Oppositional Defiant Disorder

Transcripts:

Playing with Violence: How the Virtual World Impacts Bullying & Aggressive Behavior 1

Good evening. It's so

good to join you today. Excited about presenting

this information to you and spending

some time together. We have a lot of material

to cover an hour, two hours, and I'm going to go as

quickly as I can. So glad you have

your resources there in front of

you to use as well. And when I started

thinking about this, the playing with

violence webinar, I believe for most of us, we don't know what that is. I think a lot of

us as parents and a lot of us that

have worked with counseling with kids and working with you have not actually seen the

violent video games that our kids are playing. So I went to a website, ask man.com AS K, m0 and ESPN.com, and

found what they listed as their top ten most

violent video games. And the reason I went to Assmann.com has it as a mainstream it's a

mainstream Website. I it's not faith-based. I it's what the

mainstream media has decided we're top

violent video games. We're going to look and

see what those are. And they start out, I think it's very

interesting. They start out by saying that violence in

video games is synonymous with success

in the industry. And I think success

is equated with dollars and the amount of sales that are made. So violence sales. Number ten, karma

Ghaidan, 990s seven. I'll give you a little

bit of a description of what's in the games. The violence and

Armageddon comes from the sheer ability

to run people down in the most

imaginatively brutal ways with a multipurpose

road hog ramming pedestrians into steaming piles of bloody flesh, hitting massive

roadside bombs. Part of what's

involved in the game. Perhaps the tagline on the box of karma GED

and says it's best. The racing game for the chemically imbalanced. Number nine is shoulders, is soldier of fortune. 2 thousand in showed

in soldier of fortune. It's a physics-based game engine that allows you, for lack of a better term, to torture and brutalize your enemies at your

most sadistic desires. It's the sick

little pleasures of blowing off him enemy lambs with a shotgun and watching blood

spray and gut spiel. That makes this game one of the most truly violent

titles of all times. Got divorced. Two is

number eight from 2007. God of war to promotes

ruthless weapon use, stylized and gory

finishing keels. Two enemies and

brutal cut things, including one final

keel where you continually slam a door on another God's heads

numerous times. Number seven is

Gears of War, number two from 2008. Slicing a flow

with a chainsaw from the groin upward

is gruesome enough. However, getting

to use a corpse as a human shield when

taking fire takes the KC. Number six is mortal

combat from 990s to kids love the fatality finishes

in mortal combat. Including upper

cutting your opponent only to have him land torso deep and razor

sharp spikes finish him became one of the most recognized

one liners in the history

of video gaming. Number five is

three alkyl from 1998 armed with

syringes, cattle prods, severed Liam's, and more

players simply beat the daylights out

of one another with grotesque fetish and,

or sexual maneuvers. Always with the results of too many bloods

bladders to count. Number four is Mad World 2009. What's

black and white? Red all over your

victims as her splattered against

the wall after being skewered

on a lamp post. Then that also includes disposing of

your enemies and a meat grinder

or playing darts using only your opponents

and a baseball bat. Number three is manhood. 2003. The player

sneaks around a 3D environment and

commits heinous acts of murder as parts of a statistic form

of entertainment. Decapitation, steel object to the

brain impaling, and even the ability to jam a sickle up into someone. It's just part of the

manhood experience. Number two is Grand

Theft Auto 32001. You're out to

make a name for yourself by accomplishing Miss missions in a

third-person environment, and stealing cars is the most lighthearted crime you can commit for massive Gang style

beat downs to Barbara queuing prostitutes for

flame throwers. Nothing is too vile or unrealistic in the

face of death. Blood and may him. And number one, ask Amend.com says is the most violent

video game, postal two from 2003. This is a game

in which it is not uncommon to drop kit grenades and whip size it unsuspecting civilians. That also include using cat carcasses as

silencers on your guns, hitting people with

anthrax laden cow heads, and playing fetch

with dogs using the severed heads of your dismembered victims. Postal too, was the

epitome of senseless, over-the-top video

game violence. Our kids, or play in this. I think it's important

that we let that sink in for just a minute. Researches showing our seven-year-olds

are playing this. R, eight year-olds

are playing this. Who's not playing

it is me and you. So we don't know

what they're saying. So there needs to be an

opportunity for us to become educated in

order to know what, what are our kids watching? The more, more importantly to

know how important it is to provide other

alternatives to them. So we're gonna

be looking at that the rest of

this evening. But I felt like

we needed to lay the groundwork because

I know so many of us are very unfamiliar

with the games. I also wanted to

start before we actually get into

my information. In July of 262 thousand, there was a joint

statement on the impact of

entertainment violence, entertainment

violence on children in front of a congressional

Public Health Summit. This statement was

presented and signed by the American

Medical Association, the American Association

of Pediatrics, the American Psychological

Association, the American Psychiatric

Association, the American Academy of

Family Practitioners, and the American Academy of child and adolescent

psychiatry. These are people we trust. We trust them to give us guidelines for our kids. And here's just some of

the things they said. Almost 15 years ago,

14.5 years ago. Media, We know that media provides good

thinks this is media. We are taking advantage

of media right now for you to hear

this information. We have online education. There are so many amazing

and positive things that media brings

to the table. And it says here,

and they said in 2 thousand media

can and often does. Provide is used

to construct, encourage, and

even inspire. But when these

entertainment media showcase violence, and particularly

in a context which glamorizes or trivializes

the violence. The lessons learned

can be destructive. The conclusion of the public

health community, based on over 30

years of research, is that viewing

entertainment violence can lead to increases in aggressive attitudes, values, and behavior, particularly in children. Those of you out there that work with children. We know that

children's brains are developing. And what happens during particular times

of development are very, very significant. So the impact on a child's brain is different than the impact

on an adult brain. And we need to

keep that in mind of the younger the child, the more I think we do need to protect them as they, as they grow and as we want them to learn and, and root truly ground themselves in

areas of value. It goes on to say

that the impact of entertainment

violence has effects that are measurable

and long lasting. Here's some of the

effects that they have. Thing. Number one, children who see

a lot of violence are more likely to

view violence as an effective way of

settling conflict. They see violence.

Therefore, it's an, it's a tool that

they can use, more likely, not always. Number to entertainment

violence feeds a perception that

the world is a violent and mean plays. Viewing violence

increases fear of becoming a

victim of violence. With the result

in increase and self protective

behaviors and a mistrust of others. We know this to be true. How many times have

you gone to see a movie that was frightening even

as an adult? When you come

home, you're more wary of walking into

a dark environment. You're a lot more

concerned when we watch the news

at night and we see the violence

that's happening on our streets were much more alert to locking

our car doors, parking under a light, having our keys out

before we go to the car. These are good

things to do. They're smart things to do. But part of the reason we have the perception that the world may not

be a safe place is attributed to

this media violence. Viewing valence

number three, viewing violence may lead to real life violence. It is not predictive, It is not a plus B

equals C. But it may, it may have an impact. We're not always sure

which child is going to have an impact on children exposed to violent

programming at a young age have a higher tendency for violence and

aggressive behavior. This is from the report from these people we trust. And I think this

was important too, because I don't

feel like we should throw throw out the baby with

the bath water, as we say in the

mountains of North Carolina, where I'm from. We have to have a balanced way of looking at this. And I like what

they say here we in no way mean to imply that

entertainment violence is the sole or even necessarily the

most important factor contributing to

use aggression. Anti-social attitudes

in violence. There are other

contributing factors. Family breakdown,

peer influences, the availability

of weapons. Numerous other factors may all contribute to

these problems, nor are we advocating restrictions on

creative activity. The purpose of this

document is descriptive, not prescriptive.

We sick delight. We seek to lay out

a clear picture of the pathological effects of entertainment violence. But we do hope that

by articulating and releasing the consensus of the public health

community, we may encourage greater public and

parental awareness of the harms violet entertainment and

of the harms of violent entertainment

and encourage a more honest dialogue. This was from 2 thousand. I share this

information with a lot of people that have never heard of this. So we've laid

the groundwork. I've given you an idea of some of the violent

video games that are out there. I've given you some

documentation from people that we know and trust that tell us that, that it could be a problem. So now let's just jump in and see what else we have. First objective

was to explore the negative

neurobiological impact on today's youth, the violent content

marketed as entertainment through gaming movies

and television. And I want to say

right off the bat, I am a lay neurobiologist. I am a clinical

social worker with a doctorate degree in

Education. I'm a mama. And everything I know

about neurobiology, I've been taught

or I have read, but I am not a

neurobiologist to myself. So I'm going to

present this in laypeople terms to you. Indiana University. My you have the information there

in front of you. Using functional MRIs. The researchers

have found that playing violent

video games for one week causes changes

in brain function. Indiana University is

showing us through functional MRIs that playing violent

video games, the visual imagery is changing the brain

of our kids, not permanently, but it does change brain function. The brain regions

affected by violent video games

are associated with the cognitive

functioning and emotional control. The change in brain

function was reduced after game play was discontinued for one week. I have a brain scan for

you there to look at. And what we saw is for

the control group, for the video

game, excuse me, for the video game group, when they played

video games, there was a decrease in

brain function based upon functional

MRIs a week later, that brain function

increased. The way I have

heard it described. Is it the violent

visual imagery? And the research

has shown it's the violent visual imagery rather than what we hear, what we actually see. There's a school of

thought that we are geared to look at violence as a

protective manner, which makes perfect sense. If there's violence, it we need to see it so that we can make a decision how to get away from it, how to protect ourselves. So school fights, everybody wants

to go watch, you know, we call

it rubber neck. And when everybody

stops as I drive down the interstate

and there's been an accident on the

side of the road. There's something

about us as humans. We need to see it so that we can

be defensive. We can get away,

we can dodge it. We don't want to

be blindsided. So we look at it. So the violet

visual imagery has a different

level of impact. Science Daily.com, Iowa State University,

March 24th, 2014. Children who repeatedly play violent video games, learning thought

patterns that will stick with them and influence their behaviors. I think one of the problems we have is people

think that the violent video games

are desensitizing us. That's part of it, but

it's bigger than that. Children aren't just

being desensitize, their, their learning

new thought patterns. They're learning

new skills. And sides daily

here likens it to learning math or

playing the piano. It's a skill this learned. It's a thought pattern

that's learned. And later it's still there because it's been

myelinated in the brain. Research in Singapore,

Iowa State University. There was a two-year

study of three thousand, three thousand third through eighth

grade students. And approximately 9% of the gamers were found to be pathological

players or attics. So what we're seeing

in the research now is that video games does

impact the brain. Because we are seeing

pathological gaming. We're actually seeing

an addiction to gaming. Research were shown

in the United States. It's about the say, about non-person is

around nine to 10%. United States, China,

Australia, Germany, Taiwan, pretty much, pretty much

across the board. Israel, nine to

8% of addiction. Pathological video game

use is an addiction. We are seeing that

greater amounts of gaming are producing lower social competence and greater impulsivity seem to ask as risk factors for becoming pathological gamers. So the people who

are gaming more, they come into this having lower social competence and they have greater

impulse tivity, tend to be more

of an addict. As game use increased. The research is

showing us as game use increased. So did the mental

health issues as game use decreased. So did the mental

health issues. For most of us that

are clinical people, we know what the DSM is, the Diagnostic

Statistical Manual, and the new one came out in May of 20135, the DSM-5. And they are introducing internet

use disorder. It's a condition warranting more clinical research. As we all know, the DSM usually introduces

something, does more research,

more studying on it before they actually

make it a diagnosis. So right now what

they're saying is the gamers play compulsively to the exclusion of

other interests. And they're

persistent and recur online activity results in clinically significant impairment or distress. People with this

condition endanger their academic or

job performance because of the

amount of time they spend playing. This is really important. Gamers experience

symptoms of withdrawal when pulled

away from gaming. Another thing that

they're saying of the DSM current steady suggests that

when these individuals are engrossed in

internet games, certain pathways in their brains

are triggered in the same direct and

intense way that a drug addicts drain is affected by a

particular substance. The gaming prompts a

neurological response that influences feelings of pleasure and reward. And the result

in the extreme is manifested as

addictive behavior. Just as gambling. Justice, gambling does not introduce a substance

that changes the brain, but rather the act of gambling impacts the brain and it becomes

an addiction. The act of gaming

has the potential of impacting the brain and becoming an addiction. I think it's really

important for us to say just as our public health

communities group said, not everyone who plays violent video games

will be addicted. Not everyone who drinks alcohols an alcoholic. There are

multifactors here. If we look at heart

disease as an example, heart diseases,

multifaceted multifactors. There's weight to

be considered, there's activity level

to be considered. There's heredity,

there's diet. Well, in violence

among our youth, there's a lot to

be considered. Gaming is part of that. Violent gaming

as part of that, as we've already discussed. So was peer pressure, so was our home situation. So is our social

competence. We're seeing

that people have more social competence are less likely to be as

drone into gaming. But I think it's

really important that the gaming piece is

part of that equation. So just as in

heart disease, if we want to, to

prevent heart disease, there are certain

things we can do. We can exercise,

we can eat, right? We can stop smoking,

game-changer heredity. But there's some other

things we can do well, if we're looking at

violence among youth, the gaming's a pace. We can do something about, we have control over that. We can draw what we

bring into our homes. We control what

we purchase. And I think I'll get so passionate about this. We need to

educate our kids. If we educate our kids, then they can

make a decision. I think a lot of our kids, they don't know this. They don't know that these violent video games are impacting their brains. And so if we teach

them some of the things I'm teaching

you, I've, I've, I believe with all my heart, our young people, they will rise

to the occasion and they will make

better choices for them. Sales, I have

that much faith in the young people

of our world. Gaming addiction

is not new. It's very important for

us to look at that. I just pulled a

few examples from each, from each decade. 2009, a 17-year-old of Ohio shot his mother and injured his

father after they confiscated his

Halo three video game because they feared he was playing it too much. 2010. A Korean couple

was arrested after their infant

daughter starve to death while the payer played an online

game for hours. The video game The

two were playing involved raising

a virtual baby. A child died while

they were raising a virtual baby online.

It's addictive. 2011. A 20-year-old

male suffered a blockage to his

lungs and died while playing his Xbox for up to 12th

straight hours. 2012. Another gaming

attic died after playing an online video

game for 40 hours straight at an internet

cafe in Taiwan. Gaming addiction

is not new. It's been around

for a while. We're just now starting

to understand it. We're just now starting to really look at

it, research it. One of the things,

and this comes straight out of CNN.com. You have that

reference there. The top five warning signs of gaming or

internet addiction. A disrupted regular

life pattern. If a person plays games all night long and sleeps

in the daytime, that can be a

warning he or she should seek

professional help. If the potential gaming or internet attic loses his or her job or

stops going to school in order to be online or to play

a digital game. So warning sign, so warning sound when

there's a need for a bigger fixe. Does the game or

have to play for longer and longer

periods in order to get the same level of enjoyment from the game. We know from other addicts. We know from other attic. They increase, they

have to increase the substance to stimulate that Pleasure part

of the brain. It's the same with

our internet gaming. Number four is withdrawal. Some internet and gave me addicts become irritable or anxious when

they disconnect or when they are

forced to do so, they actually suffer

physical withdrawal after gaming and cravings. Some internet and gaming ed experience cravings

or the need to play the game or to be online when they are away from the digital world. You know, I think I think another warning sign is not one of these top five. This is just

mine. But I think another warning sign is people are people

that look healthy. You're not healthy when

you sit in front of a TV screen or a video screen or when

you're not outside. We're going to talk about that after the break, about the significance of, of movement, of being outside and

embracing nature. And you can tail teachers, tell me all the time. At the end of a

summer break. They can tail

which kids were out playing all summer and which kids spent the

entire summer playing video games. They're pale. They don't look whale. They have dark circles

under their eyes. They don't, they

don't look healthy. So that finishes

up objective one. We know by research

that there is a neurobiological impact of gaming on the brain. And we know that this, this impact

changes behaviors, changes social competence. We know that it potentially can lead to addiction. Not everyone's going

to be addicted, but 10% of the gamers

statistically will be. And then we're going to get objective number two, identify how repeated

exposure to violence in the virtual world

can manifest itself in bullying, aggressive behaviors,

and gun violence. I show you on my handouts the pyramid of violence. The pyramid of violence

in the beginning, you know, it starts with teasing, just kidding, telling jokes, targeting

physical appearance, disability, race, gender,

sexual orientation. It's just those main little things

that people say ont his teeth and

I'm just joke and I'm just playing. But it's not playing

unless both, both people think

it's playing. If someone is hurt, funny, and if someone is doing

it with the intention to hurt, that's playing. The next level up we

look at put downs. Intimidating looks,

excluding people. Excluding people is when

you have a group of four or five

people in someones over there and they

want to come join us. We don't let them.

We don't want them. Or we invite everybody in the classroom to

a birthday party except for that kid. And one of the things that, one of the things I tell

my teachers when I, when I train my educators, often ask my

educators, I said, think of the kid in your classroom that

you don't like. They want to admit it.

But I've worked with educators for a

very long time. There are often children in their classroom that

gets on their nerves, that is difficult for

them to interact with. And I will always

tell my educators, that's the child. The very child

that you don't like is the child

you need to go to? That's the child that needs you to be

their advocate. They need you to

be their champion. Because if you feel

that way about him, chances are classmates or fill in that way about him. And we need to change that perception and

the best person in that classroom to

change that perception as the educator at the

front of the room. So we want to encourage our adults to reach out to those kids so that we don't perpetuate what the

kids are starting. Name calling,

spreading rumors. Oh my goodness, the

cyber-bullying. It's really easy to get online and spread rumors. It's very easy

to text rumors. That's a big place

for cyberbullying comes in. The

next level up. Now we just gotta

straight verbal assaults, verbal assaults,

threats, cyber threats. And then it goes up

to cyber stalking, harassing, choosing one

student to pick on, and a group is

coming through and picking on them, mobbing. Then we go up to

another level. There's assault

and challenges. Challenges the

victim to suicide. We, there's a

term out there, if you're not

familiar with it called bully side, where young people choose suicide as their only way out of being bullied. It's termed bully side. And it's, it's preventable. Children do not

want to die, they won't to escape. And they are completely hopeless at escaping

the bullying. And they choose death. And then you go

up and you have murder or suicide

by victim. And then victimless. And then you come

up to the top of the pyramid where the victim becomes

the murderer. And we've, we've seen that where someone that's

been bullied, the pyramid of violence

on the bottom. As they work their way out, they then become the bully. As an educator myself, I've worked in the

school system for years as a school

counselor. And I would see big

brother bullies, brother number to borrow the number two bullies, the baby in the family. The baby and

family comes to school and bully

somebody on the bus. So there's actually,

it's very, very often it's very, very common for

one individual to be the bully

and the victim. I don't like to use

the victim, excuse me, to be the bully

and the target, we should say the

target of bullying. It's very important.

