Tag Archives: ADHD

What Are Personality Disorders? #Write31Days

31 Days of Mental Health

Welcome to day 10 in the #Write31Days challenge on mental health. Today, I will discuss the broad category of disorders I’ve been diagnosed with: personality disorders. Though there is some debate as to whether borderline personality disorder should be conceptualized as a personality disorder, it currently is.

A personality disorder is a pervasive pattern of dysfunctional thought, behavior and emotion that is stable across time and across situations. It is out of line with cultural expectations and causes distress or impairment. It usually emerges in early adulthood, though adolescents may be diagnosed as being at risk for developing a personality disorder. In fact. when I attended a conference on BPD in 2013, a psychiatrist specializing in this said that BPD can be reliably diagnosed from age sixteen on. In other disorders, such as antisocial personality disorder, there is a specific age requirement of being over eighteen.

The Diagnostic and Statisticla Manual of Mental Disorders, both DSM-IV and DSM-5, divides specific personality disorders into three subcategories, called clusters. These are:


  • Cluster A includes paranoid, schizoid and schizotypal personality disorders. Individuals exhibiting these disorders often appear odd or eccentric. The disorders in this cluster can precede schizophrenia. I tend to think of cluster A personality disorders as “psychosis light”.

  • Cluster B includes antisocial, narcissistic, borderline and histrionic personality disorders. Individuals with disorders in this cluster are often seen as dramatic, emotional or erratic. People with cluster B personality disorders are often perceived as among the most difficult people to get along with. When peope think of personality disorders in general, they mostly mean cluster B disorders. The same goes for treatment programs focused on personality disorders.

  • Cluster C includes avoidant, dependent and obsessive-compulsive personality disorders. Individuals with cluster C personality disorders tend to be anxious or fearful.


In DSM-5, it is stated clearly that the clustering of personality disorders, while it has some merit, may not be very useful in clinical practice. After all, many people exhibit traits of personality disorders across clusters. When a person has features of more than one personality disorder but doesn’t teet the full criteria of any, they may be diagnosed with an unspecified personality disorder. People with other specified personality disorder display behavior that is seen as a personality disorder but isn’t listed specifically in DSM-5. Examples include passive-aggressive and self-defeating personality disorder.

There are some clear gender differences in how commonly personality disorders occur. Antisocial personality disorder occurs far more often in males than females. Borderline, histrionic and dependent personality disorder occur more in females. Though this may reflect real gender differences, it is also likely that stereotypical views shape clinicians’ diagnoses. For example, I once read that BPD is really about as common in males as in females but is overdiagnosed in women and underdiagnosed in men. Women misdiagnosed with BPD are often later found to have ADHD, which interestingly used to be seen as a typical male disorder.

diagnosticians always need to be aware of a patient’s cultural background and life history. After all, in some cultures, behavior that is seen as disordered in the western world may be normal. People who experienced extreme stress or trauma may also exhibit long-lasting dysfunctional behavior patterns and be misdiagnosed with personality disorders when they really have PTSD. Veterans are disproportionately often diagnosed with personality disorders, for example.

Teaching Your Child Organizational Skills

Organizational skills are very important in learning for children and adults of all ages. When they are lacking, a person struggles in unstructured tasks or in completing work independently and efficiently. Usually, a child develops better organizational skills as they age, being able to meet age-appropriate expectations. Still, children with even the best of organizational skills may struggle with major transitions, such as the transition from elementary to secondary school.

Other children have difficulties in organizational skills. Some can learn to overcome these as they mature, while others lag further and further behind. I am an example of the latter. In elementary school, I aced most classes, compensating for my lack of organizational skills by my high intelligence. In secondary school, I still did well because I had learned to read faster. I could therefore read the material being tested once at the last moment and still get a decent grade. Academically, my organizational skills didn’t get the better part of me till I was in college, when one reason I dropped out was my inability to plan my work.

Organizational skills are part of executive functioning. If a child struggles with organizational skills despite adequate parenting and teaching intervetnions, it might be that they have a learning disability or attention deficit disorder, but some kids have executive functioning difficulties without a learning disability or ADD/ADHD.

Here are some tips for encouraging the non-disabled child to develop their organizational skills. Some of these strategies will work to an extent with children with executive functioning difficulties too. At the end of this post, I will give some tips for dealing with kids with executive functioning difficulties specifically.

1. Use checklists. Help your child develop a to-do list. That way, the child will be able to visualize what they stll need to do and what they’ve already done. Have your child carry a notebook with them for writing down assignmnets and household chores. Have the child check off items that have been completed. You may need to monitor that they don’t check off unfinished tasks. You can have your child use step-by-step checklists for cleaning their room, too.

2. Use calendars and schedules. On a calendar, you will put all family members’ important appointments. It depends on you and your child how detailed a calendar needs to be or can be. On a weekly schedule, you list each family member’s household chores.

3. Buy your child a planner. Have them choose one that suits them or buy one for them that appeals to them. The child can put activities into their planner, but you’ll need to help them get their planner in sync with the family calendar to avoid conflict.

4. Involve your child in cleaning and cooking activities. Particurly cooking is a fun way to learn organizational skills. A child will need to learn to read a recipe, check steps they have already completed, assemble the right tools and ingredients, etc. Involve your child in meal planning too, challenging them to help you write a shopping list. Cleaning, while not as fun, is a necessary task that also requires organization.

As I said, many of these strategies will work for a child with executive functioning difficulties too. They may need more support while learning to organize their day. Here are some tips for helping a child with EFD to learn to become the best organizer they can be:


  1. Use written and/or visual step-by-step guides for chores and assignments. Incorporate as much detail as the child needs – I needed every step almost literally spelled out.

  2. Have specific tasks on a specific day of the week. Don’t have too many tasks in one day. For example, Monday is for cleaning the child’s room, while Thursday is for organizing their backpack. That way, the child will get into the habit of performing these tasks.

  3. Discuss new or unexpected situations with your child and help them prepare for what might happen.

  4. Repeat, repeat, repeat. Often, children with EFD have trouble learning to automate a skill, so you may need to help them, instruct them and supervise them for a longer time than you would a non-disabled child. Use the same schedules, reminders etc. for the same tasks over and over again.


It is very important to realize that your child with EFD is not being lazy, but they have a disability that makes it harder for them to organie their work. You may need to provide more support for them to complete their chores or homework than you would a similar-age non-disabled child.

Mommy Needs a Timeout Thursday Link-up

Me Want It (But Me Wait): Teaching Self-Control to Children

In the summer of 2013, Sesame Street released a fabulous video in which Cookie Monster is learning about self-control. Self-control is an important skill for children to master, as it will help them succeed at school and manage their behavior at home. Naturlly, young children have no self-control. Children with ADHD or similar issues may lack self-control up till a much older age./P>

There are many ways in which a parent can teach a child self-control. With babies, you need to begin by modeling. Remain calm yourself when your child is distressed. There may be various ways in which a baby is calmed. Some need lots of physical contact, while others need to be laid down for a bit. People vary in their opinion on self-soothing, ie. whether you need to attend to a baby when crying or ignore them. I think it depends on the baby.

Listening skills are a first requirement. Teach your child to come when you call them. Rigidly enforcing social skills like eye contact may not be appropriate for some children, like those with autism, but your child needs to learn to listen to their name and to attend to you.

When a young child cannot get what they want, cannot do what they want to do, or for another reason gets frustrated, they may tantrum. For a one-year-old, consequences don’t work, but distraction does. When your child is a little older, like from the age of two on, use brief time-outs as a consequence for tantrums. Like I’ve said before, make sure your child knows when the time-out is over. This means for a young child that you will need to call them back out of time-out. Again, this reinforces listening skills. For older children, you can ask that they come back when they’ve calmed, but this may not work for children who are still unable to understand their own emotions, like most children with autism. You can point out signs of them being calm again when you call them back out of time-out. This may help children learn about their own emotions and behaviors.

