What is Parentification?

Introduction

Parentification is the process of role reversal whereby a child is obliged to act as parent to their own parent or sibling. In extreme cases, the child is used to fill the void of the alienating parent’s emotional life.

Two distinct types of parentification have been identified technically: instrumental parentification and emotional parentification.

  • Instrumental parentification involves the child completing physical tasks for the family, such as looking after a sick relative, paying bills, interpreting foreign language, or providing assistance to younger siblings that would normally be provided by a parent.
  • Emotional parentification occurs when a child or adolescent must take on the role of a confidante or mediator for (or between) parents or family members.

Background

Melitta Schmideberg noted in 1948 how emotional deprivation could lead parents to treat their children (unconsciously) as substitute parent figures. “Spousification” and “parental child” (Minuchin) offered alternative concepts exploring the same phenomenon; while the theme of intergenerational continuity in such violations of personal boundaries was further examined. Eric Berne touched on the dangers of parents and children having a symmetrical, rather than asymmetrical relationship, as when an absent spouse is replaced by the eldest child; and Virginia Satir wrote of “the role-function discrepancy…where the son gets into a head-of-the-family role, commonly that of the father”.

Object relations theory highlighted how the child’s false self is called into being when it is forced prematurely to take excessive care of the parental object; and John Bowlby looked at what he called “compulsive caregiving” among the anxiously attached, as a result of a parent inverting the normal relationship and pressuring the child to be an attachment figure for them.

All such aspects of disturbed and inverted parenting patterns have been drawn under the umbrella of the wider phenomenon of parentification – with the result (critics suggest) that on occasion “ironically the concept of parentification has…been as over-burdened as the child it often describes”

Choice of Child

For practical reasons, elder children are generally chosen for the familial “parental” role – very often the first-born children who were put in the anomalous role. However, gender considerations mean that sometimes the eldest boy or eldest girl was selected, even if they are not the oldest child overall, for such reasons as the preference to match the sex of the missing parent.

Thus where there is a disabled child in the family to be cared for, “older siblings, especially girls, are at the greatest risk of parentification”; where a father-figure is missing, it may be the eldest son who is forced to take on his father’s responsibilities, without ever obtaining the autonomy that normally accompanies such adult roles.

Alternatively a widower may put a daughter into the social and emotional role of his deceased wife – “spousification”; or a mother can oblige her daughter to play the caring role, in a betrayal of the child’s normal expectation of love and care

Narcissistic

Narcissistic parentification occurs when a child is forced to take on the parent’s idealised projection, something which encourages a compulsive perfectionism in the child at the expense of their natural development. In a kind of pseudo-identification, the child is induced by any and all means to take on the characteristics of the parental ego ideal – a pattern that has been detected in western culture since Homer’s description of the character of Achilles.

Disadvantages

The almost inevitable byproduct of parentification is losing one’s own childhood. In destructive parentification, the child in question takes on excessive responsibility in the family, without their caretaking being acknowledged and supported by others: by adopting the role of parental care-giver, the child loses their real place in the family unit and is left lonely and unsure. In extreme instances, there may be what has been called a kind of disembodiment, a narcissistic wound that threatens one’s basic self-identity.

In later life, parentified children often experience anxiety over abandonment and loss, and demonstrate difficulty handling rejection and disappointment within interpersonal relationships.

Case Studies

  • Carl Jung in his late autobiography reports that his mother always spoke to him as an adult, confiding in him what she could not share with her husband. Laurens van der Post commented on the grown-up atmosphere surrounding the young Jung, and considered that “this activation of the pattern of the “old man” within himself…was all a consequence of the extent to which his father and mother failed each other”.
  • Patrick Casement reports on a patient – Mr T – whose mother was distressed at any and all his feelings, and who therefore protected her from them – mothering her himself.

Literary Examples

The Tale of Genji tells that for “Kaoru’s mother…her son’s visits were her chief pleasure. Sometimes he almost seemed more like a father than a son – a fact which he was aware of and thought rather sad”.

Charles Dickens’ “Angel in the house” characters, particularly Agnes Wickfield in David Copperfield, are parentified children. Agnes is forced to be the parent of her alcoholic father and seems to strive for perfection as a means of reaching the “ego ideal” of her deceased mother (who died upon child-birth). Agnes marries late, has relationship and intimacy problems (she has a hard time expressing her love for David until he reveals his own love for her), and has some self-defeating attitudes; in one scene she blames her own father’s misfortunes on herself. However, she proves to be resilient, resourceful, responsible and even potentially career-driven (she forms her own school). She also manages to marry the protagonist David and the two live happily together for 10 years with children by the end of the novel.