It empowers them. Victims are helpless. Young people actually

have the ability to, to change and to

seek assistance. So let's call them the

targets of bullying. But it's very,

very common for one individual to

be both a target of bullying and a bully. It's the gift that keeps

on giving in a very, very, very sad, sad way. As we continue. Some of the things

we're seeing with online gaming. And I know a lot of

a lot of people, parents, they see this as their child's

only social outlet. Say they don't want to discourage it because

they're like, well, but if all

of his friends are doing the

online gaming, If I tell him he can't

than he doesn't fit in and but let me

tell what's going on on the online gaming. There's something out

there called agree for g are IETF ERS grief for a grief, or is a bully in the

world of online games? Grief or don't play by the rules that apply

the rules on the game. They attempt to

causes much distress and discomfort for other

players as possible. Their only task

is to get into the online game and

mess with people. Many people get

pleasure from griefing others because it often becomes a

competition to see who can cause the most chaos. So their particular

online games or your, your young person

can get on there and build something

productive. It's not a violent

video game. It's a productive gang

where they can go do something and

build and build something and agree

for will come ONE industry it for fun. Just a way to bully online. Cyberbullying is

recognized as a thread on social media, but are video games, especially our online

video games are often overlooked is battlegrounds

for bullying. I think it's very

important to understand how intense

bullying can get. When you're hiding

behind the screen, I like to tell people

I used to work, I used to work in a

fast-food drive through. And it always

surprises me how mean people would

be at the speaker. This was years ago, way before all this

video game stuff. I would be Hello,

welcome to again. Take your order, please. And and they would

be mean and rude and and then they would drive around and

at the window, they were nice to

me face to face. It's much harder

to be rude. It's very easy

to be rude to that little box back there. You know, I said I wanted

a large French fry. Whereas in person, they're much more

likely to say, I can have a latrine

trout, please. Well, that's what's

happening with our we have kids hadn't

behind screens. We have kids,

Timmy kids that wouldn't ever threaten

someone to their face, sand horrible, awful things online because they can hide behind the screen. And that includes

the online gaming online

gaming concerns from no bullying.com. There's messaging. A lot of our online games. You're not just play

in the game that you can message

during the game. The messaging during

the games can become harassing and can turn

into cyberbullying. There's often

offensive language, offensive language, verbal abuse,

unacceptable slurs, degrading terms to

belittle players. When they say they're

talking trash, they mean their

talk and trash. So you may know that your, your student, your

child is playing a video game where you're one of your clients. But do you have any

idea what would that undercurrent of

messaging is as well. There's also a

gang mentality on the online games. People can gang up online, identify somebody

they don't like, go after their character, destroy their character. And I think as we

continue to talk, I think it's really

important to ask the right questions about our violent

video games are violent visual imagery. You know, we were

always wanted to ask, is there a cause

and effect, does this cause that? We've already said No. We've already said it's part of the risk

assessment. It's part of the

equation. I think. I think it's a question

that actually allows people to get

bogged down in the question so

they'll have to do anything about it. You know, sometimes

there are people like bus that just passed

and they argue, will stop argument

and make it, make it move, do something. Well, instead of asking, does it call

something negative? Maybe we need to ask, does this came promote

anything good? Forget, forget,

does it cause violence? Is it promoting? Good? When my child plays this game as he or she learning how to be

a better citizen. When my child

plays this game? Is he or she

learning how to be a better saw on how to

be better daughter, how to be better

family member. When they get off the game, are they happy

and pleasant? They Solon an irritable? Let's look at the

behaviors we want. Does this game provide us with the behaviors

that we're looking for, especially in

our faith-based Christian world. Does this game

reinforce my values? We get so bogged

down in the wise. And I think that we need to look at risk management. I think we need to look at an elimination diet. You know, my

daughter has had a lot of health issues and we've learned

that she can eat no gluten, no dairy. Well, we started out

by eliminating things. If she eliminated them,

does she feel better? And I think that's

the place to start with these

video games and elimination diet. Let's just say,

let's just go off of this for a little while and see

if you feel better. Let's go back on it.

How do you feel now? And look at these

elimination things? Dr. jug, Dr. Doug Gentile, this was tilt from

Iowa State University has told to Fox News.com, cause and effect. I think it's the

wrong question. Whether there is

a link between mass shootings and

violent video game play. I understand people want to look for a culprit. But the truth of the

matter is that there is never one cause. There is a cocktail of multiple causes

coming together. And no matter what single

thing we focus on, whether it be

violent video games abuses a child doing

drugs, being in a gang. Not one of them is sufficient to

cause aggression. But when you start

putting them together, aggression becomes

pretty predictable. And I will remember,

let's go back to that. Heart disease,

multiple factors. You start chicken, yes,

yes, yes, yes, yes, yes, yes, you're

at a higher risk. Let's look at violence. Let's start looking

at balance. What do we, what are we

thinking about there? Playing violent

video games? They're watching

violent movies there at less than the violin music. They're behaving

violently at home. They have a volun attitude. They have all the, when you start looking

at the risk factors as the number of risk

factors increase, the likelihood of

violence increases. Once again, not encountered

present even then, we all know people

who have come through amazingly difficult

trials in their life and, and have overcome them and have sweet spirits. So this, once again,

is not a 100%, it's a risk assessment. Iowa State

University continues to tell us there's a strong connection between violent video games and youth violence

and delinquency. The results show that both the frequency of play, how many, how

much you play, and the affinity for

violence were strongly associated with delinquent and

violent behavior. When studying

serious aggression, looking at multiple

risk factors matters more than

looking at any one. Some serious problems including

depression, anxiety, social phobias, lower school performance seemed to be outcomes. A pathological video play, Science Daily.com,

April second, 2014. I think this was

interesting. I just found

this criticism, a violent video games by journalist,

has decreased. When I first read

that, I thought, okay, so they're

not criticizing it. They think it's OK. Not in Science Daily goes on to say they don't

think it's okay. They wonder if it's

because our journalist, the age of our journalists

are now the age of the young people who they grew up with the games. So they, it's more

accepted in the norm. Our culture accepts

the violence more. I have seen personally. I have witnessed a

significant increase in violence, except it

culturally accepted violence on our mainstream

television shows. And so it's not that the risk factor

has lessened. It's that we're not talking about us

so much because we don't even recognize

it's a risk factor. Fewer people are seeing

it as a risk factor because of the recognition

is being missed. One of the things

violent video games are providing

powerful role models. We need to question the character, a video game. He rose. Watch,

watch video game. Watch it with your

with your son, your daughter, your

nephew, your client. Watch it with them. Who's the hero of the game? Who's the hero?

Grand Theft Auto? The winner of the games. The mean is baddest person and they're out there. You get points

for being bad. You have sex with a prostitute,

you get points. You kill the prostitute,

get your money back, you get more points

than more vicious. You kill somebody,

you get points. So the one with

the most points at the end of the game is the one who's

done the most, the most horrific

acts of violence. So look at this,

watch it with them. Ask them, you know, what have we learned

from this hero as that is that who

you aspire to be. Are these the traits that you want

for your child? Are these the traits you want for your neighbor? Are these the

traits you want for your future son or

daughter in law? For the future parents

of your grandchildren. You know, what are, what are the traits

we want to reinforce? Many of today's media role models are lawless, sociopath, schoolyard

killers that had been turned in the

media celebrities. We reinforce the notion that the bad guys win. Not only do the

bad guys win, but the bad guys are

really cool due in it. And the good guys

look like DA offices. So we're, we're really not only just show

him bad guys win, but we're showing that good guys aren't

something we want to be. And one of the

things we know is the juvenile killers

do it for the fame. So notes on media and juvenile

violence in Japan, in Canada, it is

punishable criminal act. It is a punishable

criminal act to place the names and

images juvenile criminals in the media. The media has

every right and responsibility

to tell a story, but do they have the right to turn killers

into celebrities? And before I talk

about the next slide, I want to talk

about Rachel Scott. Rachel Scott was killed in the masker at Columbine. And you know a lot

about Rachel Scott. Most of you could tell me the names of the two

guys that killed or I won't repeat their names, they

do it for fame. But do you know

about Rachel Scott? Rachel's family has started an amazing program called Rachel's Challenge.org. I encourage you to

look at a Rachel's Challenge.org. And Rachel Scott's a beautiful young

woman who wanted to start a chain reaction of compassion and love. Over 21 million people had been reached by

Rachel's Challenge. Rachel Scott was never on the front of Time Magazine. But the guys,

the killer were. What message are we given? We know that the video game influenced the

Columbine killers. They had, they

recorded themselves. It was found in there, it was found

after they died. One of the killers named his sawed-off

shotgun Arlene, after a favorite

character from doom, a violent video game. On the video that he recorded just prior

to the school masker, he said, it's going

to be like Doom. That shotgun is

straight out of doom. No clear connection than the influence of

violent video games.

Playing with Violence: How the Virtual World Impacts Bullying & Aggressive Behavior 2

Welcome back. Just want to review a little

bit what we talked about in the first half. Violent video games,

we describe them and the just the sadistic and horrific

nature of them. I do think it's also important that

when we talk about violent visual imagery

inviolate mediates, not just video games. It's also the movies. I mean, look at how many of the Slasher movies Halloween around Halloween, I wanted to guess

humidity with my daughter and

I couldn't find one appropriate because

there were so many of the horror movies

that are out there in the horror movies

are rated PG 13, which means a lot of

our middle schoolers are actually

attending those, but that's something

just to be thick enough. So we talked

about the violent video games and

what that means. And then we also talked about we talked about the, the community health and our

community health, public health

community network. And talked about how, what they thought about it and how they said

that it does create a difference. It is a difference in the, in the violets and the reaction that

we have to that. And, and then we talked

about as well the, some of the research

that was done. We talked about our gaming can be an addiction. So anyway would

covered those things. And I think it's

important that we do have a conversation

about those things. But I honestly believe

it's more important to talk about what we

can do to change it. What can we do? What

steps can we take? You know, I've had a lot

of people say to me, Are you going to go to Washington or are you going to try to get them

to pass laws? And I'll be honest

with, you know, I'm not I'm not

going to Washington. I that's not where

I need to be. Some of you out there,

please, please, please at that your ministry and

your passion, please do it on. Other people have asked me, am I going to

try to talk to the video gaming

industry and tell them to change what they're doing now I'm not. Those are industries that they're doing, what

they need to do. They're not going to

change. And unless there is a supply

and demand change. So I've made the

decision that what I'm gonna do is grass roots. I'm going to talk

to you. I'm going to talk to my family. I'm going to set

boundaries in my own home. I'm going to talk to

local church leaders and local police

officers who are a lot of our school

resource officers. They have contact

with kids. Oh, my goodness. All

of our therapists and counselors out there that work with kids that

are struggling. One of the very

first questions you need to be asking them, are you playing violent video games

and what are they? List them. Talk

to them about it. You also need to

be asking kids, what movies are

you watching? What have you

seen? How much time are you spending

on screen time? There's just so

many things we need to be asking people and doing things on a proactive way that I just feel like

we need to do it, our sales just, just

at a grassroots level. And the grassroots level I think will

change the world. So that's what, that's

where I'm here. So we're gonna do that objective

number three, name and describe

the practical steps for facilitating pro-social behavior

in youth and creating a culture of respect,

honor, and kindness. Pro-social behavior. Do the video games. Encouraged that the skills that our

kids are learning, are they learning

pro-social behavior? Or the video games?

Are the movies? Are they creating

a culture of respect, honor,

and kindness? I think those are key questions

we have to ask. And there's always the question we've

already talked about a little

bit able to jump right in and talk

about that again, there's always the

question, does watching violence call someone

to become violent? Does a plus B equal thetas watching balance cause someone to become violent? Media lit.org, I think has a wonderful answer to that question. Maybe we need to ask

a different question. Maybe we need to ask, what does watching

violence over many years? What does it do

to our minds, to our hearts, and

yes, to our souls? What is the long-term

cumulative impact of violence as

entertainment? How is it transforming our personal worldview? Is long-term cumulative. Watching violence

as entertainment? Is it transforming

our collective psyche as a community

and a nation? I think that's

the question, not the question of does watching violence

cause violence? What is it? What

is it doing? How is it impacting us? How does it change the

way we do our world? How does it weigh?

Well, we just talked about it during the break. How many people see our world is a dangerous,

dangerous place. It does change the way

we view our world. Does it change the way we interact with other people? Does it change our trust? I mean, my daughter

my daughter, when she was young, she had a beautiful

question. We routed an

amusement park, Delhi would out of

Bollywood in Tennessee. We'd stopped to take

a little break. She's about five

or six years old. We stopped to get

a bite to eat. And when it was all

done, we finished with clean-up

Oliver things. She looked up at me and she said, Come on Mama, let's go meet some new

strangers. I was one. We had so much fun when

we go to the park, we talk to people

in the line. We do meet strangers. We talk to strangers. We become friends with people who are

when strangers. But we do it safely. So it's, it's so

important have we thrown out the baby

with the bath water? When we tell our kids, don't talk to strangers, what we need to

educate them, we need to role model. You can talk with

someone when I'm here. Let me help choose

safe people. Let me help educate you what safe is and

what unsafe is. It's so important that our kids understand they're never ever ever to take anything

from a stranger. They're never to leave. I'm an adamant supporter. Keeping our kids safe, but keeping them isolated. Hey, has the pendulum swung too far? I don't know. That's a conversation

we need to have about the impact it's

had on our community, on our relationships with our neighbors and

our neighborhoods. I came across

this circle of blame and I think

it's incredibly insightful when it comes to the violent video

games while the violet movie industry, let's just say medium

extreme violence on vis, visual imagery. The viewers blame those who write and

create the shows. So the viewer say, ain't it awful

that they write these awful shows and they create these

awful shows. The riders in

the directors, they blame the producers. They say the

producers require violence in programs in order to get and financed. I don't if you've

ever heard the term, if it bleeds it leads. A lot of media will use that terminology

casually, that if it's

about blood guts, then that's the

first thing you show because that's

what people watch. So the writers and

the director say producers say

we have to have violence in order

to get the money. The producers blame the

network executives. Because the network

executive say, Well, we gotta have action. We've got to

have some action in order to get

our ratings up, cuz if our ratings are nutshell

gets cancelled. The network executives say that the competition is brutal and they blame the advertisers for pulling out analyser show

gets high ratings. So they say we have to

do whatever it takes. We have Ted blood, we

have to have it bleeds. It leads to violence in order to get

the advertisers, in order to get

our ratings up. The advertisers say, it's all up to the viewers, what the viewers want. So we've created

this blame, the circle of blame. We're, nobody wants to say, I will change

what I'm doing. And truly and honestly,

we as viewers, we as consumers, we really do drive this thing. We, we really do with, with how we choose to

spend our dollars, with how we choose

to spend our time. As a collective group. We have the ability

to change ratings. We had the ability to vote with our dollars about what we want to

see promoted. So we've got to stop

the blame game. Where does have to stop at one of the ways to stop it is that grassroots effect and we have to

make an impact. I want you to make an impact on your

corner of the world. You don't don't, don't, don't get bogged down and ain't it awful don't get bogged down

and we can't change the world. Maybe not, maybe not we, maybe we can't

change the world, but we can change

our world. We can change what's

happening in our home. We can change the way we relate to our students, to our children,

grandchildren, neighbors, to the people

at the local stores. One of the best ways to do that is to increase your awareness. Increase

your awareness. I challenge you to watch the video games you have bought with

your own dollar. Watch him. Ask yourself, is this what I

want in my house to promote my

values is this, are, these, are these

characteristics that I want to

promote with my kids. Counselors, therapists increase your awareness. It should be a

regular question. What are the kids that

you're counseling? What are they watching? What do they play

and what do they do and increase your

awareness of that. I think we need to discuss volun visual imagery with the youth in our life. I think we need

to talk about it. We need to say, how, why do you enjoy this or what benefits are you

getting out of this? Or if all of your friends

weren't doing it, would you want to do this? I think we just need to

have a conversation. And I do truly

believe I've I've worked with kids

for over 25 years. I've raised lots

in my home, not just my own children, but my heart children that hang out in my house. And I do believe

that children craved conversation

from adults. They crave it.

They want to hear, they want to hear

what we have to say. As long as we listen to what they have to say, they want to voice

their opinions and, and they want to discuss

what's in there, what's in their mind and what they're thinking. And, and I believe as we educate people

I've seen happen. As we educate kids, they will raise,

they will rise to the highest level

of expectation. I think as a country sometimes we've just

kicked our kids to the curb and we think they're

not gonna do any better or that's

just the way it is. I just don't believe that our kids are

amazing people. They have amazing resources and amazing strength. And I think that

we have a lot to learn from this generation. So let's discuss

it with them. Let's bring it

to the table. Let's increase

our awareness and will step

on a few toes. One of the things

we need to do is we need to

ask ourselves, what kind of a media

role model am I? What am I watching?

What am I, what am I paying to go see? What movies do I support? What games in my Watson? What am I looking

at on the internet? What do my kids see me do? What, what, what do the kids that I influence? What do they hear from me? I think we need to

look at our sales first and then

we move forward. And I think we need to commit to get involved with activities that support

healthy living. I think that this is the hardest part for a lot of us as adults. We can't just tell our kids to do something

different. We're going to have

to do it with them. We're going to have to get more active with them. We're going to have to find alternatives

with them. It takes time to have these conversations

with kids and a carve out this time

takes a lot of time. One of the things

when I talk about stop in

the blame game. I want to urge you,

want to encourage you, I want to challenge you. I want to challenge you to mend them only minimally, the bottom-line, minimally enforce

the ratings. Enforced the ratings

in your house. Let's look at the

ratings. A0 is 18 plus. There's never been

a game actually sold with an AO rating. Ilm. M stands for mature, 17 plus T stands for teen, 13 plus E stands

for everyone. Seven plus. There's now an everyone tin plus I think I saw the other day than

everyone ten plus. Most of all all of the violent games

that I just discussed on the first

part of the break, I'll have M ratings,

mature ratings. Look at our little piece

by procure age 17. Age 17, which means if we enforce the ratings, no one under the age of 17 and our home

plays that game. I know for a fact we

have 78 six-year-olds play an M games,

17 plus games. So if life all we do, if all we do is enforce their ratings, we can

change the world. We just telecom,

sorry, you can't play that. You

can play it here. 17. So sorry. You can't play

that figure 13. You can't play that yet. You're not old enough, you're not mature

enough yet. And I think this is what we really need to think about. I think it's crazy the

way we look at it. We are basically

telling an industry, an industry that's put these ratings

on these games. We're telling an

industry we know better. We know better

than they do. They tell us that

child needs to be 17 years old to play a mature game and

we tell them, we know better, ARE eight-year-old

can fly it. We we are allowing the

industry who is pick the men know mole level in order to get these games Pass the legally through. And we are cut them in half because we know better. They go back, let us sink. And it's so important, if we will absolutely just re-enforce

the ratings. I believe personally, I believed Alma

heart that if we'll start doing

something different with our kids by the

time they're 17, they won't be interested. By the time they're

17, they'll have other interest. They'll

do other things. They won't have

the taste for blood that they get when they're 67 and then they keep playing

until her 17. That's just my philosophy. There's no

research on that. That's just my own

personal opinion. We the we that you use, that you can move

around and use the we, we mad world game is

really important. It may, in the

we mad world, you actually can take

the Wii controller. And now you are not just playing the game,

you're rehearsing it. You can actually rehearse, bussed in somebody's

head with a ball bat. You can actually rehearse slitting somebody's throat. So we've gone beyond just the mental

preparation. We are now into a full physical

rehearse thing of these activities,

which is huge. It's a huge step in

preparing for violence. And, but I think it's very interesting because

listen to what was said. When people were

talked about, why are these

games out there? Are, you know, our

kids play in them. Regarding the violence of the we mad world game where participants basically

rehearse violet acts. The guys over at Kotok who replied,

hopefully, though, concern parents will notice the M form a tour rating on the cover just

to the left of the dude wielding a

bloodied chainsaw. So basically the

industry has said, we've told him it's an AM, We've got a bloody

chainsaw there. Parents should

be able to look at that and understand that for 17 and old

are not younger. So the industry is looking back at us as parents, as educators, as

counselors and therapists, and saying it's our

responsibility. To to stop those games. The industry does put the responsibility back

on the parents. It says we tell

them the ratings, we describe the

content you goal in any program online and read the content of

these videos. If the parents decide

to buy it and they decided to let

their children play forward, it's their

responsibility. So one of the things

we need to do, we need to know the

content of the games. Google research it.

Read the boxes. What do you kids play in? Have you actually

played it? Do you actually know

what's happening within these video games and what's required to, you know, how

to get points, do you know how to win? And once again, I

just want to keep drive this point

home to this game. Reinforce your

family values. Does this game

reinforce what you would like to see happen with this young person?

Counselors and therapists. A lot of you, when you're working

with young people, they've come to you

because there's usually some kind of

an issue or problem. I think it's

really important that we understand

that the violence, visual imagery serves

to be brain altering, like we discussed

in the first half. So if it's brain altering before we put students,

young people, children on another drug, we need to take them

off the drug, the RON. So before we

start looking at medicating for

behavior modification, we need to start

doing a lot of research, a lot

of questioning, and a lot of diet

elimination of screen time to find out

if we take this away. Does this person, does

this young person actually still have

these behaviors? Do they still need

this medication? I don't know the answer. I think I think it changes from student to student, but I think it's a

question we need to ask and we need to act on. I want to read you

the description of the game ratings. Everyone, ease

for everyone, ten and older. Everyone. Content is

generally suitable for ages ten and up, may contain more cartoon, fantasy or mild violence. Mild cartoon fantasy

or mild violence, mild language and or minimal suggestive things. So this is her kids, HTN, we're going to have

mild violence, mild language, minimal

suggestive themes. Teen, the t rating. Content is generally

suitable for ages 13 and up, may

contain violence, suggestive themes,

crude humour, minimal blood,

simulated gambling and or infrequent

use strong language. So even in our teams, I just 13 These games, you're exposing

them to violence suggestive themes. Maybe exposing

them to violets, suggestive themes,

crude humour, minimal blood,

simulated gambling, and are infrequent use

of strong language. M, mature content is generally suitable for a to 17 in AP may contain

intense violence, blood and gore,

sexual content, and or strong language. Just, just reading that already tells us what's

in the material, what's in the

game. And yet. We are still letting kids much younger than the ratings play the games. One of the reasons that

I believe once again, this is just model opinion, but one of the

reasons I believe that that's happening is because the ratings were

picked brilliantly. E is for everyone. T is 14, m is for mature. What parent doesn't

want to brag that their child is more mature than the other

kids on the block. My Johnny's mature. He's so much more mature than that one or my marry. So mature. Mature

is a word that we see is a positive word when it comes to

our children. We want our children

to be mature. We don't want them

to be childish. We want them to be mature. So little Bobby comes

up and says, Mom, please let me

play this game, you know, on the tour, you know, I'm mature off feed the dog every day. I clean my room. Mature mom, you know, I am a make good grades. Mom and dad are thinking, Well, my kids mature. He can handle that game. He's mature. He's got a good head on

his shoulders. And what our challenge is, what does that, what does the ratings

were different? What if their

ratings were sick, sicker and sickest? Thinking about that,

what it would it change? It changed the way

you think about it. If little Bobby now comes up t's as I'll come oh, mom, let me play

the second game. You know, I've been

playing the sicker game for the

last two years. I'll come oh, mom, let me play the

SEC is game. It's a second

thing out there. Let me play the sick one. I think that the

ratings have, have, have changed

the way we view them. And we need to

be realizing in your own mind, mature

equals thickest. Mature equals thickest. Do we want our kids

play in the SEC is games before they're 17 years old. So

where do we start? We teach our kids

to be informed and critical

media consumers. We teach your

kids, we educate them that they're,

they're pretty small. Amazing. We control the

media influenced by limiting screen Tom in our homes and what the kids were doing counseling and

therapy with, we encourage

kids to embrace alternatives to

screen time. Like any other addiction,

like anything else. You can't take

it away without replacing it

with something. So you've got to replace it with something healthy. As counselors and

therapists before you put your kids on

I've already said this. Need Say it

again. Before you put your kids on another drug to modify

their behavior, take them off the

drugs their own. I have here from media ed. Midi's a media ed.org, ten reasons why media

education matters. Ten reasons. The average American

watches over four hours of

television per day. 56% of children ages eight to 16 have a

TV in their bedroom. The average

American child sees 200 thousand acts of violence on TV by the time they're

18 years old. The average American youth spends 900 hours in school and 11023 hours watching TV every year. The average American sees 2 million television

commercials by age 6545% of parents say that if they have

something important to do, they're likely to

use the television to occupy their child. Children spend a

daily average of four hours and 40 minutes in front of a screen. 97% of American children

ages six and under ONE products based

on characters from TV shows or movies.

That's important. It influences what we buy, it influences what

the children ask for. Nearly three out of 14

say that the portrayal of sex on TV influences

the behavioral, the sexual behavior

of kids their age. 14 admits it influences

their behavior. So what can we do? There's a wonderful

program out there. I urge you to look it up. It's free. It's

a free program. Any of you an

internationally please, you can use this as well. It's a program. Take the challenge,

take charge, turn screens off

and turn life on. Christine Paulson is an amazing educator

from Michigan. She is a woman with

a passion to get this information

education now and to provide it into, in a way that all

schools, all educators, all churches,

all counsellors can get this material free. Please go to www dot, take the challenge now.net. Take the challenge now.net. Some of the resources

you'll find there, there is a virus

of violence video that explains this. One of my own

personal mentors, Lieutenant Colonel retired David Grossman,

is on there. There's a free curriculum. There are free

lesson plans from pre-K through high

school of teaching kids how to be educated

media consumers and their free PowerPoints

to use a please go to that website and

explore if there's amazing things

there for you. Take the challenge has

promising research. They did school-wide curriculum based

initiative. First thing they did on their school-wide

initiative awareness. They asked all

their kids to keep a log, a media log. How much time do I

spend on screens? How much time?

Just keep a log. What am I watching?

What am I doing? How much time am I

spending on all this? And then after doing

that for a few weeks, they asked them

to please turn their screens off for

seven to ten days. Now, everybody has

to make a decision. What that means,

does it mean television doesn't

mean video games, doesn't mean cell phones, does it mean iPads, notebooks, everything, the make your own

decision about that. But the point

is do something in for seven to ten days. I please I will say

please make it a focus. The turn the

violent video off. Violent video games,

violent visual imagery, violent movies, at

least turn those off. And then an

alternative activities for the seven to ten days, find something else to do. So for seven to ten days, you find alternative

activities, family involvement, in

community involvement. When you come back from the seven to ten days, the students have a

conversation about what they gained by B and off there's green and then

the students put themselves on a screen diet has been really

fascinating. Research has been

fascinating. The kids decide that

they're only going to watch screens for a

couple hours a day. Some kids choose

to be screened free Monday

through Friday and do other screen time

on the weekend. That way their schools

not impacted as much. It. I told you would take that playing

the video games earlier impacts the brain. It takes about three days for the brain to detox. So really, really

smart schools, what they're

doing is they're introducing the, the, the screen's

turned screens off about three or four days before their

school testing. And then they have the turn screens off during your school testing

and they're seeing a significant

difference in their grades and then

in math scores are up, verbal scores are up. But they're also

seeing this. If you'll see one of the next slides

I have here, the media reduction is reducing

negative behavior, class negative behavior

in the classroom. Negative behavior on

the, in the playground. Please. All this

materials on take the challenge now.net, media literacy

activities to calendar the

media violence. One of the books I strongly urge you to look at is stop teaching our kids to Keil a call to action

against TV, movie and video

game balanced by Dave Grossman and

Gloria dah dah Kano. Dave Grossman's a

personal friend of mine and he is just an incredible

heart and passion to reach

the youth of, of, of our world, that global reach

of our youth. And this book has

just recently been updated in

the fall of 2014. Here are some of

the activities they suggest and stop teaching

our kids to kill. Talk about real

life consequences with your younger kids, with your younger children. When you're watching

media violence talk about real-life

consequences. If you do that, people that do

that go to jail. People that do

that, lose friends, people that do that

become hurt themselves. Help them understand the difference between the, the make-believe and the virtual violence

and what that happen, what the consequences

are in real life. We also need to have a conversation with their younger children that violence is not the

way to solve problems. There are other ways

to solve problems. And I think it's

really important. I like that they

included this, that we need to have

a conversation with our children that

angers natural, anchors a

God-given emotion. It's a natural emotion. But learning how to

handle that anger or learning how to

handle that anger in a productive way

at a young age is incredibly important to have that conversation. Have the kids watch one of their

favorite media, either television show or violent

video games. Have them watch it and

count the violin eggs. Instead of just

watching for the Khan to have

him specifically count the violent acts, talk about real

and pretend. And then talk about a world without

media violence. What would the world be like without

media violence? And then they go on to say, media literacy

activities to counter media violence

with our older youth. Discuss sensationalism versus sensitive

portrayals. What's the difference

when something sensationalized and

something's sensitive? Discuss emotional violence. And the impact of that

emotional violence. I think a lot of our

cyber-bullying can be qualified as

emotional violence. I think, you know, back when I was

growing up, well, we said sticks and stones

may break my bones, but words will

never hurt me. Well, we know that's

a lie. Words heard. Words heard us

for a lifetime. So talk about

that emotional, but let's talk

about what are the consequences of

someone that's being called the SLR or someone that's being

ostracized because of, of their ethnicity or because of their gender. You know, one of the

things that I did when, when I used to work with groups of children

in classrooms, is we would look at all the different ways that kids were bullied. And and I shared with them. I'm five foot nine. I've been five

foot nine since I was 13 years old. I was often picked on, bullied for being tall. I was way taller than my classmates until I

got to high school. And I was also called fluorides

because I wear glasses. And I and I tell the kids, you know, they were

wasting their breath. There is nothing

I can do to be any shorter than

five foot nine. There is nothing I can do to correct my vision. So we are bullying kids about things that have no no power over,

no control over. So many of our kids are bullied about their shape, their size, they're bullied about what their

parents do. I don't know about you, but when I was

eight years old OK. I could until my parents, what kind of a career to have my parents made

those decisions. I think we need

to help educate kids that were actually their bullying

each other for not and there's nothing

that can change. So we need to have real conversations

about these things. One of the things is to read about

real people who continuing on with dr. With Dave Grossman's

recommendations in his book about media violence

with older kids, read about real people who suffered from violence. Real people. It's not virtual anymore, it's

not make-believe. Real people predict

violent content. When you see it, come and discuss the value of m problems with

the rating system. Our values in the

rating system, they are tools

that we can use. Just as I said

earlier, if we just enforce the rating system, we can change the world. So there are values there, but there's still

some issues and problems they are because

they're very broad. Discuss that with

our older youth. Make a recommended

nonviolent TV and video game lists

for young children. One of the things I

have found is that older youth truly do

like to mentor younger, younger youth,

younger children. So to help them come up with alternatives

for the other kids. I think it's

very important. I think one of the things that what let me get back, I'm sorry, I'm gonna get

back a little bit to take the challenge now.net. Take the challenge now.net. When, when they did their ten they

screen turn off. One of the side

effects that they saw was the community

came to life again. We talk during

our break about how people are

scared to be out in, outside in that

we're all kind of siloed in our own homes

and neighborhoods. And Christine Paulson

talked about when when her whole school

district turn screens off for

seven to ten days, all of a sudden the

parks became alive. People were out

walking, riding bikes. People were, were

out at the YMCA, people were at the

bowling alley, people were at the library. When, when there

wasn't something to do with the house and watch TV mindlessly or to mindlessly play

the video games. People actually got out as families. They had. They asked her

kids what they got out of it and what

they valued the most, and the kids they all said they valued the

time with their family. They loved having that time with

their parents. They loved being with their other siblings

and run it into their other friends and it felt good to

be outdoors. And so I think there's some real positive

things that can come out of turn

and screens off. And once again,

it's unrealistic to say to turn

it off forever. That's very unrealistic. You turn it off for

seven to ten days. And then you have a

conversation about, okay, what's going to be now within our elimination? What's our diet

going to be? Our we add? Or we

gotta get back to watching television four to eight hours a day. Or we're gonna get

back to playing video games or, or do we have a little bit of control over that? So there's some other

things we can do to have a book

reference here for you. Last Child in the Woods, lash out in the woods. And the author of

this book references something he calls

Nature Deficit. Nature deficit. We have whole generations of that's not

getting outside. And it's not just that

they're not outside, they're not in nature, they're not appreciating the beauty of nature. I know personally, that's very healing for me. That's one of

my own personal stress management

techniques is to just stop and

enjoy a sunset, to look at a

beautiful flower. Just admire of blue sky. I lived rurally. That's my Appalachians

Bay jumps are out in the woods rule. But I live where there aren't a

lot of lights. And so when I drove him

to my house at night, I can get out of my car and I look up and I can see the stars and I do it every single night

that I'm home. I spend two seconds, three seconds to just admire the beauty

of the stars. Nature is so important. So I want to read you a

summary of this book, last Child in the Woods. In his influential

work about the staggering

divide between children and the outdoors. Child advocacy expert, Richard Louve has turned, has turned this

wire generation, he calls it nature

deficit to some of the most disturbing

childhood dreams he is linked this. We have an issue with

childhood obesity. And some of the things that they're finding is with

the turn screens off. Stanford University

actually started that turn screens off. And they found out

their number one, the number one thing

that changed was obesity decreased when you turned

screens off. Kids move more. When they move more, they weigh less. So that was one

of the things Attention Deficit Disorder, we're seeing when

kids move more, attention deficit

disorder tends to settle and depression. When we move more,

we feel better. Last Child in the Woods is the first book to bring together a new and

growing body of research indicating that direct exposure to nature is essential for healthy childhood

development. And for the physical

and emotional health of children and adults. More than just

raising an alarm, LUV offers

practical solutions and simple ways to

heal the broken bond. The book has a 100 actions that you can take to create change in

your community, school and family. 35 discussion points

to inspire people of all ages to talk about the importance of

nature in their lives. I know not family. We talk about nature every single time we're together. You know, every single time will stops isn't

just beautiful. Isn't that

beautiful? Oh wow. Did you see the way the fog is settling in the

valley and that beautiful aren't the leaves gorgeous isn't just beautiful to see

this, no, like that. We talk about it

all the time. Last Child in the Woods, saving our children from nature deficit disorder has spurred a national dialogue among educators, health professionals,

parents, developers, and

conservationist. It is a book that'll change the way

you think about your future and the

future of your children. There's another book

that I've given you as a recommendation to, to give children as alternatives to

screen time. The name of the

book is smart moves by Dr. Carla Hanford, while learning is not

all in your head. And I don't think I gave you this particular

resource. I gave you a resource

for smart moves. But Dr. Hannah for

talks about brain gym, Gy am brain GM. You can find that

resource under brain GM.org, brain GYN, brain gym.org,

and brain jam on, encourages movement that

crosses the midline. It encourages bilateral stimulation of the brain. Some of you may

have seen my bumper where I was actually

doing cross cross. I was touching my

knee, my elbow to my knees that they brain gym movement that they call cross crawls. And you'd be amazed if, when your children are playing violent

video games or video games if anytime or screen time or even

just reading a lot, get them up and having

to cross crawls. 75-25 cross calls

where they're actually touching their elbow to

their opposite knee. And just doing that engages both hemispheres

of the brain. It's a bilateral

stimulation. You're crossing the

midline of the body. And that alone

can help reset the brain and help

them actually kind of disengage mentally from the task of

the video games. Carla Hanford, some

things that she says, read you some summaries

from her book. Hand referred

examines the ways that sensory-motor

experiences effect short and long-term memory from infancy

through adulthood and argues that movement is crucial to learning. Movement is crucial

to learning. I've, I've, I've read that. Everything we learn, we lock in with movement. Everything. If we learn it, we look a certain way. If we learn it, we

touch something. If we learn it, we,

but we lock it in with a movement that all learning is actually

tied to movement. One of the things that, that smart moves

the book indicates is we need to have less labeling of

learning disabilities. We need to have more

physical movement, more personal expression

through the arts, through sports and music, less prescribing

of medication. Hanford is an advocate

of movement and play in learning and

how critical it is. It's important

in the sensory motor development. Your visual auditory, tactile kinesthetic

readiness is all part of the learning, the learning process. Those of us who know

child development and different

ways of learning, we know that some children are more visual learners, some are more auditory. Some of us, including me, some of us are

more kinesthetic. We have to move

on the person. If I sat in your class, I have to take notes. And people would say you don't need to take notes. It's all there for

ot understand. I need to take

notes or I'm not going to pay

attention at all. I won't remember any of it. So I'm a kinesthetic

learner, so I write, I may never read

the notes again, but the fact

that I'm writing the notes as what

locks in my learning. I learn, but

physically moving. I'm so proud of my son. He just graduated from college with a degree in physical education

because he too believed the

importance of movement. And he's working

with elementary ed. It's so good to

see a young man want to come in and

teach children, elementary aged children

physical education rather than being at

the high school level. But he says, Mom, I

want them to learn to love to move. I want them to love to move. I want to have fun. I know it will

change their world, it will change their lives. So this book

talks about that. So I want to just

encourage you, you know, what do you do and what do we do and what am I doing? What am I doing

to counteract the impact of violent visual

imagery on our kids? You know, am I being the role model

I need to be. I encourage you to

be that role model for other people. And as I've finished

my section of this, before we go to the

last section of Q. And a, I'd love

to finish with just a quick word

of prayer, please. Oh, Heavenly Father, you, You Lord can use this

amazing media event and this opportunity to reach the people that

are tuned in. God, I just am so excited that each

person here can now impact their corner

of the world and the number of kids

that can be touched. And, and Lord, I just

praise you for raising, raising up a generation

of amazing kids who have the ability

to understand and make healthy

decisions if we will, just be the role models we need to be Lord into

do the education. Father asked you to finish this up in a positive, healthy way and the

precious and holy name of Jesus Amen. Thank you.

Diffusing the Teenage Time Bomb

The mother of a preschooler asked me the other day

how she could raise her little girl

so as to minimize the chances of adolescent rebellion down the road. Dr. James Dobson,

for family talk, she had seen teenagers and other families get into drug abuse in

pre-marital sex and other harmful stuff. So she wanted to

know if there was anything she could do now to set up a more

tranquil adolescence? Well, I told her that

when I was a kid, my parents kept me out of trouble with a

battalion of rules, regulations for

every misbehavior inserted most

other parents, and then the culture reinforce those rules and somehow it usually

worked out pretty well. But that won't get

the job done today. It's a different

world and they're just too many opportunities for kids to go wrong. They still need boundaries and limits certainly, but something

else is required. They need the motivation

to do what's right. And that desire to live responsibly comes

principally from a loving, caring relationship

built through the years by parents who have invested themselves

and their children. Author Josh McDowell

put it best, he said, rules without relationship leads to rebellion. There's great wisdom. Their parents need to make a concerted effort to build bridges

to their kids, starting very early to

have fun as a family, laughing and talking, doing things that bond the

generations together. That's the best

way to disarm the teenage time bomb

for the fuses slit. Dr. James Dobson,

per family talk.

 Choose Battles Carefully

And here's Dr. James Dobson and with family talk, one of the most

delicate aspects of raising a teenager is figuring out what's worth a showdown and what isn't. And I remember talking

to a waitress, a single mother in a restaurant a

few years ago. When she found out I

was a psychologist, she began telling me about her 12-year-old

daughter. We fought tooth and nail for this entire year. She said, it's been awful. We go out it every night, usually over

the same issue. What's that I asked? Well, she's still a

little girl but she wants to shave her legs and I

feel she's too young. But she gets so

angry she won't even talk to me during the eye. And I said, lady, go by your daughter eraser, that 12-year old

girl was paddling into a time of life

that were rocker, canoe, good and hard. As a single parent, mom would soon be

trying to keep this rebellious teenager from getting into drugs, alcohol, sex,

and pregnancy. Truly, there would be many

ravenous alligators in her River within

a year or two. In that setting, it

seems unwise to make a big deal over what was essentially

a non-issue. I see other parents

fight similar battles over what we're really inconsequential issues. I urge you not to damage

your friendship with your kids over

behavior that has no great moral

significance. There'll be plenty

of real issues that require you to stand

like a rock savior, big guns for those

crucial confrontations. Dr. James Thompson

with Family Talk.

Complex Oppositional Defiant Disorder and Explosive Children I - Dr. Gary Sibcy

We want to cover what is oppositional

defiant disorder complex Oppositional Defiant Disorder. What are some of the committees

that go with it. And then what are some of the treatment

strategies that we want to use my myself being a clinical psychologist a

child clinical psychologist we're going to look at some of the family and individual

treatment strategies in particular an attachment informed approach to doing

what is called collaborative problem solving skills and

we'll talk you through how that's done and hopefully give you some basic skills

that you may be able to transport into the treatments that you're currently using

import you in the right direction about how to get more training in those areas

the other thing is Dr Cooley will spend some more time covering with you

some of the some of the differential diagnostic issues that you'll see and

then also go into. Some of the different

psychopharmacological treatments and some of the complexities

of going with that so we're hoping that this will be pretty

informative to you we look forward to your questions be sure to send us you

know questions that you have about whether it be cases or points of

clarification we always want to hear and other people tend to benefit from

that a great deal as well but as far as the understanding of

oppositional defiant disorder. Unlike a lot of psychiatric disorders

that you may see like eighty. In children. Oppositional Defiant Disorder has a. A number of relational dynamics that are

involved in it so I want to set the stage very quickly there's other places where

I talk about attachment theory and its relevance for treating kids and

families I simply want to touch on it here so we won't have to

cover that ground later in. And then will help make sense of

why the treatments that we will use will work so attachment theory is

a sort of a med a theory that helps us make sense of other treatments and

other theories when we use them so let's just quickly dive

into a task theory and the best way to go through this

is I have a diagram that up that outlines the core components

of attachment theory and I just want to quickly go through these

and the best way to understand attachment theory is to understand what we

call the secure base system. And the secure base system has several

components will walk through those and. The thing we want to keep in mind is that

this these secure base in the areas that unfold in a child's life

beginning very early. Really through teenage years. Become really in coded into

the child's brain such that it becomes a working model for

how they do close relationships. And it also plays an important role

in how a child's brain actually develops especially in terms of

its capacity to self regulate the billet to use coping skills

self soothing skills and problem solving skills with other people

really occur in that kind of context so let's go through the system real quickly

the first notion is the idea of secure base that children require a caregiver. Attachment figure in order to provide

a sense of felt security and this is even at the biological level that children come

into the world with without the capacity to self soothe and self regulate so

they use the parent as a secure base so think of a of a child say a twelve month

old who would be in a room with a mother. It's a strange room it's called a strange

situation where we can actually measure this but when a child comes

into that room with its mother it's going to really clean to

the mom until it feels secure so it's using the mom as a secure

base once it feels secure or achieves felt security which you can see

there on your screen then that turns on a system called the exploration system

now exploration is the precursor to self-confidence so a child sense

that they can explore the world and. In sort of move around the room and

look at the toys and the things that are involved in it that's

the exploration system it's contention on the child's felt security now should

something occur that creates stress for the child different sources of stress so

it could be a stranger coming into a room that's always stressful to

younger children toddlers or so the child starts feeling

badly hungry tired or if the parent leaves the room and there's

a question about the parents availability all of these are perceived threats

when that occurs then that turns on the attachment system per se and

the attachment system is characterized by anxiety and anger the child is one to get back into proximity with the caregiver

so when the when the attachment system comes on then they're signaling behavior

that there's a problem that can be yelling screaming running you name

it those behaviors are. A part of that attachment system now

it's also important to realize that this activates in the caregiver a signal

detection system in other words how well is it that the caregiver is able to

read the child signals and to decode. Those signals as being a part of the of

the child's need for attachment or need for proximity at that point the child

moves in proximity toward the caregiver and when the caregiver responds to

this and they sort of work together to create a safe haven experience

a safe haven experiences are occur when the parent

the child reunite and there's a return to baseline or

felt security so that gives you the whole secure base in the area now

there are some parts about the system that are important because they play a role in

your assessment when you think about this attachment system or secure base system

let's look at it for a second for example. In in some homes. There is difficulty for parents to even create secure base

that can be things like parents having anxiety disorders depression there could

be a lot of family chaos substance abuse issues with finances moods anything

that can stress the family creates difficulties in the family being able to

create a secure base when that occurs and you have kids who are under chronic stress

and this can affect them on a number of different levels right so exacerbates

whatever problems they may already have. And interferes with the ability to

have felt Security Now remember we had two sides of the cycle right one side

is the self-confidence exploration and the other one is proximity seeking. In some families. The parent may inadvertently

unintentionally discourage the child's exploration and

these families may. Give the child the sense that

the world's really a dangerous place so they deemphasize self-confidence and

exploration and overemphasize proximity seeking So these kids sometimes have

a hard time with separation they. And be very clingy and very controlling

of the caregiver and wanting to keep the parent in proximity we see this

with kids who have anxiety disorders for example where inadvertently parents give

a message to kids that the world's a very dangerous place and they don't really

help their children achieve secure base through collaborative means they tend

to use more avoided coping kind of mechanism mechanisms where they they sort

of try to just distract the child from what's stressing them rather than helping

them problems all right on the other end you see parents who sometimes

over emphasize exploration and and self advocacy so

they push the child to be more. Independent than what

they're actually ready to and when the child seeks proximity or

closeness to parents tend to ignore it and this can create problems where kids

have a hard time using parents as a secure base and this is more of. A dismissive or

avoidant type of attachment so in secure families though the parents

respond in the sense that they encourage kids to explore the world

once they feel secure but when they do get upset they respond to

their emotional signals or emotional triggers sensitively and in a way that

helps the child calm down but also teaches the child how to calm themselves

down so there's a good balance in that. So sometimes you'll see in these families

different patterns of dealing with secure base and we'll have time to go into all of

those different possibilities but I but those are some of the concepts that you

may use now in particular when kids get stressed the way that they signal that

there's a problem can can actually throw parents off so some kids are extremely

reactive to stress and their own stress response floods the parents so

it has sort of this contagion effect. If parents get overwhelmed then they're

not able to sort of respond to the child's stress in a way that is collaborative and

that helps them get sued and calm down so that's an important piece and if that's

occurring then you want to look at what is the stress in the parent out that they

can't do that they may have their own mood dysregulation their own anxiety

problems and sometimes they haven't their own history of and secure attachment

that interferes with doing this. And then there's other times where kids

are under reactive the stress of not very well when they are stressed they don't

really communicate that at a an emotional level or at a signal fashion that allows

the parent to know that there really is a problem and so we want to work at

helping parents become a little bit more sensitive in seeing these problems and

we'll talk more about that later as we as we move through this

the effects of secure base the idea is that these create internalized

working models of relationships right there carried forward from not

just a parent child relationship but into a new relationship experiences and

they shape what it is that you expect to see in those relationships and

how you're supposed to behave so what we find is that these models often

get carried over from home into school and other types of attachment relationships

important to realize that their kids have more than just parents as attachment

figures and that teachers and coaches and these people play important secondary

roles as attachment figures and sometimes you'll see kids carry these insecure

models over into other relationships and they be Haven ways that poor tug for the same kind of responding that the kids

are used to so we want to keep that mind sometimes kids are very especially

kids of experience a lot of trauma. They can be very adept at

being able to pull for experiences that are traumatic from

other adults even when adults aren't on. Typically going to act that way. Secure base also has an important

effect on the development of different neurobiological systems all right it's

been linked to emotion regulation sensory integration language development

and many of the executive skills which we're going to touch on a little bit later

like shifting monitoring labeling and problem solving we're going to get into

what those skills are a little later and how they are a part of many of the kids

with complex Oppositional Defiant Disorder now sometimes kids can have problems

developing some of these executive skills that have nothing to do with parenting or

secure base. And then sometimes. Chronic failures and secure base in

attachment can lead to these types of problems so the arrow can go both

ways and that's important to realize sometimes people think that the arrows

just go either or one direction or the other direction most of

the time they go both ways now when you see healthy

neurobiology healthy neurocognitive system development there's three in a

related systems that are involved in these all occur in different parts of

the brain but in an integrated way. The first is the ability to think right

this is the ability to think logically goal directed Lee All right

the ability to problem solve. The ability to feel the capacity

to feel things in them with intolerable tolerable limits that once you

start to get upset you have strategies for calling them back down and

the ability to relate and communicate. Systems of said Million back and forth

communication you know some kids are able to benefit from you being able to

relate to them and this gesture. You can make eye contact with them you can

read their signals they can read yours relating and communicating. And then the ability to do these things to

think feel relate and communicate all and integrate it goal directed collaborative

fashion so now some kids can think but when they start to feel they stop losing

the capacity to think some kids can relate and communicate but not when they're

upset and some kids can work with you and they can be goal directed

they can problem solve but the question is can you do all these

things at the same time when you can't and this is a non integrated system you've

got fragments you've got splinter skills that you'll sometimes see

kids engage in right for example sometimes you have kids are really

good at math or the really good. In certain language skills or

they're really good. At art. But these are just splinter skills healthy neurocognitive system is where all

the different players are able to play together very well even though

any one player when it's my. As you're just very specifically may

not be superior This is important when you look at cognitive testing that you'll

see that's done on some of these kids some of them have very high verbal cues

where they may have very high. Spatial reasoning or

visual processing capacities but these are just splinter

skills they're not. You know looking at the whole system and how well they all play together it's kind

of like looking a basketball team when you look at Dr COOLEY likes to play basketball

and he's actually very good at it. But a good basketball team you can't

really know how good a basketball team is by just looking at each player

independently you have to look at how well all the players play together

that's that's the idea of a good team. OK so. When you see attachment problems or

failures in the secure base system a lot of times you'll look at some of

the effects that you see maladaptive relationship models develop problems

at the neural biological level and then some of the neuro

cognitive deficit you'll see a lagging skills in the thinking feeling

relating communicating which we'll get to in a few minutes when we look at complex

Oppositional Defiant Disorder and the related disorders that go with

them that all these kids have failures in these areas of

neurocognitive skill development and that's going to be crucial now it's not

always a result of attachment problems or attachment failures but

I will tell you that when kids have severe deficits in these

areas it can produce a tremendous amount of stress on the parent child relationship

and so it can create attachment problems. So that's something to keep in mind it's

not necessarily the attachments that problems or what cause these

neurocognitive the facts although that can happen but sometimes these neurocognitive

deficit and effects can create attachment problems that's important

to keep in mind so let's go. To the disruptive behavior disorders and these include

Attention Deficit Hyperactivity Disorder oppositional defiant

disorder conduct disorder. Now when I say in mention

that it's the most commonly referred referral to community mental

health centers what they usually means is that the primary problem they're being

referred for and we're focusing mostly on Oppositional Defiant Disorder kids

are referred because of this problem but what's important to realize is

that many of these kids with oppositional defiant disorder are going to

have other disorders that accompany it but the parents are most

stressed about the symptoms. Here's a list of the symptoms of

oppositional defiant disorder she'll see temper tantrums right these kids can

have meltdowns now temper tantrums for the kids with complex oppositional defiant

disorder tend to be meltdowns that go beyond just the event itself so

when they get what they want from a temper tantrum even then they don't really get

calmed down that the effects continue. Arguing with with adults questioning

rules act of defiance and refusal to comply with rules. Deliberate attempts to annoy people so

these a lot of times this is when kids are upset and ticked off this is more of

a passive aggressive type of behavior where they're getting even in their

mind they they tend to annoy people and walk away as this is their mode of

operation in terms of how they interact especially with adults and they can be

touchy easily annoyed when they get angry they tend to also get resentful and

this builds so it has a carry over effect. They can be mean and

hateful when they get upset spiteful and vindictive revenge seeking All right so. A lot of parents can describe some of

these symptoms in their kids at any time in their child's development but when

it becomes disorder then these become more pervasive more enduring and

they last for quite some time. Kids with complex Oppositional Defiant

Disorder they meet the criteria for oppositional defiant disorder

which we just looked at plus they tend to have some other

disorder that accompanies it such as a mood disorder like depression or

anxiety disorder. Or going back to the mood

disorder many of them may have. A bipolar disorder and Dr Coolio go into

a little bit more detail about some of the differential diagnostic

considerations with that. And a lot of them have attention

deficit hyperactivity disorder or at least a sub syndrome version of that so

they're going to have problems with inattentiveness or

empathy impulsivity or both but they may not fully meet the criteria for

eighty H.T. and that's an important thing that those symptoms still even

though there are some clinical are quite relevant especially when you package

it together with the other problems. But these kids also have problems

that instead of looking at it just diagnostically let's look at it

in terms of significant skill problems many of these kids have executive skill

dysfunction and neurocognitive skill dysfunction which we're going to

get into in just a few minutes. Problems with a motion dysregulation

which we'll talk about more relationship disturbances which include the attachment

system so many of the parents when they come when we talk about a disturbed

attachment system is that the child does not believe that the parent can actually

be helpful to them they don't believe that if they're in trouble that the parents the

one that they can actually count on and and who are the parents have an extreme. Only global negative rigid view of

their child that doesn't allow them to respond to the child more flexible

sensitive kinds of ways and that's usually an indication that you've got

a relationship disturbance on your hands when people look at their relationship

in such a negative kind of way. And kids with complex Oppositional Defiant

Disorder are extremely resistant to traditional parenting practices right so

their traditional parenting practices and much of your your basic behavioral

therapy programs or are going to usually fail fairly miserable miserably for these

kids and we need to be able to talk about that because if you've treated these kids

you probably tried to do some form of behavioral parenting which included

things like time outs removal privileges. Token economies these kind of things and

they tend to crash and burn and

you're frustrated parents are frustrated. The tell you a little bit you know in

the clinical practice that I work and these are the type of kids I get

as a referral most often and many of them have been through several

different providers several different therapist from counselors family therapist

clinical psychologist who have tried a number of different treatments most of

them all behavioral and they failed so I'm in a advantaged position because

they're open to trying just about anything at this point and this can be a good time to learn some of the stuff that

we're going to go over tonight. All right so this is a piece that we want to be able

to work on in working with parents. I want to be able to explain

this to you in a way. That I also explain to parents one

of the first pieces of treatment and working with with with one of these

systems is in a parenting system is to realize that we want to

work with the parents of primary. So if you only get a chance to try to

work with with a parent or with a child you want to start with a parent and

I'm going to present to you a way of helping parents immediately refrain their

child's problems remember they've got these global negative views of their

kid they're rigid they're inflexible. And you've got to help them begin to

reframe their child's problems from just being a kid who's spoiled and

who wants attention and it is all bad to a child who's got

skill deficit that we can work on and this is a crucial part to

make treatment work so what I do is I start here at the top

I usually just draw that first. Triangle of self-control and I draw

that out and I point out to parents I said look this is one of the preeminent

goals that parents have for their children if they want their child to

have self-control or behavioral control. And most parents will nod

to that yes that's it and then I draw the rest of the pyramid and I

say that's an important goal now the thing to keep in mind is that that goal rests

upon the ability to do these other cognitive skills and other words

the ability to control yourself and to deal with the demands of life requires

your ability to do these other skills and let me explain what they are and

what we find is that kids who have complex O.D.D.

kids who also have bipolar disorder. And a lot of kids who have A.D.H. T. have significant problems in

these neural cognitive skills and I go through my ask them does

this match your child so let's start at the bottom and the bottom

is the biggest because it and in the most important because when it fails

the rest of this pyramid crumbles but will start with emotional regulation now

most regulation has different components the first one has to do

with frustration tolerance. So your ability to handle frustration

is crucial many of these kids don't have much of it all so some you

think frustration tolerance is from zero to ten ten being you know

where you're really angry and in a rage and upset and falling apart and

zero been pretty calm and cool a lot of these kids go from zero

one two they just start to get a little bit stressed a little bit upset and

boom they're all the way into a rage so. When things don't go exactly according

to plan or they start to get any kind of provocation boom they lose the ability

to regulate those feelings now the other thing about emotion

regulation is after you get upset Can you down regulate Can you get calmed

down they struggle with this ability so once they get upset it's not like they can

actually call themselves down where they really struggle with that ability so

that's the second part the third part is a motional stability some

frustration tolerance usually has to do with some type of

external provocation emotional stability has to do with can't as your

mood stay relatively stable across time. Whereas these children their moods can

change relatively quickly and rapidly and it doesn't have to do with anything

that's going on externally so sometimes it's when they wake up in

the morning or when it gets bed time or if they feel hungry or they feel tired

some more internal factors can trigger significant changes in their moods next

skill social skills now we're talking about this in broad strokes but I want

to social skills sounds very broad but more specifically these children struggle

with the capacity to read how their behavior affects other people particularly

being able to read other people's non-verbal social cues that say that

this is a problem they don't they. I don't read them accurately sometimes

they think that people are angry with them and upset with them when they're not or

sometimes they just don't read them at all so they don't see that people

are getting angry and upset with them. And they fail to benefit from back and

forth communication they can't stay on track with you so you ever have

a conversation with somebody as you start to talk to them they change

topics they go someplace else that's a social skill being able to stay

focused enough to stay in a back and forth goal directed conversation where

they're able to collaborate with people their tendency is to move against

people or to move away from them but not toward them this is something

we really have to help them with. The next is language processing

OK Now this isn't about how big the vocabulary is it's more

about their ability to language to use language to label internal

processes what do they feel. Why do they feel that way

a lot of times when you ask these kids what's wrong what's bugging

you they'll say I don't know right or he's an anti it or throw out some

expletive it's important to realize that they can't do this not because they

know and they're refusing to tell you they actually don't have an internal language

for this they're not good at picking up on the internal dialogue that's

unfolding with them then within them and this is an important piece that you have

to be taught how to do this now when kids have poor language processing skills

they can't figure out what they feel why they feel that way the problem is that

they don't know what other people feel and why they feel that way so they tend to be

fairly egocentric and they lack empathy. So will move on to the next cognitive

flexibility flexibility is your ability to see things in shades of grey these

kids tend to see things in black and why all or nothing either or categories flexibility also has to

do with the ability to shift gears so with things aren't going according

to plan and you're able to shift. Years and come up with a new plan or to you know to bring your cognitive

abilities or focus onto the new plan and adjust to it when you can't do that then

you tend to see problems around transition periods now this is crucial because many

parents think that these problems come out of the blue when in fact they're

actually very predictable problems and if we help parents pay attention to these

transition points throughout the day bedtime coming home from school

study time getting ready for bed showering bathing any of these transition

points in the day can be the key triggers for

the problems with emotion regulation so they have a hard time adjusting to things

not going according to what their plan is. All right so you need emotional regulation

social skills language skills and cognitive flexibility to move

up to problem solving and these are where

the executive skills reside. There's a number of important skills

that go into problem solving. And it's actually quite complex but

these kids tend not to do it very much or very often. The first thing you have to be able to do

in problem solving and so the executive skill is the ability to have hindsight

hindsight is where you're able to see that something has happened in the past what

the effects were and whether it worked so they learn from experience these kids

typically don't that's the reason that many of the parenting practices that are

punishment based and highly consequence based don't work because these kids don't

learn from those experiences instead they feel like you're just punishing them from

out of the blue they feel they feel like victims of the universe largely because

they don't have the cognitive skills necessary to register that these are

problems that the register or the effects of their behavior on their environment and

why they're experiencing the consequences that they are the other thing they've

got to be able to do problem solving. Is that you have to have foresight So

this is the ability to a know what it is that you actually want that's

a language skill but also what are you trying to achieve what are you trying what

do you want to see happen here you'll be surprised that kids really struggle

with this now the parents will too but we're would talk about how to address that

so knowing what it is that you want and then coming up with possible

realistic plans for getting there. Being able to evaluate those plans are

they likely to work or not likely to war what are potential roadblocks

potential problems realistically and then being able to construct a plan for

I'm going to do this solution and what what would be the plans and I would need

their sequencing skills are involved here and even motor planing skills are involved

sometimes kids know what they want they kind of have a plan for an idea how

they can get their potential solution but no real plan for

how do I act that I do this this this this they don't get that and

sometimes we don't help them do that now here's the thing traditional

parenting works very well for kids who have these skills they assume

that those skills are there and behavioral approaches work well for kids

who have these skills because behavioral approaches are extremely helpful as we'll

see in the next section that I do on helping kids who have motivational

problems so they have these skills but they refused to use them because they

would rather do it the easy way. They don't want to have the problem

solving they would rather manipulate people or work around them and that's fine but these kids don't

have these skills and what's important to realize is that it's the kids

who don't have these skills who don't use this part of their brain the prefrontal

cortex the a mid to low the anterior cingulate gyrus some of these parts of

the brain they don't use these skills and what's interesting is that adults

don't let them use them if you. And seeing kids who have problems with

self control adults are constantly telling these kids what to do and when to

do it and how to do it without actually giving the kids the opportunities

to learn how to use their brain and to use relationships and to build these

skills so they can learn how to do it so what we're going to propose to you

is that the treatment that will use actually works at changing the brain. And in order to do that you have to

create the right kind of experiences that allow the brain to change

you have to challenge it so I tell parents that the skills that we're

going to teach them collaborate problem solving skills is like taking their kids

brain to the gym and using real life real problems to help them come up

with real solutions we can get kids to engage in collaborative problem solving

it requires that they use all these skills all the way up the ladder and as they

get that down then they'll be able to. Get better. At self-control and we'll also see

some growth going on at the neuro biological level which will see the doctor

currently begin to introduce how we will look at that with medications so that sort

of change in the brain from the bottom up where is the stuff that we work on help

change the brain from the top down.

Complex Oppositional Defiant Disorder and Explosive Children I - Dr. John Kuhnley

This is a very complex topic and

when I was asked to join duck to subsea on this topic

I've looked at the literature and this is State of the art issue

right now D.S.M. five is currently in development through the American

Psychiatric Association the Diagnostic and Statistical Manual fifth edition and

there's a lot of controversy and debate going on about this very issue

what do we do with these this regulated children how do we diagnose them

because bipolar disorder in children has risen from say half a percent twenty

years ago to seven percent today and I want to explains that and

they've done studies in various places and found that a lot of the children being

diagnosed with bipolar disorder truly don't have bipolar disorder so we do need

a lot of clarification in this area and why do I mention bipolar disorder because

O.D.D. is often the tip of the iceberg as Dr subsea himself pointed out that tells

us that there's other things going on. We hear the D.S.M.

four text we revision criteria for oppositional defiant disorder and I've

put in red the three emotional criteria that are involved in often lose

his temper is often touchy or easily annoyed by others and

is often angry and resentful these three criteria

predict a whole lot in terms of where this child is going in terms of the

development though I don't think there's a lot of research showing the outcome

specifically for those three areas but Dr leave unfold Dr Alan Lipman fold has

published an article in the February two thousand and eleven issue of the

American Psychiatric Association Journal that spending a lot of

time on with you today now the other criteria basically say that the

disturbance causes clinically significant impairment we're not simply talking about

someone who has temper tantrums we're not simply talking about someone who gets

annoying now and then we're talking about someone where it's clearly a disorder and

we want to make sure there were when we do our evaluations of children

we want to do a comprehensive evaluation we want collateral input we don't want

to just take the child's input we want the parents input we want the schools

input we want any input we can get to try to get as much of the picture

as possible and what we're looking for is true impairment in functioning in more

than one area of functioning because if it's only in one area functioning them

then there might be something psychosocial going on in that area the behaviors do

not occur exclusively do in the course of a psychotic or mood disorder if they do

well they were dealing with a psychotic or a mood disorder. The criteria are not met for

conduct disorder and if the individuals eighteen years or

younger then they don't meet the criteria for anti-social

personality disorder those are exclusions. Now what gets us to the point of

oppositional defiant disorder in children with Dr sibs he focused on the attachment

issues he also talked about self regulation self control having

trained it you know back in that era when I trained seventy nine to eighty

one we didn't have a lot of medication intervention we talked about therapy and

we learnt how to talk with children and listen to what they're saying and

understand why things happen the way they do and when you do that children have

a lot to say it's fascinating people wonder why why do children talk to

you Well it's because I listen and I'm interested in what they have to say

well kids told some kids can't tell you why they do what they do they just

do it but some kids are bright and articulate and able to say that they want

they want to they feel out of control and if they do what you tell

me to do then you're in. But if they do what they want

to do in a position to you and they feel like they're in control Well

unfortunately that's maladaptive and trying to get them to see that is the goal

of treatment isn't an identity formation is involved the separation individual

vision stage of development is implicated here the state anxious avoidant attachment

as was discussed earlier but Dr subsea genetics genetics controls a lot of

our predisposition to what happens for us it doesn't necessarily dictate

because other influences we now know can can affect the genetic translation but genetics affects temperament genetics

affects our neurobiology or physiology and all of that together changes

over time in development but it's one of the major contributors

neurophysiology is involved as we'll discuss in detail family dynamics

very much involved in the doctors if he's already gone over

this in beautiful detail. The best available data indicate

that there is no one single cause or main effect that results in

oppositional defiant disorder is basically the confluence of all of

these factors together in that individual over the trajectory of development

that produces what we see in those criteria that we call oppositional

defiant disorder that does tend to be familial clustering of certain disruptive

disorders which include the oppositional defiant disorder the attention deficit

hyperactivity disorder substance abuse and mood disorders and as we're going to

see as we continue this discussion there's a lot of overlap within our

conditions conditions that we diagnose and our goal is clinicians you and

I are to differentiate out of all of the evaluated data what is actually going

on with the child and oftentimes it's more than just one condition biological factors

as over dimension of very important. Talking about neurophysiology under a. Two autonomic stipulation stimulation

that's a bottom up regulation. Coming from deeper centers

of the brain is involved and we see that with low resting heart rate

in individuals with conduct disorder and oppositional defiant disorder. And this under arousal causes them to seek

stimulation to stir things up because the. Exogamous factors such as prenatal

exposure to toxins out the whole poor nutrition all seem to have effects

but the data is inconsistent on the. Studies implicate abnormalities in

the prefrontal cortex that's the top down regulation which Dr subsea else already

referred to that's our executive function our ability to hold things in working

memory to inhibit impulses or ability to think things out rationally

all of that is part of our executive center and we definitely see as

the maladies in the executive function in. And if we look to do a chemically we see

altered neurotransmitter function with the certain energy NORAD and

dopamine and IT systems. Low cortisol and elevated testosterone

levels have also been implicated in. There are three classes of behavior

that seem to be hallmarks for both oppositional and conduct problems

including noncompliance with commands emotional overreaction to life events

no matter how small and failure to take responsibility for one's own

actions and one of the questions that was posed is how do we differentiate amongst

these conditions with respect O.D.D. Well the emotional side of things goes a

long ways in helping us differentiate but what helps us to Dale down

the oppositional defiant disorder or conduct disorder side of things is

this failure to take responsibility. Is quite prevalent. Actually is six to ten percent in surveys

of non-clinical non referred samples based on parent reports co-morbidity of

O.D.D. with A D H D ranges from fifty to sixty five percent of affected

children co-morbidity of O.D.D. with and after deciding whether it's an anxiety

disorder a bipolar disorder or depressive disorder ranges around thirty five percent

and the range the rates increase with age. This is a diagram that I put together

to help with differential diagnosis and co-morbidity of the various diagnoses

that may be implicated here. Oppositional Defiant Disorder is the main

topic of our discussion today but as you can see it's the tip of the iceberg

and it's the most common presenting complaint when the child is is at odds

with the important people in his life or her life that's what's going to get them

to bring the child in and ask us you and me to do something about it and

so we do our evaluation and our job is to look for

the criteria we use the D.S.M. for T.R. Now I will discuss the S M five a little

bit as it still in development but we we want to have a differential

diagnosis other words is it is it a D H D. Is it anxiety disorder

is it one of these or there may be co-morbidity that

co-morbid means they're together you could have two of them at the same

time in fact that's the most common phenomenon is that you're going to

have co-morbid conditions together. So O.D.D. is very commonly associated

with A D H D is mentioned fifty to sixty five percent So

if a person meets the criteria for. But does not meet the full criteria for

eighty H.T. we diagnose. But we watch because we may be seeing

the inattentive subtype of A.D.H. D. for example by the way I use eighty and

eighty interchangeably I don't mean to be for to any subtype spies doing that

it's just easier to say A.D.T. but the inattentive subtype occurs in about

forty percent of individuals with A.D.T. and is often not detected because these

kids are quietly sitting there inattentive distractable they're considered to be

air head space cadets slow learners but they don't cause any trouble so

that means they're not going to get referred very often

until something happens and usually what happens is they run into

problems with anxiety major depression. And sometimes really do

the inattentive type show up with I have to admit usually

the kids show up with O.D.D. of the disruptive ones and

they they get referred for the D. or the. But we also see some co-morbidity

with bipolar disorder and major depressive disorder and

we can see the triad of O.D.D. A.D.H. dna exotic disorder or even four or

even but you can have five of these. With major depressive disorder and bipolar disorder the way we differentiate

that out is once a person has a bona fide manic episode that person has

a diagnosis of bipolar one disorder. If they have a bona

fide hypo manic episode then they have a bipolar two

disorder if they had a previous major depressive disorder they no longer

have that diagnosis all it takes is one episode manic hypomanic

to nail down that diagnosis. So what is happening in D.S.M. five right now well it's not unusual

that we have patients that come into our office with mood disorder but

they don't meet the full criteria for bipolar disorder they don't meet the full

criteria for major depressive disorder and that's what mood disorder not otherwise

specified is when they don't meet the criteria for either one but it's

clear that there's a mood disorder Well people have been trying to define

the that group of people and temper dysregulation disorder is

one of the proposed diagnoses for D.S.M. five highly debated

because the D.S.M. five panels are being accused of

trying to take temper tantrums and turn them into a diagnosis Well that's not

what's happening in an Ellen lieben fault has done a lot of work in this regard and

she's referenced in your references at the back of this presentation very

worthwhile to read that article. But she actually proposed her group

actually proposes severe mood dysregulation it will be going

over that in some detail. So as we look at this chart

right here this is how we think out what's going on with the child is it one diagnosis is it co-morbid

diagnoses we want to differentiated. So just give you an example of

that if a child comes in and the mother says the child is

inattentive distractable. Easily for us to absorb easily

frustrated where does that happen doesn't happen at home does

that at school when does that happen will if it only happens in the context

of when they're anxious and nervous but

not in between it's not a D H D It's an anxiety disorder because if you look

at the eighteen criteria for eighty H.T. that is not specific for anything they

can occur in any of these conditions. The way that we make the diagnosis

of a D D Is that when at baseline when the person is simply being

who they are they beat those criteria then that's a D H D and I use the analogy

with vision to help people make that. Differential or to understand that because

without these glasses I'm at baseline and my vision is out of focus with these

glasses I can get back into focus but at my baseline I'm out of focus if I

squint if I'm motivated to see better I can do it by squinting OK so

sometimes we can overcome our condition a little bit we just can't sustain it but

to make the diagnosis of A D H D You want to see those

eighteen criteria you want to see six of one in six of the other of the hyperactive

impulsive and inattentive subtypes. Manifested in the individual at baseline they don't go away they don't go on

vacation if they do that it's not a T.H.D. they can occur during the course of

a major depression but then disappear when the depression resolves they

can occur during a manic episode and then disappear with a manic episode

resolves will then it's a manic episode or it's a depression it's not a T.H.D. But

when the manic episode goes away and their baseline and they have the criteria for

eighty H.T. then they have a co-morbid. OK this is breaks out just aggression. Is co-morbid conditions in O.D.D.

aggression is common it's purposeful it's not impulsive and that differentiates it

from a T.H.D. and people kids with O.D.D. fail to take responsibility for

it that differentiates it from A.D.H.. A.D.H. the aggression is less common it

tends to be impulsive it tends to be when they're frustrated it's less purposeful

and afterwards they were more subtle they didn't mean to do it it was just

like they did it without thinking and that differentiates A.D.H.

O.D.D. on that parameter now. Are highly co-morbid fifty to

sixty five percent of the time so you often see them mixed up together and

you can get a confusing picture where they say will sometimes every morsel sometimes

or not and basically it's a matter of them that they have both conditions in play at

the same time just to confuse us and so that's our goal is clinicians to sift

through that isn't it one anxiety disorder aggression is not common but

it can happen when their fight and flight reaction is pressed you

getting in their way in there you go off so

anxiety can lead to explosive episodes but they tend to be more civil afterwards that

it mean to do it it's just that they were overwhelmed that they didn't know what

else to do and let's face it half of the fight flight mechanism is fight and

so that's what you're going to get. If you don't let them engage in flight and with anxiety disorder it's more directed

inward than outward which different states from the other two major depressive

disorder it's not common these kids are more withdrawn but it can be reactive

doing episodes of depression and if you try to push these kids when

they're just don't have the energy or whatever to do it they can become

aggressive but it is more directed in with an outward bipolar disorder it is

episodic we look for discreet epa. Within between functioning not showing

evidence and that's what is important in the criteria of bipolar disorder however

during the course of a manic episode or a depressive episode the aggression or

person may be sustained and when I talk about the outbursts

that occur comparing say. And bipolar disorder. When a person with in a manic

episode has an outburst it tends to be like a hurricane

it just goes on and on and on whereas with a person with A D H D It

tends to be like a hang with a. Who do you look at it. And then they settle down and

there were more subtle now we get to temper dysregulation it's order and severe

mood disorder this is a category we're looking at non episodic rages this is

the area of hot debate right now this is the one that's under a lot of study and we

just don't have enough information on it. But let's look at irritability

irritability is very key to these rages and mood disorders. Well the D.S.M. four doesn't help us

much it does not give a definition of irritability despite the fact it

is included in all of these diagnoses that you see here manic oppositional

generalized anxiety disorder dystonic disorder P.T.S.D.

a depressant What are the causes variability it can be a normal

developmental thing doing preschool and during adolescence a lot's going on in the

brain development and as a result of that development the individual tends

to be a little more irritable So if it appears to be just an adjustment

thing than we it it's not pathological we don't want to give it a diagnosis we

just want to help them get through it. Sleep deprivation can produce it would

ability psychosocial circumstances moving losing a friend things of

that nature dealing with a bully can produce irritability So we want to really

differentiate out all of these possible causes nutritional deprivation and

legit reactions psychiatric conditions and medical conditions that we have to decide

to discern what's producing the urge ability in our patients it occurs in many

different different clinical presentations chronically in severe mood dysregulation

during episodes of mania or depression so it's episodic when you're talking about

bipolar disorder or depression and in specific contexts with P.T.S.D. when

they're faced with a stressful situation and data suggest that the pathophysiology

viewed ability including the specific dates of the intentional control deficits

will vary across clinical presentations so whatever co-morbid conditions you have in

that particular clinical presentation it's going to cause a different picture for

you to have to discern. So in some clinical state such as

acute mania bottom up regulations may be particularly important since increased

arousal may be associated with increased irritability lead unfold

has this wonderful diagram which will go over with you there or

she gives three Beckett isms that cause decreased threshold of frustration

tolerance or increased probability of frustration of goal attainment or

blockage of goal attainment and the anterior cingulate cortex dorsal

prefrontal cortex etc are all involved in dysregulation attention

emotion interactions which produces an amplification of frustration because

those parts of the brain are not working properly then the person frustration

level is not being regulated so it's amplified and what that does is it

decreases the threshold of how much does it take to get that person

frustrated in the first place misinterpretation of emotional stimuli

what you find the temporal cortex in medial prefrontal cortex are involved in

face recognition of emotion and if a child is not accurately interpret what's coming

at them from the environment they can get frustrated when there's really no

reason to be getting frustrated and this discourse is a decrease in the threshold

of what it takes to get frustrated and then there's decreased context that

sensitive regulation which can involve the anterior cingulate cortex cow

date the nucleus accumbens cetera and what this does is it

increases the probability. Of goal attainment being blocked

Well we blocked in cheating our goals we do get frustrated if our dervish

system is working properly then we deal with it if it's not working properly then

we get amplification of frustration and this produces the increased irritability

and behavioral disc control. So while the criteria for

oppositional defiant disorder include often lose his temper often touchy and

easily annoyed by others and often angry and resentful which are the

emotional criteria of that condition none available children can also get that

diagnosis but it's going to be based on just the oppositional side of things and

so those would be the more simple. Than come complex. Severe non episodic irritability

in in use maybe on a pathological continuum with bipolar disorder and

major depressive disorder as you remember from the diagram I had the bipolar

disorder the major depressive disorder and the continuum in between is where this

non episodic irritability seems to fall there is no D.S.M. four category that

captures all of this has been previously Well these are the criteria I don't have

time to really go through them in great detail but what they're trying to do

here is characterize blue disorder not otherwise specified they're trying to

characterize these highly co-morbid individuals in these individuals with with

a lot of co-morbid conditions that end up with these this dysregulation mood and

we get these outbursts are grossly out of proportion in

intensity and duration to the situation or provocation and it's inconsistent with

a developmental level so they're trying to make sure that we're ruling out any

normal developmental aspects and that in between the outbursts you're going

to have this negative valence it is this it's negative mood that persists

even with a not having the rages and even though it might go away

might only be there half the day by like go away for

a week it's going to come back so you don't get these nice discrete episodes

and when it does go away didn't go away completely You still have

a negative overall temperament it gives ages of onset this is all still

in development nothing's been decided yet. And in the past year they don't meet

the criteria for manic disorder. Bannock episode if they do meet

the criteria for a manic episode we want to be considering this diagnosis

will be going right for bipolar disorder. And they don't occur exclusively doing

a psychotic disorder because if they do occur exclusively during those

episodes and that's what you diagnose. Will severe mood dysregulation I don't

have the criteria in the slides it's available in the article by leave

unfold and basically has very similar and the focus is that temper outbursts of

development venom the littlest scuse me developmentally inappropriate frequent and

extreme and negatively valence mood is in between outbursts what's

important is that she's studied the severe mood dysregulation she wants

to make sure she answers that question or we simply taking kids with temper

tantrums and giving them a diagnosis and her data says no way we're not doing

that what it shows is that eighty five percent of this sample with severe

mood dysregulation criteria for oppositional defiant disorder eighty six

percent with eighty H.T. fifty eight percent with anxiety disorder and sixteen

percent with major depression so can you see what we're looking at here when you're

looking at severe mood dysregulation you're looking at individuals with

a lot of co-morbid conditions so you are not included in the severe

mood dysregulation sample if they are attributable to a major depressive

disorder or an anxiety disorder so if they go away when the depression is not

there or they go away when the anxiety is not there then they don't get included likewise are not going to be

included if there's a manic episode. And interesting finding is coming

out of her study that the children with severe mood dysregulation appear to

go on not to develop bipolar disorder but rather to have more of an anxiety

disorder or depressive picture so pretty much to cover that so she looked at a sample of the individuals

with severe mood dysregulation and saw the three symptoms of O.D.D. in there

that the temper tantrums being angry or resentful and being touchy easily annoyed

and in her sample she saw fifteen percent of the youths bet the criteria if

they had O.D.D. they met the criteria for S.M.D. and the severe mood

disorder phenotype accounted for approximately a quarter of the youths

with D.S. So a lot of of indication of. Being the tip of the iceberg

being the indicator that something else is going on

that we have to study closer. To Oppositional Defiant Disorder does

differ from severe mood dysregulation in focusing primarily on opposition

ality not irritability and including patients with less severe illness so those

are going to be more the ones that we call simple O.D.D. they don't have as

much of the dysregulation going on. Behavioral data indicate that both use

with severe mood dysregulation and those with bipolar disorder differ

from healthy comparison subjects in some important areas the face emotional

labeling ability to belittle to look at the environment and read what's coming

at you and they misinterpret that and so they they get easily frustrated even in

situations when they have no reason to be easily frustrated they overreact because

they're not perceiving accurately to degree of subjective distress reported

while performing a frustrating task they get frustrated by their goal

attainment the Duro circuits coming from the executive center of the brain or

not helping them to module late that the arousal coming from below is

aggravating it and the end result is they're getting more frustrated and

as a result of becoming more frustrated the less the able to handle the task

which just produces a vicious circle. And it results in a blow up their

overwhelmed their raging It's like they're saying I can't handle this do

something and they're just reacting so in the first two domains data also

indicate that despite similar behavioral deficits in the two patient groups

the mediating neural circuitry differs so that severe mood dysregulation and

bipolar disorder have some overlap but they also have some

differentiating factors and while that is still under study right

now it's not real definitive there's some exciting work going on and a lot

more that needs to go on in that regard. The fact that only the severe mood

dysregulation and bipolar disorder groups differed from the healthy

comparison groups in performance on a face of motion identification task suggests

that severe mood dysregulation and bipolar disorder might share some

path of physiologic mechanisms despite similar face emotional labeling

deficits and severe mood dysregulation and bipolar disorder neural activity in

the middle differs in the two groups and that's what's under study at this point so

use with severe mood dysregulation and those with bipolar disorder

both reported that frustration. Both reported more frustration and did

the healthy comparison subjects and they look doing imaging work to try to sort

out what that could show us in terms of differentiation as we tried to develop a

differential diagnosis and use with by for polar disorder had deficient top down

executive attention specifically doing frustration while use with severe mood

dysregulation had deficits in the bottom up early attentional processes during

both frustrating and not frustrating blocks what's going to come of this I'm

not quite sure yet but it's exciting work. This was just a little bit of

differential that I put together it's much more complex than this but it

terms of trying to sort out what's A.D.H. what's bipolar disorder and mention

the hangman aid versus the hurricane in terms of how the rages might play

out sleep is an important factor if you look at children with A D H D They

have difficulty settling for sleep. Because of the end of the A.D.H.

the symptoms I practive impulsive easily frustrated just hard to settle

at night whereas the hoops the. Touch the button there were as

patients with true bipolar disorder they have a decreased date for

sleep so if you do the interview and you find out that the child didn't

go to sleep at all last night and today it looks like they have

no effect from not having slept you're probably dealing with

someone with bipolar disorder so that's one of the clues that definitive

but it's one of the clues elated or expansive mood which means that there's

a sense of grandiosity in the mood in the. It's bigger than themselves. You see that bipolar disorder but

you don't see that A.D.H. D. in fact in bipolar disorder you

can see more inflated self-esteem doing the more manic side of things and

in A.D.H. You probably see lower self esteem because

it's so accustomed to being yelled at and corrected and feeling bad because

they impulsively made mistakes and so they get a more low self-esteem

hypersexuality predominantly higher in bipolar disorder

compared to A.D.H. D. though it can occur in a small number

of individuals with just a H.T. and racing thoughts it's much

more common much more racing in individuals bipolar disorder whereas

people with A.D.H. He will tell you that they can't turn their thoughts

off either but the not quite the amplitude that you see in bipolar disorder so think

about polar disorder as higher amplitude. But other factors that you see in A.D.H.

D. overlap with bipolar disorder

don't help us at all in trying to come up with

a differential diagnosis. Irritability is not a diagnostic

criterion for A.D.H. T. but they have low frustration tolerance

and they can erupt as a result of that frustration because of

self deficits and self regulation. So the distinction between

severe mood dysregulation and bipolar disorder may have important

treatment implications we have all these children now in this country being

diagnosed with bipolar disorder and there are centers that are taking children

in who have been diagnosed with bipolar disorder putting them through rigorous

diagnostic testing including psychological testing structured interviews and

trying to sort out do they or do they not have the bipolar

disorder interestingly. Maybe ten percent of those who receive the

diagnosis truly have the diagnosis in some of these studies so that's pretty scary

why because these kids are going to be treated with some heavy duty medications

which will be talking about in part two so your job in my job is to do a good

differential diagnosis following our comprehensive evaluation determine

if there's co-morbid conditions and come up with a board targeted treatment

plan and determine whether or not they truly have a diagnosis

that we choir's Medications such years of being used I think

excessively in this country for bipolar disorder where in

fact it may not be necessary. Now that being said there are a lot of

kids who've been diagnosed with bipolar disorder who probably have this complex

Oppositional Defiant Disorder which seems to be an indicator of severe

mood dysregulation and many of those kids will require

the same kind of medications but that's that's what I have

to try to sort out and assess the risks and benefits but given

the relatively high side effect burden of medications such as the atypical

antipsychotics in the mood stabilizers coupled with the risks of using end of the

presence of stimulants in bipolar disorder the differentiation is very important

which is the topic of part two today.

Complex Oppositional Defiant Disorder and Explosive Children II - Dr. Gary Sibcy

We were on the pyramid before. And I do present this pyramid to parents

and this is an important piece of our treatment is this is sort of the psycho

education piece it helps parents begin to rephrase the problem a little and

this is crucial because a lot of the negative feelings that

they have about themselves as parents or about their child comes from what they

think is the cause of a problem and it's also important if you're going to treat

a problem it's important that you have an idea of what's really causing it what's

really what's really at the heart of it. And this plays this plays

a really important role for for your treatment alliance with the parents

I can't really go through all the sort of there's a number of different

things that we do with parents to to address some of their negative feelings

and reactions toward their child and other types of approaches that we use to

sort of soften those those feelings and we we probably won't get time

to talk about them tonight you might see in a question

in the question and answer we can talk about that maybe

during that period of time so giving parents this as a beginning or

a starting point can be important and keep in mind that what you think is the

source of the problem will affect how you go about treating it so

it's it's important because most parents will come into treatment thinking

that the problem is a motivational problem that their child is misbehaving because

they have poor motivation they want to misbehave in order to get get their

own way or get just get attention or they just want to control everybody and

everything and when you look at it as a B. as a motivational problem then you're

going to tend to want to use behavioral interventions now it is true that

behavioral interventions are extreme. Really helpful for motivational

problems so taking away privileges for you know removal of privileges token

economies timeouts punishments heavy consequences can be extremely

helpful especially when they're done consistently and realistically but

they're not helpful for these children and that's important to realize at

least on the front end that more of the problem is related to skill

deficit's And this this is an important piece this is a chart that the role

screen uses to help highlight some of the sort of the interaction between skills

and motivation and if you look at the top left quadrant is you know this

is a kid who has motivation and skills and those are usually pretty

adaptive kids now there are kids who on the top right quadrant who

have skills but no motivation and in that top White right quadrant obviously

that's maladaptive but a good be a good dose of behavioral therapy will work

extremely well for that quadrant of kids. Then you'll see kids who don't have

skills and don't have motivation. You know so these are kids that

we're going to work with and then there are skills though there's

a lot of kids out there who have. They really struggle with skills so

they don't have skills but they are motivated to do well. And a lot of kids fit in this camp

to a surprising number of kids fit into this camp one of the things

that Ross Green says and I agree with this mostly but not totally

is that there are plenty of kids out there who want to do well they really

do they don't necessarily want to get in trouble with adults they don't want to

get in trouble with their parents but they find themselves with a locked into

this this pattern of behavior in this behavior if you will and then of course

there are kids who are in the path in the they're angry they're ticked off and

they're not motivated to do well they've. Given up they've decided to crash and burn I call these kids to kamikaze

kids a college cause a pilot if you will has you know those pilots

who are willing to crash their plane into into a ship they take their own

lives in order to see that ship go down. And there's a sense in which some kids are

willing to shoot themselves in the foot figurative really speaking in

order to make others mad but usually those kids

are ticked off at something. So how do we dress this kind of stuff. So when we go to our other. Our other slide said here pull that up. OK so we're going to go into

the collaborative problem solving. Skills approach and

what we want to talk about is that with clever of problem

solving skills is that we want to work on these skills in with a child so

I begin to talk to parents about how we go about helping their child begin to

develop these skills on the pyramid I call the pyramid skills All right so

what we begin with is. The idea that parents

have unmet expectations with their children OK and

these unmet expectations show up in the context of a compliance interaction

now a compliance interaction is when a child you want as a parent

a child to do something and they're not willing to do it

that's compliance interaction or where a child once you do something and

you're not willing to do it so be in the store I want this toy

you give me this candy bar and you're not willing to do it and

it turns into a compliance interaction so many use an example of a compliance

interaction I'll just use a person. One with my son who's now seventeen but

when he was about and all about thirteen fourteen years of age we wanted

him to start taking the trash out. To the curb I felt like you

know I've been doing this for twenty five years myself it's

his turn to take the Patani. And so we decided you know

Thursday night that's your job. Now I want to compare and contrast him

to a child who may have a lot of skill deficits he has most of these skills so

I can use and could use a more traditional parenting

approach we'll talk about what that might look like versus a kid who if they don't

have a lot of the neural cognitive skills are pyramid skills then it could really

go badly as we want to keep that in mind. But anyway so the situation was that

we'd we'd told him that this is going to be his job Thursday night

comes around and as a family we had a church activity that

kept us out a little later and we were coming home were kind of Russian

home because our favorite shows get really come on American Idol and

so we pointed driveway and I realized that the trash it had taken out

I say Son you got to take the trash out. But then again watch my show know and now of course this is Preedy the are right

we didn't have this thing taped and he was every every second he was

going to miss his favorite show. And at this point we're in

a compliance interaction OK so. Now when you get into compliance

interaction it's important to realize you've got three possible pathways

that you can take in pathway a B. and C.. Now I want to go through what

each of these are just a second. In the back. Where that come from sorry about that let's look at the goals of the compliance

interaction so we tell parents. When you're in a compliance interaction we

want to keep these goals in mind they're very important. Collaborative problem solving is

a mindfulness based practice meaning that parents can't just be reactive they've

got to be mindful and reflective So if they're going to do this appropriately

the goals of the compliance interaction are to take one is a take parent concern

seriously so my concern here was what I as parents that what was my concern

I wanted the trash to be taken out and it's important to distinguish between what

my goal is here and what my strategy My strategy was for it to be taken out

right now before the show and that's important to realize that strategies and

goals are two different things. But my goal my concern was to get

the trash taken out the wall we also want to take the child concerned seriously

now this is important because if we want children to learn how to take other people

seriously we need to be able to model it OK but what was a child was my

son's concern that he wanted to be able to watch the show he didn't

want to miss any of the show OK. Third goal we want to

reduce meltdowns right and challenging behaviors but

especially meltdowns Why do we want to reduce meltdowns Well first

of all meltdowns are bad for a child's brain when you

have a meltdown your brain your body gets flooded with adrenaline and

cortisol cortisol especially is a nasty little little hormone that

causes many of the din dry it's in the brain in some of the din dripping

connections between different brain. Circuits to literally shrink OK

it's destructive to the brain and. This is important because these brain

circuits that we're trying to work on. The Accord is all actually

breaks them down and. In so we're trying to build

this pyramid of skills but meltdowns actually work against

us at a neurobiological level second is the C.E.O. R.'s these

are conditioned emotional responses so what ends up happening is that the brain

becomes more conditioned to react this way in the face of frustration in. And challenge so it's interesting

that the brain actually shrinks and becomes more reactive and less reflective

The brain is really more in a. Defensive mode and in a crisis survival

mode rather than a learning reflective mode and this is important because

this you know if you will meltdowns beget meltdowns beget meltdowns this

is probably the reasoning behind the Scriptures admonition to parents to

not provoke their children the wrath. Writes And then last is that it reinforces

in secure relationship models when kids have meltdowns they think thoughts like

I HATE YOU I HATE ME I hate the world and what happens at these

literally becoming coded into. They become encoded into their brains

such that in the future when they have stressful events and they have nothing to

do with parenting in the same patterns of negative thinking about themselves

the world and others get really surface. So so those are the reasons why we

tell parents meltdowns are good let's avoid them fourth is that we want

to work on neurocognitive skills for the work of the pyramid in five we want

to work on improving secure base and secure base is the child's perception

that the parent can be helpful to them during times of stress so those are

the goals of the compliance interaction Let's go back to this so

let's look at the different pathways and what are the advantages and

disadvantages now going down pathway Ebay is where parents typically go and parents

who come to see you with these children. Often take pathway and they're committed

to it the problem is that pathway tends to lead to meltdowns exclusively and we walk

through it with parents that of the five goals that we are trying to accomplish

a pathway a tends to get you nowhere. It may get you goal number one now pathway

a with my son might look something like this you're going to take the trash out

and if you don't take the trash out and you don't stop giving me some lip about it

then you're not going to watch it tonight and if you continue not going

to watch it for the next month. Now if my child has all those skills

what I'll probably get would be some eye rolling some teeth sucking maybe

slamming the door to the truck or to the van and then stomp and out as he

took the trash cans down to the curb and I would feel OK about that as a parent

I feel like I was pretty successful and you know I tell parents I have

no problem with that approach if you want to use it but

it's not very effective for meltdown as it could literally lead

to holes in your wall curtains pull off the wall physical aggression a lot

of problems can in Iraq come from that. So the next option would be pathways see now pathway

see is where you would temporarily. Drop the concern some pathway is forcing

the concern pathway see would be temporarily dropping the concern now

the worst way the worst possible way to do pathway see is to say you're going to take

it out now or else argue about it and then say whatever and go do it yourself

that's the worst way of doing pathways. But there's a lot more creative ways

of doing it you know pathway see is essential to the same

thing as a punt in football that you realize that we are not

going to get there it's this. Concern that I have right now is is

coming is not going to happen tonight and it may be as simple as saying you

know before I even got home I could have realized this isn't going to happen

and say something like you know it doesn't look like that trash is going to get taken

out tonight and I'm not real happy about it we're going to need to talk about this

and I punt and I will go to pathway B. which I'll talk to you

about in just a second but pathway see that that would be sort of

a temporary dropping of the concern in the moment sometimes pathway

see is about a parent in parents coming to terms with the fact that

this may not be a good goal for this child at this point in their life so if my child

was was having problems with homework relationships getting other chores done in

the house and I tried to add another one this may not be the time to do that that's

another way of thinking of pathways. But in many cases pathways see is

being able to drop it temporarily and come back to it later OK

that can have a tremendous effect on a number of different levels we

look at those five goals is go back to those goals real quickly

is that I would get gold to write take a child seriously I would

reduce the chance of getting a meltdown which is very important and I but

I wouldn't be working on cognitive skills. I would be taken number one seriously

the parent concerned seriously. And as far as secure base goes I

probably would get a half a point for that because at least I'm not pushing

the child to melt down state. But what we want to teach parents

is more about how to do pathway be all right now pathway B. is the collaborative

problem solving method so this is a skill set collaborative

problem solving that teaches kids how to experience and also how to do. Do all of the skills on the pyramid. So there's five skills involved in

teaching parents how to do this the first one is the still of empathy and

empathy sounds easy but it's hard to do. It's essentially acknowledging the child's

concern and taking it seriously so in this case what's my child's

concern he wants to watch the show so being able to state that would be look I

know you want to watch your show I don't have a problem with that that's all that

empathy is but in this case it helps reduce his frustration and agitation

immediately it has an effect on the brain. In the same way that you know when

we teach people how to calm down we're teaching we we start with empathy So this starts affecting those circuits in

the brain that bring about regulation. And I'm also stating his half of

the problem because I'm starting and I'm really working on problem solving but

I'm stating only one half of the problem I know you want to watch your show us

a is the assertiveness All right so parents have to be able to acknowledge

their concern right they need to be able to frame the other side of the

problem a lot of times kids can't see that they can't see past into their nose so you

need to be able to assert what the other side of the problem is so what's the other

side of the problem well I know you want to watch your show empathy but the

trash does need to be taken out tonight that's assertiveness now I have set up the

core components of a problem that you want this I want that the third skill is

teaching parents how to use respect. Now essentially respect is

the ability to stay call and because while you're engaging your child

remember you're modeling to him or her how to do this if

you can't be call him in doing this if you're too fired up be

too angry too frustrated then you need. To go pathways see you

punt come back to it later there's no sense in doing this if

you're too frustrated and angry because your child is not going to operate at

a higher level than you are you know so if you're expecting your child to regulate

the situation that's not going to go well so teaching pets love the work that

we do is helping parents see when to do these skills and when to if

you will punt and go to pathway C. and come back to him later. So if I say to my son look I know

you are what you show I don't have a problem with that but we need to get

the trash needs to get down tonight OK. I've set the stage for problem solving

this reason I draw a line here the next two pieces are extremely important

especially the I or the invitation many times parents as I said

before do the problem solving for the child if you do the work for the child

the child not to learn how to do this you have to control your impulse here as

a parent or teach parents that you've got to let the kid do the work don't do

the work for so a lot of parents ago so here's what we're going to do when the

show's over then you're taking the trash out that's not a bad solution nobody is

saying it's not a good one but we want that we actually want the child to do this

to do the work not you and you've got to be open to the fact that your child's

not going to do a really good job so throw it out there OK It looks something like

this the invitation would be you know so how do we fix this what do we do have how

is it that the trash gets taken down and you watch your show that's like throwing

them a big old softball underhand it for them to hit you'll be surprised

that these kids miss it. You know start taking it out next week. Right that's certainly a possibility. This is where collaboration comes to play

right this is where you're helping them evaluate their consequences. The effect on other people the realism

of their of their solutions so you have to start back with empathy

Well that's certainly takes care of your concern right where you get to watch your

show but on the one taking the trash out I don't know if I like that one that

well you got any other ideas right so you may go through this several times. You know I Why won't you help me take

the trash out well it's a possibility but I'm hoping that this is something

that you learn how to do. Right now let's step back for

a second for parents and we're going to you know when you're

collaborating with parents it's hard for them because parents get stuck on

that one solution that they have and often the parents have as much cognitive

rigidity and in flexibility as your child does and this is something that you

have to be able to work with them on but a lot of parents think like this if I

don't get the strategy the solution that I want here then all of my parenting

comes to a screeching home that I will be a total failure as a parent

this is important realize parenting is not like going to a chiropractor So when

you go to a chiropractor you go in and you expect to come out with results

at least I do my chiropractor says I look at it that way but a lot of

times that's what you're looking for. Parenting is really more especially

with these children is really more like going to see an orthodontist hopefully you

know going to the orthodontist thinking that you're going to walk in with Kirk and

walk back out with straight teeth now you know you might be able to do that

if you go see an oral surgeon who will pull your teeth and give you some false

ones to walk out with but it's not really going to work that way that parenting

is is an ongoing process you're applying pressure so any time you try to

introduce something new to your child or for your child you've got to realize that

there's going to be a lot of kinks in this so giving parents to

permission the freedom to see that if you don't get the trash taken

out exactly the way that you want. Taken out tonight the world won't come

crashing to an end you will be a total failure as a parent your child won't

learn how to just walk over top of you if you simply capitulate to your child and

say Fine whatever and you go stomping out of the house and have

a temper tantrum about it yourself and take the trash out and sock about it for

a couple days maybe your child will but what we want parents to see and what we

want to teach parents is that it's OK to flex here with your kid in

order to get them thinking and collaborating and problem solving so

it might be all right you know what do you think about taking the trash

out after your show well I should do that if you will if you'll help me why

is it that you want me to help you so badly it really is your job right that's

moving toward the empathy I want to really help this help him explain to me

why right these kids need help all know why I have a good idea why

because it's dark outside and there's trees by the by the driveway and

he's a little bit afraid of the dark why don't I just say that to

him because I want him to get better at using his language skills I

want him to be able to tell me if I can or I may throw it out as a hypothesis or

as as a possibility might say you know I'm one of the few really more

a little afraid of the dark out there will you know would you be yeah sure I would

be I'm willing to help you if that's what you need if you want me to stand out there

hold the light where you take the trash and I'll do that that's working

toward a collaborative solution. Now many parents will say yeah

man that's a lot of work and I would say yeah you're absolutely

right this is not easy. As I said before this is a lot

like walking through a swamp if you ever walked through a swamp before

you know that it's a lot of hard work it's it's a wear you out to walk

twenty thirty feet in this wall. This is not taking a walk down a nice. Open sidewall on flat ground it's nothing

like that it is a lot of work but you really are challenging

the child's brain to do this. This collaborative problem solving

Now the problem is that pathway B. which involves these five skills if

you're doing it in the heat of battle with certain children it's going

they're not going to be able to come up with a collaborative solution with

you and sometimes that's when you need to punt go to pathways see it may be you know

it looks like it's not going to get out tonight by you and if I'm taking it

out we really need to be able to talk about how we're going to get this trash

out next week so that not the one who's taken it out that's a perfectly acceptable

way of doing this it's not ideal but I mean obviously a parent wants a child

to comply with their request but if it was that easy I don't think

the parents would be in to see you. But that's that's what we call

going to pathway see punting and doing pathway be more collaboratively so

doing pathway be I mean collaboratively but more proactively

would be to to back it up and go to. Talk about this issue in a peer

in a non-critical period so it may be the next day on a Friday morning

that we talk about hey what are we going to do about next week I don't

like the way it turned out this week so we can do some problem solving ahead of

time it may be that next Wednesday night. Hey remember the trash has to be taken

out tomorrow remember what our plan is so some prompting to them about

the plan that they've come up with it's this can work in

a lot of different ways so kids who are having problems would take in

showers this is quite common their kids don't want to take showers empathy

would be hey I know it's been you've been having problems taken showers

you really resist us on doing this what's what's the deal why don't you want

to take a shower I just hate take an hour. As it takes so much time out of

my evening I usually play and then I have to stop plan and

then I come in and take a stupid Sharon or do that right so getting the child again

to use language skills to actually explain to you what they think the problem is and

sometimes parents can help them come up with solutions that are a little bit more

effective it may not be that they're just trying to resist too it can be that

they really think that it's interfering with something else you might be able

to use this pathway to to engage them. Other times you find that kids might you

know it's not uncommon that these kids don't like the feel of water that comes

down on them they have some sensory. Overload they don't like showers

in the way they feel but they would be willing to do

a bath which is interesting. But without the empathy and teaching

parents how to ask their kids the why question what's the problem why is this a

problem what do you think the deal is then you can't really hear what their

concerns are to empathize with so we work a great deal with helping parents

with that now let's just talk about some special we got some other Scott slides on

on how to use empathy as sort of this and respect the invitation about collaboration

and some qualities of good solutions. Let's step back a little bit and. And talk about a way of getting parents to

do this so a little bit on the method of doing collaborative problem solving skills

I teach the parents the psycho education piece with the pyramid usually in one

session and I'd begin to talk about the pathways in that session in a second

session I'll talk about the pathways much like what we've just discussed and

then we begin to talk about a method for delivering this and usually the method

is we want to help parents get better at describing these situations

where their children. Are having problems now you'll find

that parents have a great deal of problem giving you specific

situations if you want to help parents use these skills you have to get

them to break down situations so that you can look at them and

help coach them on these areas so we use the parent child interaction

questionnaire it's a questionnaire that I developed out of another treatment. For treating chronic depression in adults

by the way we see the lot of parents who are struggling with kids who have really

severe problems with this have begun to develop some depressive symptoms but

the point is that they get so flooded in these situations that they

actually check out and don't pay attention to important details so what we do is that

we give them this form in the for and what we tell them is that we want you to

pick a very discreet period of time where this behavior occurred so we don't

we want to get past generalizations he's always have a difficult time in

the morning he never can go to sleep at night no matter what we do it won't

work nothing ever seems to happen see these globalization's make it impossible

for you to help those parents so we try to get them very

specific Let's take just a little clip let's imagine that

it's a video clip that has you know that you're going to decide here's the

beginning and here's the end all right so the other morning we were getting ready

for school and Johnny came downstairs so that's the beginning and what happened I

asked him what kind of you know what kind of he's going to eat some breakfast

he said I don't want to watch T.V. I don't want to eat I want to watch T.V.

all right and then what did you say what did he say what did you say what

did he say and how did it end so we have parents be able to

describe exactly how the situ a. An end it and we have them be able

to tell us what their behavior looked like in cases sometimes parents

will describe their behavior though say well I told him that he's got to eat some

breakfast first before he watches T.V. or I told him that you know. There's no you know we're not going

to be able let you watch T.V. anymore if you don't sit down here and

practice they'll tell you that that's the way they set

it or that's where they describe it but I asked him more specifically to describe

the behavior show me what it looks like you'll find that you'll get a very

different picture sometimes and that's important so you can get an idea

of what they actually look like. Next we want them to be able to give us

their interpretations of what was going on while this was happening and this is very

important because you'll see tapped into some of these globally negative and rigid

cognitions that parents have about their child here we go again no matter what I do

nothing helps he's trying to manipulate me he's just like you know he's just like my

brother used to be when I was a kid always manipulating people I'm helpless This is

hopeless What's to use those are important cognitions for you to tap into if you're

going to help these parents because they interfere with their ability to use the

skills that we're trying to teach them so this this this questionnaire helps

to tease that out with them. Next you want them to describe what was

the actual come what was it how did this actually in you know he threw a gigantic

temper tantrum threw his clothes all over the floor slammed his book

bag down kicked his shoes off and ran downstairs and stuck his head between

the pillows on the couch All right so that's the actual outcome. What was your desired outcome what did

you want to see happen here right well I wanted him to sit down and

eat breakfast and to and to you know pay it and to pay attention

and then after a breakfast go watch T.V.. Now that's a desirable outcome there's no

doubt that what we mean by desired outcome is realistically given this child and

given this situation and what was the best possible

outcome you could have had right. Obviously you want it you want him

alternately to be able to come downstairs eat eat and then go and

then what Stevie but in this situation what did you want to see happen I didn't

want him to have a meltdown All right. So we want to look at what

kind of things did you do that led to the actual outcome right a lot

of times you'll see the lack of behavior that we're trying to get them to engage

in the lack of using these skills and what kind of behavior what kind of

parenting might have helped to get that outcome what might have prevented

this meltdown right in this case right in this in the best possible moment

probably allowing him to watch T.V. and eat at the same time which is

not your alternate goal would have. Would have probably prevented the meltdown

and you setting the stage to do problem solving collaborative problem solving

about this later like tonight or tomorrow or today after he comes home from

school talking to him about how we're going to handle the morning situations

would be would be optimal right how and then role playing with parents how

to do these these role plays and you could have them play their child so

we do a reverse role play. And you actually model for them how to do

the collaborative problem solving skills with their with their child

that can be extremely helpful I don't want to downplay the importance

of that now one other suggestion for this I think that really helps right so

the remediation phase if you will is where you're doing the the problem

solving with the parents and role playing but

I would encourage you to have parents as. Actually record the sessions with you so that they can listen to them over and

over again so they can begin to think about what empathy looks like and what

the collaborative problem solving process looks like with their child I have found

that parents who tape these things and listen to him outside of session tend

to get the most benefit from them and they can be quite helpful and say one

other thing a lot of times you'll find that parents themselves have their own

set of issues that they're dealing with whether it be depression anxiety marital

conflicts you need to be very sensitive to these issues and help parents

get help when they need it I would say that probably thirty percent of the

cases that I see the parents are also and they also need to be treated for

an anxiety disorder or depression or stress related problems you've

got to get those treated and. In some cases I end up doing a certain

amount of therapy just with the parents themselves that is sort of prepare the to

being able to do the collaborative problem solving with their child

if they parents are stressed and overloaded with too many

life problems teaching them these skills were overwhelm them

until you help them get calmed down.

 Complex Oppositional Defiant Disorder and Explosive Children II - Dr. John Kuhnley

This will be part two of my presentation

tonight treatment strategies and psychopharmacology already heard Dr Sipsey

talk about collaborative problem solving. Here's my diagram again for different for diagnosis and

co-morbidity because this is going to. My discussion tonight now much of what I'm

going to say tonight is not on the slides because it's virtually impossible

to put it all on the slides the number of algorithms that I would

have to put forward my goal tonight is to show you how a child

psychiatrist thinks out diagnosis and targeted treatment especially when

it comes to psychopharmacology So if you remember the differential diagnosis

and co-morbidity here we have oppositional defiant disorder which is the main topic

of our discussion tonight is that as I discussed in Part One it usually

comes with company usually comes with other co-morbid conditions including the

eighty eight the anxiety the depression or the bipolar disorder and this new

condition which is not a diagnosis yet temperate does for you lation disorder and

severe mood dysregulation So when I think about how I'm

going to approach patients medication was a management must be part

of a comprehensive treatment approach that includes the other modalities of that

are used appropriately in an integrative matter where the teacher counsellor the therapist the psychiatrist

are all working together even the pediatrician is often necessary

to be part of the whole treatment process to have an integrated

approach to diagnosis and treatment and multi-modal treatment is

essential once you get into the complex clinical presentation that

we're talking about tonight so there are a lot of treatment strategies

these pretty much summarize the major ones you can have individual therapy family

therapy parenting intervention training we've heard about it Ted's been

intervention and hence spiritual count. Psychosocial interventions

psychoeducational interventions lifestyle inventions and

medication and yes lifestyle ventures are very important

we don't want to lose track of those because there's a lot that could be done

in just controlling the lifestyle terms of sleep attitude nutrition exercise and

relationships so I call that essay and are saner how to

be more healthy more of sound mind and body than you otherwise would have been

and if you had best those five elements you can be sated than you would have

been under the same circumstances and then of course medication which is

the main topic of this presentation. Of the treatment of a child with impulsive

affected aggression as an example. Would fall one on one sessions or group therapy may include anxiety

meds if the person has a disorder going on correct of cognitive distortions

if the way they are approaching the world is is misperceiving developing

these cognitive sets. Automatic negative thoughts etc

assertiveness training impulse control strategies being able to think before

acting training a child to do impulse control had a child in Pennsylvania

years ago that had psychosis. And A D H D and

that families religion form bade the use of medication altogether and

so I had to try to address those three areas two of which were severe enough that

medication would have been a good idea. But this family was willing to work with

me this family was willing to be patient the school was willing to work a little

bit with me they weren't as patient but worked with this child in individual

psychotherapy major focus was on developing sequencing of events what

happened then what happened then what happened helping him understand

cause effect helping him to organ. His thoughts experiences helping him

to think things out for he acted gradually advancing in play therapy to

being able to do the checkers where the child wants to impulsively make their

move without thinking out what will die. So if you move there what

am I going to do and he had never thought things out like that before

but through the game of checkers and then that advance to other games able to

get him to realize that there is a game to be had if you think things out

before you act upon them and so on LOT of practice in these sessions which

was translated into helping the payments be able to do the same at home to enhance

the Malle of time in practice and this child actually developed good

impulse control skills sequencing and self control me still had a D H D There

was no doubt about it the psychosis disappeared and the opposition and

defiance disappeared but the poorer underlying problem of a B.H.T. Well it's

their baseline it was still there but he had more self regulation more building

to control it than he did before so a lot of these non medication

strategies are very powerful and we don't want to lose sight of the but

sometimes they're not enough sometimes we get to the point where you just can't

get the child response officially and the impairment is that severe that

we need to consider medication acts of aggression in youth or

anti-social children while adolescence. There in question has to be predatory

in play and it's not impulsive anxious children their aggression tends

to be a reaction out of fear they're overwhelmed you're in their way they

can't get away therefore they fight and that's where the pressure comes. May be rigid and

inflexible as an oppositional defiant disorder pervasive developmental disorder

or obsessive compulsive disorder or impulsive with poor executive control or

self-regulation as a result of A.D.H. the fetal alcohol syndrome brain injury or

substance abuse can even produce this or can be dysregulation in terms of their

mood which is what we're going to see in bipolar disorder mood disorder

not otherwise specified which we may be calling severe mood

dysregulation depending on what happens with the discussions in the D.S.M.

