Health and Psychology

I've heard from several people in the past month, referring to their adolescent children in terms I think of as reserved for the seriously mentally ill or criminally insane.  When I attempt to clarify the nature of the delusional psychosis, criminal conduct, or psychotic mood disorder it seems to be non-existent.  What is being described by these parents, step-parents and legal guardians of teens are temper tantrums. 

There are several variants of these tantrums so let me clarify:

1.  Temper tantrums and crying.  This may include yelling and screaming and stomping in or out of rooms and slamming doors.  This is often preceeded by setting a rule or limit not desired by the teen, such as "you have to turn off your cell-phone, we're going to have a quiet dinner."  For some reason this is perceived by some parents or caretakers as either psychotic, suicidal, or seriously emotionally disturbed.

2.  Temper tantrums and breaking or throwing things around.  This may also include yelling, screaming and door slamming.  This is an escallation of the prior level of tantrumming with crying.  For some reason this is perceived as criminal conduct, psychotic, bipolar disorder, suicidal or homicidal.  In some cases parents or caretakers call police.

3.  Temper tantrums with non-responsiveness.  This may include falling to the floor, elective mutism, or failing to respond to any conversation or request.  For some reason this is perceived as a medical condition requiring treatment or hospitalization.  In some cases paramedics are contacted.

4.  Temper tantrums caused by a side effect of medication or a medical condition including atypical psychotic or dissociative disorders.  This may include atypical reactions to antibiotics, prednisone, acne medications, allergy medications, or an undiagnosed medical condition such as lupus, hypothyroidism, or others.

Temper tantrums are a normal stage of development for children between the ages of 18 months and about 4 years of age.  In recent years children have not been taught how to self-regulate and parenting practices have made it seem easier for parents and caretakers to manage tantrums by either not having a system of discipline or by giving in after a period of screaming, crying, or falling on the floor.  As these children get older, it is increasingly common to see these children having what are the same behaviors that are normally seen in an average 3 year old.  When the children are teens and the expected recapitulation of responding to limits and rules arises again, these children are ill-equiped to manage the slightest amount of frustration and limit setting.  The rage is poignant and infantile.

It's one thing when a toddler is told they have to wait until after they have dinner to eat a cookie, and they pitch a fit, grab a cookie, throw it on the floor, and hit their mother, and something else entirely when it's being done by a teenager.  But the rules and lessons are the same.  The child doesn't get the cookie, they have to calm down and control themselves, and they need to apologize for throwing the cookie and hitting their mother.

Unfortunately, some of these teens are being given psychiatric medications used to manage psychosis, are psychiatrically hospitalized, or are arrested by police and placed in juvenile detention centers.  What is needed is a method for the teens to gain control of themselves and the family has to place rules, boundaries, and order back into families where it has never existed in the past.  None of these are appropriate or effective options, and none address the underlying issues in the family system.  The risks of some psychiatric medications such as Abilify, Seroquel or Zyprexa in teens and children may far outweigh the benefits as all these medications CAUSE problems with blood sugar regulation and there is a risk of a potentially lethal condition called neuroleptic malignant syndrome when these medications are used in people under age 40.

Psychiatric diagnostic labels are not well equipped to manage this type of behavior.  The oppositional defiant teen label pathologizes the teen when it's a family issue.  Some of these teens are given diagnoses of bipolar disorder, when there is no evidence of any manic episode, and some are diagnosed as psychotic, depressed, or given personality disorder diagnoses.  None of these are appropriate either.

Appropriate treatment involves significant family therapy to help the family put in place a disciplinary system that has been needed for years and to carefully differentiate any medical or psychiatric condition that may be present and contributing to the difficulties.

A careful evaluation including analysis of precipitating factors and evaluation of behaviors can help to clarify what is going on with the teen and their family.