Besides giving consequences for impulsive behavior or tantrums, it’s also very important to reward self-control. If you’ve promised your child ice cream after dinner and they’ve behaved according to your reasonable expectations, give them the ice cream. That way a child learns that not only will impulsivity be punished, but also that patience and self-control are indeed going to get you farther along in life.

Motivation is not the same as self-control. If a child can focus fine on a computer game but not when tidying their room, that’s not a problem with self-control. It is more likely that they lack the motivation to tidy their room. It is however possible to change your attitude. Children will need help with this. For example, as a parent, you may turn tidying the child’s room into a game. You also need to model the right attitude. If you approach tasks like they’re nasty chores, much energy will go into motivating yourself to do the task. If you approach them with a positive attitude, you will find it’s much easier to stay motivated and thereby use your self-control skills. With children (and as adults!) who have a special interest, you can use the special interest as part of the nasty chore.

Of course, there are other skills required for completing tasks besides motivation. Your child will need to have the attention span to focus, the working memory to remember what they need to do, and the organizational skills to plan their task and get it actually finished. Until I did my research for this post, I thought this was the problem with me, but then I realized I can focus fine on this blog post, which requires reading and summarizing multiple sources. I’m now thinking that motivation may be an issue for me, and see above for solving that.

However, when someone truly has poor atttenion, working memory and/or organizational skills, these skills still can be trained at least in children. Computer-based games that reinforce memory or attention have some evidence of effecitveness behind them. Similarly, there are games that reinforce self-control directly. You know the game of stop and go, where a green light means go and a red light means stop? When the child is used to these rules, reverse them and your child will practice keeping their impulse to follow the original rules in check. I’m pretty sure there are computer-based variations to this game.

Mood Disorders in Children

Mood disorders in children, especially bipolar disorder and explosive mood disorders (also known as severe mood dysregulation and called disruptive mood dysregulation disorder in DSM-5), are controversial. Many children after all have temper tantrums, hyperactivity, sleep problems, etc., yet do not need a diagnosis. I found a list of fifteen symptoms of childhood bipolar disorder, of which I easily met the required four as a child. However, I never had the classic symptoms of bipolar disorder and do not have bipolar disorder now that I’m an adult. I did have mood disturbances as a child, but these could also be due to my autism and emotion regulation disorder.

Dsiruptive mood dysregulation disorder (DMDD) has much stricter criteria than those proposed in the above article for childhood bipolar disorder. In order to be diagnosed with DMDD, a child needs to meet many criteria, including temper outbursts on average at least three times a week over a twelve-month period, persistent irritability most of the day, nearly every day, symptoms occurring in at least two contexts and being severe in at least one (home, school, or with peers), etc. The diagnosis cannot be made in a child under six and should not be made for the first time in adulthood.

The diagnosis of disruptive mood dysregulation disorder cannot co-occur with oppositional defiant disorder (ODD), intermittent explosive disorder or bipolar disorder. If a child meets both criteria for DMDD and ODD, only the mood disorder needs to be diagnosed. If a child has ever had a manic or hypomanic episode, only the diagnosis of bipolar disorder must be made. For childhood bipolar disorder, the same criteria for a manic or hypomanic episode apply as for adults, except that the duration may be shorter. According to the accompanying text in DSM-5, rates of conversioon from DMDD to adult bipolar disorder are low. Adults with a history of DMDD are more likley to suffer frm depression or anxiety.

Mood disorders, including DMDD, can however co-occur with other disorders, such as ADHD or autism. ADHD and autism can also mimic a mood disorder. For example, if a child with autism or ADHD won’t stop talking, this shouldn’t be confused with the talkativeness seen in a (hypo)manic episode. However, mood symptoms can also be missed if a child has ADHD or autism, because irritability, temper outbursts, etc. are seen as a normal part of the ADHD or autism.

If a child’s mood disturbances are interfering with their daily functioning, take them to their doctor or psychologist for assessment. It isn’t always necessary to give them additional labels or prescribe them medication. Sometimes, just a change in handling strategy may help. You could’ve noticed this already, but, with a problem child, it’s often helpful to have a professional be your second pair of eyes.

Gender and Autism Stereotypes: Problems for Autistic Girls

Yesterday, I bought Parenting Girls on the Autism Spectrum by Eileen Riley-Hall. I’ve only read bits and pieces of it yet, but what struck a chord with me are the problems faced by both passive and aggressive autistic girls due to gender stereotypes and stereotypes about what autism should be.

First, most girls on the autism spectrum are passive. This can easily lead to them being ignored in a classroom or even at home. I notice this on my ward, too, because I’m fairly withdrawn. Because of this, my needs are not always met, as there are many patients who act out to get what they need. In the book, Riley-Hall talks about a girl in her daughter’s nursery who was so shy that she could easily be isolated if not for her attentive teacher. Passive autistic girls, according to Riley-Hall, need as much one-on-one attention as possible. This seems coutnerintuitive, because they aren’t causing any trouble or being a danger to themselves or others. Then again, they too need to learn to relate to others. It is sad in this respect that isolation is no longer a ground for care in the Netherlands. Apparently, you need to be aggressive to be seen. Please note that, in DSM-IV, passive autism is seen as more severe than the active-but-odd type.

Yet aggressive autistic girls are also often mistreated. According to Riley-Hall, gender stereotypes dictate that less aggression should be expected and tolerated from girls than from boys. Consequently, if an autistic girl acts out, she’s punished more harshly than a boy. Riley-Hall does not say this, but it is my expereince that aggression in women and girls is also interpreted differently than in males. For example, many more women are diagnosed with borderline personality disorder rather than for example ADHD. Fortunately, researchers and clinicians are becoming more and more aware of gender differences in the symptoms of psychiatric and neurodevelopmental disorders.

Executive Functioning Disorder (EFD)

Lately, I’ve mentioned executive functioning problems a lot. Though executive functioning disorder (EFD) is not formally recognized, it is pretty common in individuals with ADHD, learning disabilities and autism spectrum disorders, particularly Asperger’s Syndrome. So what is executive functioning disorder?

First, let me explain what executive functioning is. Executive functioning is a set of mental processes that enable people to connect past experience to present actions. These processes include planning, organization, motivation, maintaining attention, anticipation of alternative consequences, and generalization of what has been learned. People with EFD have impairments in many of these areas. Thogh executive functioning is often related to attention, not all people with EFD also have attention deficit disorder.

Here are a number of characteristics of executive functioning disorder:


  1. Difficulty ad/or apparent lack of interest in setting goals.

  2. Difficulty initiating a task or generating ideas independently.

  3. Difficulty comprehending how much time a task will take.

  4. Troulbe telling a story (in spoken or written language) because of difficulty organizing details.

  5. Inability to stop and think of a strategy to solve a problem.

  6. Continuing to use the same strategy to solve a problem, even when it’s ineffective.

  7. Difficulty following instructions that consist of multiple steps.

  8. Swinging from impulsivity to rigidity.

  9. Difficulty handling change.

  10. Inability to reflect on past experience to plan for the future.

  11. Past consequences don’t effect future behavior.

  12. Little awarness of or interest in learning about personal limitations or weaknesses.

  13. Mood swings and emotional instability. May react to emotions rather than verbalizing feelings.

  14. Seeing personal problems as externally caused; inability to see one’s own contribution to a problem.

  15. Difficulty taking another person’s perspective.

  16. Risk-taking or thrill-seeking.

There are a number of situations in which a person’s executive functioning disorder may interfere with their academic, social and daily living skills. In the area of time management, I have a lot of difficulty thinking of what to do during the day. This is not because I have few obligations – oh well, that is part of the problem too -, but even when I have a lot to do, I can’t seem to organize or plan for it. I procrastinate, too, as do most people even without EFD, but in my case, it’s sometimes due to inability to organize an activity. Initiating an activity may also be a particularly hard skill for people with EFD. This is sometiems called inertia.