The theme of parentification has also been explored in the Twilight series, with particular but not exclusive reference to the character of Bella Swan.

An Overview of Bipolar Disorder in Children

Introduction

Bipolar disorder in children, or paediatric bipolar disorder (PBD), is a controversial mental disorder in children and adolescents that is mainly diagnosed in the United States, and is hypothesized to be like bipolar disorder (BD) in adults, thus is proposed as an explanation for extreme changes in mood and behaviour accompanying periods of depressed or irritable moods and periods of elevated moods so called manic or hypomanic episodes.

These shifts are sometimes quick, but usually are gradual. The average age of onset of paediatric bipolar disorder is unclear, but the risk increases with the onset of puberty. Bipolar disorder is rare in childhood. Paediatric bipolar disorder is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

The DSM has specified that the criteria for bipolar disorder can be applied to children since 1980. However, the exact criteria for diagnosing paediatric bipolar disorder remains controversial and heavily debated. There are big differences in how commonly it is diagnosed across clinics and in different countries. There has been a rapid increase in research on the topic, but training and clinical practice lag behind.

Identifying bipolar disorder in youth is challenging. Children often exhibit chronic rather than episodic mania periods. Almost always, these chronic problems have causes other than bipolar disorder. The criteria for paediatric bipolar disorder can also often be masked by developmental differences. Comorbid disorders make determining what symptoms are signs of bipolar disorder and which are due to other disorders (e.g. OCD, ADHD, disruptive behaviour problems) difficult, leading to complications in treatment. For example, a common treatment for OCD are serotonin re-uptake inhibitors (SRIs), however, SRIs can lead to mood instability and worsening bipolar disorder.[5] The most common misdiagnosis for ADHD in the USA is paediatric bipolar disorder due to hyperactivity being described as prolonged periods of mania. Empirical research conducted in 2004 found that “bipolar disorder (in preadolescence) was initially misdiagnosed in 12 out of 24 youths” (Mahoney, 2004). This is a dangerous misdiagnosis due to the vastly different treatment forms. Firstly, ADHD does not require mood stabilisers like paediatric bipolar disorder. Secondly, the stimulants given to treat ADHD have been shown to cause psychosis and exacerbate mania in paediatric bipolar disorder (Wendling, 2009). This misuse of medication can lead to mood episodes, suicidality, and hospitalisation.

Brief History

Descriptions of children with symptoms similar to contemporary concepts of mania date back to the 18th century. In 1898, a detailed psychiatric case history was published about a 13-year-old that met Jean-Pierre Falret and Jules Baillarger’s criteria for folie circulaire, which is congruent to the modern conception of bipolar I disorder.

In Emil Kraepelin’s descriptions of bipolar disorder in the 1920s, which he called “manic depressive insanity”, he noted the rare possibility that it could occur in children. In addition to Kraepelin, Adolf Meyer, Karl Abraham, and Melanie Klein were some of the first to document bipolar disorder symptoms in children in the first half of the 20th century. It was not mentioned much in English literature until the 1970s when interest in researching the subject increased. It became more accepted as a diagnosis in children in the 1980s after the DSM-III (1980) specified that the same criteria for diagnosing bipolar disorder in adults could also be applied to children.

Recognition came twenty years after, with epidemiological studies showing that approximately 20% of adults with bipolar disorder already had symptoms in childhood or adolescence. Nevertheless, onset before age 10 was thought to be rare, below 0.5% of the cases. During the second half of the century misdiagnosis with schizophrenia was not rare in the non-adult population due to common co-occurrence of psychosis and mania, this issue diminishing with an increased following of the DSM criteria in the last part of the 20th century.

Epidemiology

The prevalence of bipolar in youth is estimated at 2%.

Diagnosis

Diagnosis is made based on a clinical interview by a psychiatrist or other licensed mental health practitioner. There are no blood tests or brain scans to diagnose bipolar disorder. Obtaining information on family history and the use of questionnaires and checklists are helpful in making an accurate diagnosis. Commonly used assessment tools include the:

Signs and Symptoms

In both the American Psychiatric Association’s DSM-5 and the World Health Organisation’s ICD-10, the same criteria used to diagnose bipolar disorder in adults are used to make the diagnosis in children with some adjustments to account for differences in age and developmental stage. For example, the DSM-5 specifies that in children, depressive episodes can manifest as persistently irritable moods.

