that cup because it is very hot and you could hurt yourself.” The child looks at the parent, experiences that the parent is not angry at the child, and then the parent repairs the relationship and reconnects with the child. When this happens repeatedly, the child moves from shame to guilt. The child learns, experientially, that while the child is loved and loveable, it is what the child does, not the child, that is upsetting the parent. Guilt is about what you do; shame is about who you are. When you feel shame you hide; when you feel guilt you want to confess and fix it.

Feb 1, 2010

Finding homes for Children in Foster Care

A recent article in the NY Times describes the efforts of one man to track down the relatives of children in foster care and to help children move into permanent adoptive homes. His work is quite inspiring. Mr. Lopez, a former police detective, now does gumshoe work for what he calls a more fulfilling cause: tracking down long-lost relatives of teenagers languishing in foster care, in desperate need of family ties and in danger of becoming rootless adults.

"Finding an adoptive parent for older children with years in foster care is known in child welfare circles as the toughest challenge. Typically, their biological parents abused or neglected them and had parental rights terminated. Relatives may not know where the children are, or even that they exist. And the supply of saints in the general public, willing to adopt teenagers shaken by years of trauma and loss, is limited."

This is an inspiring article.

The article can be found at: