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Bipolar, Reactive Attachment, and Oppositional Defiant Disorders An Introduction and Overview


Carrie Shapiro, Psychologist. Schalmont Central School District. November 21, 2005 ... Bipolar disorder is a brain disorder that causes unusual shifts in a person's ... – PowerPoint PPT presentation

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Title: Bipolar, Reactive Attachment, and Oppositional Defiant Disorders An Introduction and Overview

Bipolar, Reactive Attachment, and Oppositional
Defiant Disorders An Introduction and Overview
  • Carrie Shapiro, Psychologist
  • Schalmont Central School District
  • November 21, 2005

What is Bipolar Disorder?
  • Bipolar disorder is a brain disorder that causes
    unusual shifts in a persons mood, energy, and
    ability to function.
  • Symptoms can range from mania to depression
    severe symptoms as opposed to normal ups and
  • Bipolar disorder typically develops in late
    adolescence or early adulthood, however, some
    individuals may experience some symptoms as early
    as childhood.

Bipolar cont
  • Like most mental health disorders a person with
    bipolar will need to seek treatment for the rest
    of their life.

Bipolar Children and Adolescents
  • Although not common in children, both children
    and adolescents can develop bipolar disorder.
  • Most likely to affect the children of parents who
    have the illness.
  • Unlike may adults with bipolar disorder, whose
    episodes tend to be clearly defined, children and
    young adolescents with bipolar disorder often
    experience very fast mood swings between
    depression and mania may times within a day.

Children and adolescents cont
  • Children with mania are more likely to be
    irritable and prone to destructive tantrums than
    to be overly happy and elated.
  • Bipolar disorder in children and adolescents can
    be hard to tell apart from other problems that
    may occur in these age groups.
  • For example While irritability and
    aggressiveness can indicate bipolar disorder,
    they also can be symptoms of attention deficit
    hyperactivity disorder, conduct disorder, or
    oppositional defiant disorder.

Bipolar disorder Adults
  • In adults, bipolar disorder can be mistaken for
    major depression or schizophrenia.
  • Drug abuse may also lead to similar symptoms.

Bipolar disorder/ manic-depression
  • Until recently, a diagnosis of the disorder was
    rarely made in childhood.
  • Doctors now will recognize and treat the disorder
    in young children.
  • Early intervention and treatment offer the best
    chance for children with emerging bipolar
    disorder to achieve stability and gain the best
    possible level of wellness.

Symptoms of Mania (manic episode)
  • Increased energy, activity and restlessness.
  • Excessively high, overly good, euphoric mood.
  • Extreme irritability.
  • Racing thoughts and talking very fast, jumping
    from one idea to another.

Symptoms Cont
  • Distractibility, cant concentrate well.
  • Little sleep needed.
  • Unrealistic beliefs in ones abilities/powers.
  • Poor judgment.
  • Substance abuse.
  • Denial in regards to behavior.

Symptoms of Depression (depressive episode)
  • Lasting sad, anxious, or empty mood.
  • Feelings of hopelessness or excessive pessimism.
  • Feelings of guilt, worthlessness, or
  • Decreased energy fatigue.
  • Difficulty concentrating, remembering, or making

Symptoms Cont
  • Sleeping too much or insomnia.
  • Change in appetite fluctuation in weight.
  • Chronic pain, or bodily symptoms with no medical
  • Suicidal ideation suicide attempts.

Diagnostic Criteria
  • A manic episode is diagnosed if elevated mood
    occurs with 3 or more of the other symptoms, most
    of the day, nearly every day, for 1 week or
  • A depressive is diagnosed if 5 or more of these
    symptoms last most of the day, nearly every day,
    for a period of 2 weeks or longer.

Other symptoms in young children may include
  • An expansive or irritable mood
  • Depression
  • Rapidly changing moods.
  • Explosive, destructive rages
  • Separation anxiety.
  • Defiance of authority.
  • Bed wetting and night terrors.

Types of Bipolar Disorders.
  • Bipolar I (6 Different Specifications)
  • 1. Single Manic Episode
  • 2. Most Recent Episode Hypo Manic
  • 3. Most Recent Episode Manic
  • 4. Most Recent Episode Mixed
  • 5. Most Recent Episode Depressed
  • 6. Most Recent Episode Unspecified
  • When an individual goes from one extreme to

Types Cont
  • Bipolar II
  • Recurrent Depression Episodes with at least one
    Hypo manic Episode.
  • Symptoms are not as extreme as Bipolar I, they go
    from hypomania (which is above normal in elation)
    to major depression.
  • Bipolar NOS
  • A mix of symptoms without specific criteria to
    allow for a specialized diagnosis.