In the area of problem-solving, I have a hard time following instructions that aren’t spelled out. I don’t have troubl memorizing multiple steps, but they do need to be clearly stated. For example, last week, I was planning on going for a walk. I had my shoes off and the nurse told me to put on my shoes. I did, but I didn’t put on my coat. I am not particularly literal-minded, so that wasn’t really the problem. Now that I think of it, I realize that maybe besides sensory processing difficulties, EFD might contribute to why I have a hard time deciding on which clothes are appropritate for the weather. In school, I had specific rules on what to wear during specific tempetrautres. I have been in situatiosn where it was over 30_C and I was still wearing a sweater because I hadn’t watched the weather forecast.

Emotion regulation problems may or may not be due to EFD in my case, since borderline personality disorder causes these problems too, and I exhibit some stereotypical BPD reactions. Then again, low frustration tolerance, which is not per se a BPD characteristic, is definitely related to executive functioning, and this has always been said to be a core problem of mine.

Sleep Strategies for People with Autism or ADHD

For as long s I can remember, I’ve had skewy sleep patterns. I either slept too little, too much, at the wrong time, or didn’t feel refreshed during the day. Sleep problems are pretty common in people with neurodevelopmental disorders like autism or ADHD. It is not fully understood why autistic and ADHD people have sleep problems, but there may be several reasons, such as fear of going to sleep (due to for example fear of the unknown) and difficulty breaking out of routines. I for one have a terrible time switching from one activity to another, and that includes shifting from waking to sleeping and vice versa. For people who have ADHD, both its symptoms and the medication taken for it may also keep you awake.

There are many strategies for people with autism or ADHD to use in order to get a better sleep/wake cycle and more refreshing sleep. on the World of Psychology blog, Margarita Tartakovsky lists some strategies for adults with ADHD, many of which can also be used by autistics. For example, it is important for autistics to realize the importance of sleep too. It may be useful to have someone create a social story for you to learn why and when to sleep. If it’s possible, create a separate sleeping space. Use your bedroom only for sleeping or, if that’s not possible, at least don’t take your electronics to bed.

Sensory issues may also be a factor in difficulty sleeping. Tartakossky suggests using noise-canceling tools for sleep, but some people can’t sleep without sound. For them, it may be useful to listen to music while in bed. Maybe a plain and simple MP3 player is best rather than your smartphone, on which you can be tempted to chck Facebook rather than just listen to music while falling asleep. In addition to sound, consider smell and light in creating a comfortable sleeping space. Again, some people like a certain smell, such as lavender, in their bedrooms, while others hate any smell. Some people, even adults, need a small light on while sleeping, while others need complete darkness. It may be hard to know whicch level of sensory stimulation is most comfortable to you, so it may take some experimenting. That’s okay. You can’t get a proper sleep/wake cycle in just one night.

Medication Treatment of ADHD Symptoms in Autistic Children

Autistics often have symptoms of ADHD. These symptoms are often treated with medication. About 15% of autistic children take psychostimulants or atomoxetine (Rosenberg et al, 2010). Stimulants are proven to be effective for ADHD in non-autistic children. Whether the same holds true for autistics, however, had not been systematically researched until now. Reichow, Volkmar & Bloch (2013) examined seven randomized, double=blind, placebo-controlled studies comparing methylphenidate, clonidine or atomoxetine to placebo in children with autism spectrum disorders and ADHD symptoms. Four trials were found for methylphenidate, two for atomoxetine and one for clonidine.

According to Reichow et al. (2013), methylphenidate was found to be effective for ADHD symptoms in autistic children. The effectiveness was slightly lower than it is for typically developing children with ADHD but still statistically significant. There was a greater risk of side effects in autistics, particularly for irritability, depression and withdrawal. The risk for common side effects such as insomnia and decreased appetite was similar to that found in typically developing children. One of the studies involved preschool children, and it was recommended by Reichow et al. after reviewing this study that methylphenidate-taking preschoolers with autis be closely monitored due to increased adverse events.

Clonidine and atomoxetine both showed moderate but not statistically significant effectiveness in autistic children (Reichow et al., 2013). These medications warrant further study, also given the fact that only one or two studies were found that met the inclusion criteria for a systematic review.