five abuse and traumatized children which have autonomic overdriven

they're faced with some trigger to the. Noxious experience to

traumatic experience and it sends them off in to this aggression or unstable family environmental

learned lots of factors to. Seek through what's going on with

the individual to try to sort out a targeted intervention the way

we're going to approach that and a social child is going to be different

than the way we're going to approach that anxious fearful job in the child

with an a social problems you have to make sure that there's

something in it for them because that's the way they think that's the way they

approach life if there's nothing in it for them why should they bother after all it's

not my problem with your problem they don't own the problem whereas

the anxious child the do the problem is they want to get away

they want to avoid it so you help have to help them develop anxiety

bad IT skills and self-confidence. So the type of clinical picture. That we see is going to

determine our interventions and we want to make sure that we get

as big a picture as possible as comprehensive as possible so

that we're addressing the right issues. Well let me go through the medications

that are available in my argument Terry I'm as I think things out in

the consultation you do by the time the patients get to me they've had some

very fine player who's who a lot of work and they get to the point with this say

John do something with this one please because they're not responding quite the

way we'd like them to they're usually they responded somewhat which is good we can

see that the capable of responding but there's something else going on that's

getting in the way of a full response and usually it's neurological DRO

biological nerve physiological and that's where medications come into play. Well for anti-anxiety medications we

have things like and the histamines specifically hydroxyzine you might have

heard of it is Vista real or add or X. It has a calming effect then so they as

opinions on the fire extinguishers of the brain they work at the level of gamma. Acid the homely neurotransmitter

produced sedation calling. Which is a very mild anti-anxiety

medication you'll hear a lot of doctors say it's

not really that valuable but there are a few patients that

truly respond well to it and it's very friendly medication low side

effect profile so if you have someone with mild anxiety responding to the other

medication measures something like this part might be useful the selective

serotonin we have taken hitter's S S R are the mainstay of anti-anxiety treatment

when it comes down to medication and you go through a list of those a little

bit cyclic and a depressants were the ones that we had back when I was coming up as

a young psychiatrist we called them dirty medicines we called them broad spectrum

medications and they did seem to hit a lot of neurotransmitters but because

they hit so many neurotransmitters. They also cause a lot of side effects

Dr Alf blurred vision constipation urine a retention things of that

nature very uncomfortable but when it's all we head we do what we could

to help the patient respond tolerate benefit from the medication Tetra cyclic

compound you've heard of has a PM which is otherwise known as REM Ron I don't use it

a lot because it can cause weight gain and especially a lot of young ladies in my

practice I go through the side effect with them beforehand so they know what they're

getting into and they hear that side effect of weight gain and they usually say

Next they want to hear about something else that doesn't cause side effect and

then there's bedlam vaccine which you may have heard of as Effexor that it's

extended release formulation effects. The. Medications. You notice many of the medications that we

use are treating Zadi or any depressants but they they work at the transmitter

levels of the Saratoga in the dopamine and the new often effort and have an impact

on both things and depression and in fact if you would have to look at

the criteria and the symptoms involved in general General Anxiety Disorder

generalized anxiety disorder and in major depression what we did you would

see is that there's a few hallmarks that delineate major depression and

this is major degree of overlap of symptoms then you have a few hallmarks

that delineate generalized anxiety so what we're seeing is there is a big

overlap between anxiety and depression. Seems to be a continuum but some distinctions now among the Saratoga

in the weapon effort we have taken have it is which means that they

inhibit uptake at the priests and they have to sell when you have two

neurons meeting we call it a sedan and this is the precept it with the messages

coming from this is the pose and have to when they come together the do or transmitters are released crossed

it this receptor is over here and off goes the message that happens

millions of times a second in your brain. Now if there's not enough

nutrients bit of in the messages are not getting through effectively if

there's too much they're getting through radically there's not a smooth. To the transmission of

messages in the brain. So what we're doing when we're using

these medications is we either blocking we SEPTA's on this which

causes these dual trends but as to not get taken back

up into the cell or. In some other medications which block

the breakdown of the medications or we block the effect at

this which we end tag the effect of the neurotransmitter or

we replicate the effect. Of the neurotransmitter which we call

agonise and it's an egg an IST So it produces the same effect that

the do transmit it would so those are the kind of

effects that we're doing. With our medications there's

other effects at all as well but we don't have time to go into all

of the multifaceted effects and we're still learning

new ones all the time. So we'll be talking about Sarah tone and

the of the nets and the uptake inhibitors that means that

these medications have a dual action they're working on both the Saratoga and

then or up a different neuro transmitters and we have try cyclic ended

presence such as it nipple mean Emma trip to Lee or

tripling these are all that are older and in the press medication which I mentioned

which we call dirty the because of the side effect profiles those of the tri

cycling's we have the better the facts in which is affect newer one do locks

a teen otherwise known as some ball to these medications affect

both sever tone and Orpen F. and. Interestingly the ones that affect your

pain effort also help out with pain. So look for affects there the ones

that affect your Panesar and also help out with A D H D A little

bit necessarily but a little bit. Then of course we have the touch of psych

and a depressive again showing appear as an end of the present medication

generally speaking very sedating So it's not unusual that you'll see REM or

unused at night to help people sleep moving along this is

a breakdown of the most common selective serotonin we have taken have

it is for their working selectively yet on the Saratoga and their transmitter and

I'm sure you're familiar with with all of these medications Paxil Prozac Zoloft

the box select Lexapro. They tend to have side effects. Do sexual drive. Sometimes headache but generally well

tolerated they canned someone who can cause weight gain Paxil in particular

I don't use very much of it because again I go to the side effect profile of it

some people come to me who reported much excessive weight gain on the Paxil so

I don't use much of it as a result but I see people respond absolutely beautiful

to it there is no advantage that any one of these medications has over the other

in terms of efficacy in general so any of them are just have to look at how

they are tolerated by the patient and whether or not the patient responds

to that specific medication and if using these medications for

patients if I give them Paxil for example they don't respond that doesn't mean they

won't respond to a different chemical formula that also effects Sarah told in

terms of we have to take in Bishan So failing in this class doesn't mean

you'll fail on all of them so these are the kind of things that I

have to consider as I'm going through. Medication trials for patients. And we have no weapon efferent

mean we have taken have better bupropion otherwise known as well and

marketed as banned for smoking cessation and

this medication has been studied in eighty eight Stephen though it's not

F.D.A. approved for treatment of A.D.H. T. It has been found beneficial

in many patients with a H.T. because of its impact on and

or epinephrine. Then have Sarah told an antagonist which

means it blocks the effect the posts that have to excite and blocks we

update this includes a medication which was withdrawn because of liver

problems but later it was found out that the liver problems weren't really

that significant but it was the prof that. Was known as Desert rail which

generally is not used for depression because it's short

acting lasting about eight out. Hours and it makes people very sleepy but

it only lasts eight hours and it makes people very sleepy so

what's a prescribed for sleep it's one of the most prescribed

medications in the country for helping people sleep in most people

respond rather well to it you simply adjust the dose to help get the eight

hours and help that wake up without being grog too groggy you reduce the dose a bit

and try to adjust it to get the timing for sleep Unfortunately not

everybody was spawns to it but it's a good medication for that purpose

though it's not F.D.A. approved for sleep. They do have a new form of

president that just came out. And I don't remember the trade name

forward but it's basically X R. Tended to meeting on a few

weeks ago very exciting and looking forward to seeing what that will

do for people with apparently doesn't produce as much sedation

Moving along we have nor up and there for an antagonist and

Sarah tone and tagging this again. We have model will mean oxidation

hitter's these are very good medications they're very potent medications

medications the older ones of which we had to watch the diet very closely

because things like pizza. Remember all the dietary

things you had to watch for I didn't use of because when you're

talking about children if you have to cut things out of the diet I looked at

the list and said wait a bit how can I can control what happens to Bobby when

he goes over to Billy's house and they're having something to eat that

might send them into a crisis and so I generally do not use the model mean

oxidase and if it is in children but that doesn't mean they're not very

effective they are in fact very effective model I mean oxidase breaks down the

transmitter in the preset have to excel so that the components are available to be

reconstructed into the neurotransmitter to be released later by breaking by

inhibiting the break down big board New or transmitter to be currently available

to be released into the Senate's So that's what model of the oxidation

have to do supposedly the newer model I mean oxidation evidence don't

have as much as the dietary concerns but since I just never got around to using

them I generally don't use them but that's my personal preference and that's what you'll find when you talk

to physicians we develop our personal preferences as a result of any number

of factors including experiences we've had if we've had a bad

experience with a medication we tend to shy away from it a bit we've had

good experience with medications that's the one we want to go with and

so we all develop our preferences because we have a lot of

medications to choose from and sometimes we just have to go through medication

after medication if I want to work. For Attention Deficit Hyperactivity

Disorder the gold standard since thirty seven is extra unfettered. And middle and came along

the was known as methylphenidate I think it was in the one

nine hundred fifty S. and those were short acting medications until they tried to make Ritalin sustained

release which didn't work at first but then they formulations of extended

release Ritalin that do work better you probably heard of better date CD You've

probably heard of concert a concert very excellent medication for extending the

release of the medication a little in L.A. These are all attempts at making

the medication last longer because what happens to these stimulant medications is

they get into the body getting quick and they get out quick the body destroys

them very rapidly so the life expectancy of a stimulant medication

in the body is only forty six hours for an infected made in three to four

hours for a methyl fed a day or so in order to get these medications

to last all day and not have to do a rollercoaster ride all day of

the dead for the treatment of A.D.H. we have to hide the medication from

the metabolic effects of the body so we hide in the little tube and

call it conserved we put it in a patch and call it a trauma we put it in

little beads that says half of which we lease right away and half of which we lease at the delayed

fashion the immediate release ones are set to release in the acid of

the stomach in the delayed release ones are set to release in the base

of the do it in small intestine. So by doing it that way were hiding the

medication from the metabolic effects of the body so it can last longer and

do its job and you don't have to dose so frequently and then of course they have by

Vance which is ingenious they they took. The gold standard dextroamphetamine

attached it to an essential amino acid L. lysine and created a little protein and

that's readily absorbed the body doesn't seabed occasion it sees protein it gets

into the bloodstream and by virtue of. Contact with red blood cells to get

split off and then the deck to infamy can go do its job and the lysine Well it's

an essential amino acid the body can use it though there's not a whole lot of

it with the doses that we're giving but these are the still it medication

Zz different formulations and our goal with the treatment of A.D.H.

is try to have a sustained response over the course of the whole day and not have

up and of which is what you're going to see generally with short acting

agents back in the seventy's and eighty's I would have to study when

the medication was wearing off and have the parent dose the next dose about

a half hour before the first Those wore off so that while this was coming down

this was going up never quite get the full Valley effect because that full Valley

effect when you talk about stimulants for example can be a rebound of symptoms

with a comes back even worse than they were at baseline and then settle

back down again but at least it could be a return of symptoms which are disruptive

especially if it's happening in the middle of a school day. So those are strategies that we use for

attention deficit hyperactivity disorder we also have atom oxygene which

you've heard of Strattera terror is an anti-depressant medication

which failed to beat placebo for the treatment of depression but they

noticed that it helped attention span and a little bit with the activity level

impulse therefore it was studied it chilled with A D H D and

it did please be placebo in the treatment. So it is F.D.A. approved for

the treatment of A.D.H. and though its effect size is small

compared with the stimulant medications there are patients who just don't

respond to the stimulant medications and there are parents who don't want their

kids on the civil medications that matter what you have to say about it

well then we have to tell. It is it is an effective medication a lot

of doctors gave up on it because it didn't have the impact that stimulants have. But if you're patient with it it works

like an edit a present without a presence it takes three to eight weeks to see

the full effect with stimulants it takes a half hour to an hour so when you're

dealing with with medication like for terror I have to remind myself

this is going to take a while so I advise the pair this we have to be

patient it's going to gradually improve it will see if it gives a response and

sure enough when you when the when you do patient education and the

patient knows what they're looking for and what they're up against they

tend to do a whole lot better. Alpha two receptor agonists clonidine and

want to see clonidine you've heard of ten explore offices Clementine

you've heard of scatter press ten X. wants to see and they have a new one for

scene out that's called in to move it's extended release it's been F.D.A.

approved for the treatment of A.D.H.. Clonidine came out with. HEP they think is the name of it and

that's been F.D.A. approved for the treatment. But until now we have these medications

only been used off label for the treatment of A.D.H. and while the effect is not as

big as the stimulants once again there's another option that we have available to

us in treating these individuals because again sometimes they just don't

respond to the similar medications for the treatment of A D H D For example

sometimes I can get a really good response but I get side effects with the stimulants

if I back off I lose some of my effect but not all of it but I lose the side effects

Well if I add something like clonidine to it or office into it I can get the rest

of the way to where I need to get optimal response with age and with A D H D As I

mentioned in my first talk I compare it to vision because they both

involve focus on the both biological and our goal in treating A.D.H. T. is to get as close to twenty

twenty focus as we can get. And get it sustained all

day if we can do it and so sometimes use combinations of medications

to accomplish that goal these medications have been studied and for example to

move is now approved for a combination therapy with stimulant medications so

it has been approved by the. Cyclic. Bupropion both have some effect for

the treatment of A.D.H. to use Perowne in a surprise a list it is

having some effect I'm not convinced and most child psychiatrists I've talked to

they don't know where that that's from either I think what it comes down to

is thirty three percent of individuals with A D H D will also have an anxiety

disorder if you treat the disorder that we do says the total impact but if you pretty

exotic disorder there's no way to H.T. that it was never a D H D in the first

place if you treat the anxiety disorder and the A.D.H. He is still there

the you've got a Kobo but condition and as you're probably aware disorders

of the amplifier of everything else. The Alpha to a Agnes was kept. Her memory did serve me this is a list

of the Alpha to agonise state work posts adaptively to to smooth

the tone of the transmission of. Messages through the nerve cells. This is a slide which shows that

the actual studies which give us evidence based support for the use of these

medications I won't go over that today when it comes down the bipolar disorder

bipolar disorder does occur in children in adolescence as I mentioned in the first

Talk believe it's over diagnosed and many centers are now demonstrating that it

does indeed appear to be over diagnosed when you use strict criteria

a comprehensive review but these are the kind of medications that you might

see being used in patients who are getting the diagnosis of bipolar disorder they

may be used in other conditions as well some of these medications are used for

example in severe conduct disorder for the aggression when you have severe

aggression these mood stabilizing medications actually may be medically

necessary because if you can't get them to stop being aggressive any other way there

may be something neurologically neuro physiologically driving that aggression

and you call that with a mood stabilizing agent and they're more manageable at that

point more reachable more able to respond to the other very good treatment

modalities that we have available. So the dopamine receptor

antagonists Saratoga dopamine Tegan this these are the anti-psychotic

medications when it comes down to treating mood disorder we're talking about

some heavy duty sluggers here the side effect profile of these medications

is very significant and I take great caution before

prescribe these medications to make sure that they're

truly medically necessary. Unfortunately under the impression that

there are prescribed is out there and taken quite as much caution and that's of concern a lot of kids

are being misdiagnosed and put on these medications probably in

appropriately I say probably because I. Can't.

People what they what they're seeing and I've had patients come to me with

diagnoses and medications and they're having problems and

I take them off the medications and the three other Coble be conditions and

they respond much better so was it ever bipolar disorder in the first

place probably that there is a day as opinions can also be used as an IT

manager call people the more quickly. And psychotic so used for

aggression psychosis and mood stabilization we have our

conventional end of psychotics. They are conventional because

they're used to cause the extra peer Rabba the side effects of Parkinson

like symptoms of the shuffling gait the drooling the stiffness of posture and

the pill rolling tremor and basically that's how we knew they were

working is when they cause the symptoms heck of a way to go about it that along

came the atypical antipsychotics that they were called atypical because they

don't cause that stuff as readily as our conventional at a psychotic state

but they it's still a risk factor they still can cause those things so

we have to be very attentive that you're probably familiar with our list

of atypical antipsychotics available. Well despite all the claws are real but that's generally used for

treatment resistant patients I don't use it I've only had a couple

of patients in my career who were on it they were responding very well managed

very well when you're talking about. Approaching children if you get a response

with these other medications you don't have to be thinking about clothes a little

bit it's attendant possible risk factors. And a psychotic side effect sedation

very common weight gain very common What is that doing it aggravates

metabolic issues Excel rates the risk of diabetes etc and some of these medications

are worse than others restlessness can occur in five to ten percent we

call it apathy sheer where it's of a. Restlessness that's uncomfortable it's not like hyperactivity where they

just want to keep moving but the comfortable with it when they're

moving these kids are uncomfortable when they have ACA teaches the Parkinson's

symptoms of bents in the involuntary movements things like tardive

dyskinesia that's when they might have. Things of that nature that's not a good

sign we generally want to back off when we see that because it is possible that

tardive dyskinesia movements can become irreversible. So that's a significant risk

factor in my career I've had a couple kids come to me that it had

tardive dyskinesia movements so far. Ahead and have other than the reversible. And so that's been. A bench in the mood stabilisers

here we have the list with the. With the names that you might see for

patients that you might be seeing. All been proven to be effective to some

extent some more so than others and some are effective in adults but

not children so when I deal with children adolescents I have to be

looking at what if one of the members of the family been is that my guide me

as to what child might respond to. Generally I would serve

these medications for when they can't get the a typical

us a cutting to this. Or to benefit the patient so if we go

back to differential diagnosis and co-morbidity again if I have a patient

come to me with simple O.D.D. I'm not going to be thinking

about medication anyway. About all the other measures of

the one she throw in eighty eight the milder forms of can respond

to medication measures but generally speaking

moderate to severe eighty. H.T. You probably need medication

to help them get the best responses won't she throw in bipolar disorder

in there or severe mood dysregulation you're probably going to be thinking

about a typical in a psychotic. Or other mood stabilizers. If I'm making a diagnosis of a patient and

I see bipolar disorder and A.D.H. the I'm going after the bipolar disorder first

because if I don't if I go after the first I may actually aggravate the bipolar

disorder with stimulant medications or if I see a disorder I may

give an end to medication and a depressant which can aggravate bipolar

disorder so as I go through my list of possibilities my differential diagnosis

determine which ones or require prioritization for treatment and bipolar

disorder is going to be top priority inside of disorder dependent civility

you have anxiety disorder in A.D.H. D. If the gains I disabled is severe I need

to go after that first then the A.D.H. if the A.D.H. T. is severe that's going to get him kicked

out of school I need to go after that first and sometimes the anxiety just goes

away sometimes it doesn't have to go after that second this is the way I think things

out in terms of the differential diagnosis and cold will be conditions and how I make

choices with respect to medications so this is a list of the conditions this

particular slide is not meant to say that what's across from it is what you do with

it basically we have all these medication options we have all these conditions and

we can have combinations of conditions and depending on the combinations is going

to depend on what medications I use and sometimes I'm to have more

than one medication because I have to target more than one condition or

we're talking about complex O.D.D. that's usually the he did nor is it will

be to have multiple conditions to target.