  • Drug therapy mood stabilizers
  • - Anticonvulsant medications (Depakote,
    Tegretol), most commonly, Lithium (used to
    alleviate manic episodes).
  • Counseling Individual cognitive-behavioral
    therapy and family or group counseling also

For more information…
  • National Institute of Mental Health (NIMH)
  • Office of Communications
  • Information Resources and Inquiries Branch
  • 6001 Executive Blvd., Rm. 8184, MSC 9663
  • Bethesda, MD 20892-9663
  • Phone (301) 443-4513 Fax (301) 443-4279
  • email
  • website http//
  • Child and Adolescent Bipolar Foundation
  • 1187 Wilmette Ave., PMB 331
  • Wilmette, IL 60091
  • Phone (847) 256-8525
  • website http//

What is Reactive-Attachment Disorder?
  • Individuals who show a nearly complete lack of
    ability to be genuinely affectionate with others.
    They typically fail to develop a conscience and
    do not learn to trust.

Children with healthy attachments to a loving
  • Feel secure and loved.
  • Can attain their potential.
  • Can develop reciprocal relationships.
  • Can develop a conscience.
  • Can cope with stress and anxiety.
  • Become self-reliant.

Children who do not have healthy attachments with
  • Do not trust caregivers or adults in authority.
  • Have extreme control problems, manifested in
    covertly manipulative or overtly hostile ways.
  • Do not develop a moral foundation no empathy,
    no remorse, no conscience, no compassion for
  • Lack the ability to give and receive genuine
    affection or love.
  • Resist all efforts to nurture or guide them.

  • Lack cause and effect thinking.
  • Act out negatively, provoking anger in others.
  • Lie, steal, cheat, manipulate.
  • Are destructive, cruel, argumentative and
  • Lack self-control are impulsive.
  • Are superficially charming and engaging.

Common causes
  • Abuse/neglect in the first 3 years of life.
  • Multiple primary caregivers.
  • Separation from birthmother due to
    hospitalization, incubator, etc.
  • Many placements foster care.
  • Unresolved pain (e.g., ear infections, colic,
  • Maternal alcohol/drug use.

Causes Cont
  • Maternal depression.
  • Lack of attunement between mother and child.
  • Young or inexperienced mother with poor parenting

Symptoms of RAD
  • Severe need for control.
  • Toileting issues.
  • Poor eye contact.
  • Lack of cause and effect thinking.
  • Accident prone.
  • Homework problems.
  • Poor peer relationships/poor social skills.
  • Forgetfulness.

  • No conscience shows no remorse.
  • Speech and Language problems.
  • Developmental Delays.
  • Food issues.
  • Sleep problems.
  • Parents appear hostile and angry.

Behaviors associated with RAD
  • Purposely destructive to self, others, and
    material things.
  • Argumentative.
  • Demanding/clingy.
  • Extremely emotionally reactive (e.g. episodes of
    rage) OR apparently totally unemotional (dead
  • Very poor impulse control.
  • Chemical self-medicating.

  • Phoniness/ theatrical displays.
  • Stealing behaviors.
  • Poor self-soothing techniques (e.g. head
  • Sexual behaviors excessive or inappropriate to
  • Acts confused.
  • Indiscriminate affection.
  • Hypervigilant/hyperactive.
  • Pathological lying and/or crazy lying.
  • Cruelty to animals and/or people.
  • Fascination with fire, blood, weapons, or evil.

Teaching Teachers about RAD
  • Establish Eye Contact Insist that the child
    maintain normal eye contact during the
  • Establish Who Is Boss When a child tries to
    manipulate, remind them in a calm, firm,
    controlled voice that you are the boss.
  • Recognize the Childs subtle attempts to control
    Unattached children often deliberately omit
    parts of an assignment, letters, words,
    sentences, problem numbers or their names. Ask
    the child to continue working until they produce
    adequate and acceptable work.

Teaching cont
  • Win all control battles Structure all of the
    childs choices so that the teacher remains in
    control. (e.g. Do you want to wear your coat
    or carry it.)
  • Recognize good and poor decisions
  • Recognize good decisions as if you expected this
    behavior all along (e.g. I see you made a good
    decision to finish your math. Recognize poor
    decisions with a similar suitable statement such
    as, I see you chose to have incomplete work
    today. You may finish it at recess.

Teaching cont
  • Allow the child to accept responsibility look
    for creative ways to allow the child to
    experience the natural consequences of their
  • Be consistent Do not allow the child any slack.
    Confront each misbehavior and support each good
  • Remain calm A child who manages to upset the
    teacher is in control of the situation. Model
    and verbalize desired behavior.

Teaching cont
  • Document interactions and observations of the
    child Unattached children can inflict injury
    upon themselves and claim abuse. They can easily
    assume the role of an abused child and
    manipulate outsiders to rescue them.
    Documentation is necessary to help the educator
    remain objective if the child accuses parents or
    classmates of abuse.