References

Reichow B, Volkmar FR, & Bloch MH (2013), Systematic Review and Meta-analysis of Pharmacological Treatment of the Symptoms of Attention-Deficit/Hyperactivity Disorder in Children with Pervasive Developmenetal Disorders. Journal of Autism and Developmental Disorders, 43(10):2435-2441. DOI: 10.1007/s10803-013-1793-z.

Rosenberg R, Mandell BS, Farmer JE, Law JK, Marvin AR, & Law PA (2010). Psychotropic Medication Use among Children with Autism Spectrum Disorders Enrolled in a National Registry, 2007-2008. Journal of Autism and Developmental Disorders, 40(3):342-351. DOI: 10.1007/s10803-009-0878-1.

The Childhood Bipolar Controversy Reviewed

Bipolar disorder in children is controversial. It didn’t use to be diagnosed as often as it is now, especially in the U.S., and more atypical symptosm are suggested to be bipolar. In the journal Child and Adolescent Mental Health, Boris Birmaher reviewed the literature surrounding this controversy. It’s an interesting article, viewing the controversy from all sides.

Birmaher starts by describing the diffiuclties diagnosing manic, hypomanic and depressive episodes in children and adolescents. Particularly, it is hard to distinguish symptoms of (hypo)mania from normal episodes of increased activity or from ADHD. Depressed symptoms are also hard to diagnose because children do not always feel or look depressed all the time. Adolescents experiece more atypical symptoms (increased sleep and appetite and weight gain) than adults do. Birmaher discusses whether onepisodic mania can be seen as bipolar.

He fortunately also shreds the idea that irritability only is bipolar. It isn’t. In fact, it is not severe mood dysregulation (also known as disruptive mood dysregulation disorder) eitehr, which surprised me. Irritability only is more indicative of ADHD or disruptive behavior disorders than of bipolar or SMD. Elation only, also, is not common in childhood or adolescent bipolar. More likely, patients experience both irritability and mood elation.

Birmaher is quite clear that pediatric bipolar disorder exists. The prevalence is around 2%, with just over 1% of children and adolescents presenting with bipolar I. For some perspective, Levorich et al. (2007) show that as many as half of adult bipolar patients in their study reported onset in childhood (14%) or adolescence (36%).

Birmaher is not a bipolar proponent, in the sense that he thinks atypical symptoms warrant a diagnosis of BP. He makes it quite clear that more research is needed into the risk factors for converting from atypical or subsyndromal bipolar-like symptoms into full-blown bipolar in children and adolescents. It looks like family history of bipolar is one such factor. Levorich et al (2007) found that, the earlier the onset of bipolar disorder, the more likely the patients were to have a parental history of bipolar or depressive disorders.

Levorich et al. (2007) particularly studied prognosis in adults with bipolar disorder, comparing those with (retrospectively reported) childhood or adolescent onset bipolar to those with onset in adulthood. They found that, the earlier the onset of the disorder, the more likely patients were to suffer from dysphoric (irritable) rather than euphoric mania and the more likely they were to have comorbid anxiety and drug abuse. In addition, the researchers tracked all participants’ mood over a year’s period. This showed that those with early onset bipolar had more depressed episodes, more severe manic and depressive symptoms and fewer good days in a year than those whose bipolar started in adulthood. For these and other reasons, Levorich et al. advocate an active ruling in or outo f bipolar d isorder in children and adolescents, rather than it being considered a last resort diagnosis.

References

Birmaher B (2013), Bipolar Disorder in Children and Adolescents. Child and Adolescent Mental Health, 18: 140-148. DOI: 10.1111/camh.12021.

Levorich GS, Post RM, Keck PE, Altshuler LL, Frye MA, Kupka RW, Nolen WA, Suppes T, McElroy SL, Grunze H, Denicoff K, Moravec MKM, & Luckenbaugh D (2007), The Poor Prognosis of Childhood-Onset Bipolar Disorder. Journal of Pediatrics, the, 150(5):485-490. DOI: 10.1016/j.jpeds.2006.10.070.