Teaching cont
  • 10. Request help Administrators,
    psychologists, and social workers can be good
    resources in your building. These supports are
    invaluable for teachers of unattached children.

Oppositional Defiant Disorder 313.81 Diagnostic
  • A pattern of negative, hostile, and defiant
    behavior lasting at least 6 months, during which
    four (or more) of the following are present
  • 1. Often loses temper.
  • 2. Often argues with adults.
  • 3. Often actively defies or refuses to
    comply with adults requests or rules.
  • 4. Often deliberately annoys people.

Diagnostic Criteria Cont
  • Often blames others for his or her mistakes or
  • Is often touchy or easily annoyed by others.
  • Is often angry and resentful.
  • Is often spiteful or vindictive.
  • NOTE Consider a criterion met only if the
    behavior occurs more frequently than is typically
    observed in individuals of comparable age and
    developmental level.

Criteria cont
  • The disturbance in behavior causes clinically
    significant impairment in social, academic, or
    occupational functioning.
  • The behaviors do not occur exclusively during the
    course of a Psychotic or Mood disorder.
  • Criteria are not met for Conduct Disorder, and if
    the individual is 19 or older, criteria are not
    met for Antisocial Personality Disorder.

Possible causes
  • Biological inherited predisposition,
    neurological, or chemical imbalance.
  • Parenting/environmental runs in families of
    alcoholic parents and family history of
  • Abuse is positively correlated with the
    likelihood of ODD occurrence.

  • Modeling of appropriate behaviors by adults.
  • Consistent rules.
  • Fair consequences.
  • Punishment used when reasonable.
  • Consistency among caregivers.

General Intervention Strategies
  • Individual Therapy Should focus on
    understanding the reasons for childs
    frustration, and defining concrete ways to
    address and reduce behavioral issues. Also,
    social skill training.
  • Family Therapy Provide parents with educational
    materials about the problem behaviors and spend
    time discussing possible parental issues that may
    be contributing to the problem behaviors.

Interventions cont
  • Behavior Modification Parents and teachers are
    taught to reward cooperative behavior
    consistently and to ignore or punish oppositional
    behavior. (e.g. token economy). Criteria
  • Target a few important behaviors.
  • Operationally define behavior.
  • It must be consistent.
  • Gear rewards/punishment toward individual.
  • Rewards should not be tangible, but rather
  • A mix of positive and negative reinforcement.
  • Written contract.
  • Note Does not work for everyone. Very time
    consuming in that it requires constant and
    multiple revisions.

Controlling Antecedents Alternative strategy,
focus on prevention of behavior
  • Antecedents to avoid
  • Sharply worded directives (e.g. Tony, stop
    playing with your crayons!)
  • Unexpected and unannounced deviation in routine
    (utilize presets for transitions).
  • Tasks that are beyond the childs ability.
  • Gestures, or body language suggesting

Antecedents that promote appropriate behavior
  • Choices Giving the child with ODD choices
    allows them to gain a sense of control over a
    particular situation.
  • Routines Often children with ODD can not cope
    with verbal directives or unexpected requests.
    Possible solutions could include posting the
    childs schedule where he/she can see it.

Antecedents…pos. beh. cont
  • Foreshadowing Using a cueing system to let the
    student know that they should be getting ready to
    transition to the next activity.
  • Classroom rules Modify classroom rules in order
    to allow students with ODD to experience success.
  • Take a break A plan for students to
    voluntarily leave the classroom and enter a safe
    location where he/she can calm down.

Social Skills Training
  • Children with ODD have problems relating to
    adults, and they often fight with, bully and
    annoy their peers. These children will usually
    benefit from social skill training, (individually
    or in groups) focusing on relating and
    interacting with others.

Parenting Skills Training
  • One of the most well-established methods for
    treating children with ODD is parent training.
    There are two highly recommended parent training
  • 1. Parent training programs based on Patterson
    and Gullions (1968) manual Living with Children
  • 2. Webster-Strattons parent-training program,
    which includes a videotape series of
    parent-training lessons.
  • Note Parents receiving this type of
    training have rated their children as having
    fewer problems and as having better attitudes
    toward their children and greater self-confidence
    regarding their parenting role.

Prognosis for children with ODD
  • Depends greatly on the timing and the child and
    familys response. In general, 4 possible
  • 1. The child will grow out of it.
  • 2. ODD may turn into something else (e.g.
    ADHD, Conduct disorder, etc.)
  • 3. Continue to have ODD without the presence
    of any additional disorders.
  • 4. Continue ODD, but comorbid with anxiety
    disorder, ADHD, or Depressive disorder. Also
    possible mood disorder or anxiety issues that
    are disabling.