In diagnosing manic episodes, it is important to compare the changes in mood and behaviour to the child’s normal mood and behaviours at baseline instead of to other children or adults. For example, grandiosity (i.e. unrealistic overestimation of one’s intelligence, talent, or abilities) is normal at varying degrees during childhood and adolescence. Therefore, grandiosity is only considered symptomatic of mania in children when the beliefs are held despite being presented with concrete evidence otherwise or when they lead to a child attempting activities that are clearly dangerous, and most importantly, when the grandiose beliefs are an obvious change from that particular child’s normal self-view in between episodes.

Controversy

The diagnosis of childhood bipolar disorder is controversial, although it is recognised that bipolar disorder typical symptoms are dysfunctional and have negative consequences for minors suffering them. Main discussion is centred on whether what is called bipolar disorder in children refers to the same disorder than when diagnosing adults, and the related question on whether adults’ criteria for diagnosis are useful and accurate when applied to children. More specifically, main discussion over diagnosis in children circles around mania symptomatology and its differences between children and adults.

Diagnostic criteria may not correctly separate children with bipolar disorder from other problems such as ADHD, and emphasize fast mood cycles.

Treatment

Medications can produce important side effects, so interventions have been recommended to be closely monitored and families of patients to be informed of the different possible problems that can arise. Atypical antipsychotics are more effective than mood stabilizers, but have more side effects. Typical antipsychotics may produce weight gains as well as other metabolic problems, including diabetes mellitus type 2 and hyperlipidaemia. Extrapyramidal secondary effects may appear with these medications. These include tardive dyskinesia, a difficult-to-treat movement disorder (dyskinesia) that can appear after long-term use of antipsychotics. Liver and kidney damage are a possibility with mood stabilisers.

Psychological treatment usually includes some combination of education on the disease, group therapy and cognitive behavioural therapy (CBT). Children with bipolar disorder and their families are informed, in ways accordingly to their age and family role, about the different aspects of bipolar disorder and its management including causes, signs and symptoms and treatments. Group therapy aims to improve social skills and manage group conflicts, with role-playing as a critical tool. Finally, cognitive-behavioural training is directed towards the participants having a better understanding and control over their emotions and behaviours.

  • BPD I, manic or mixed, without psychosis:
    • Stage 1: Monotherapy with a mood stabiliser (lithium, Divalproex, or carbamazepine), or atypical antipsychotic (olanzapine, quetiapine, or risperidone).
      • Lithium or Divalproex is recommended for first-line treatment.
      • Partial (minimal to moderate) improvement with monotherapy, augment with another of the first-line recommendations.
    • Stage 2: Monotherapy with an alternative drug, then augmentation.
    • Stage 3: Possible medication combinations – lithium plus Divalproex, lithium plus atypical, or Divalproex plus atypical.
    • Stage 4: Combination of 2-3 mood stabilisers.
    • Stage 5: Alternate monotherapy with oxcarbazepine, ziprasidone, or aripiprazole (all Level D).
    • Stage 6: For nonresponse or intolerable side effects – clozapine for children or adolescents, or electroconvulsive therapy (ECT) for adolescents only.
  • BPD I, manic or mixed, with psychosis:
    • Stage 1: Same as BPD I without psychosis except for first-line treatment warrants a combination of mood stabiliser and an atypical antipsychotic.
    • Stages 2-4: Varying combinations and augmentations.
    • Stage 5: Alternate monotherapy (oxcarbazepine) plus an atypical antipsychotic.

Prognosis

Chronic medication is often needed, with relapses of individuals reaching rates over 90% in those not following medication indications and almost to 40% in those complying with medication regimens in some studies. Compared to adults, a juvenile onset has in general a similar or worse course, although age of onset predicts the duration of the episodes more than the prognosis. A risk factor for a worse outcome is the existence of additional (comorbid) pathologies.

Children with bipolar disorder are more likely to suicide than other children.

Dr Alex: Our Young Mental Health Crisis (2021)

Introduction

Dr Alex George explores the wide range of mental health issues children and young people are facing, and finds out how projects funded by Children in Need are making a difference.

Outline

Dr Alex George follows the journeys of young people across the UK who are living with mental health issues. He explores the wide range of difficulties they face and finds out how local charities, including projects funded by Children in Need, are making a difference.

As an A&E doctor and the UK Youth Mental Health Ambassador, Alex has seen at first hand the effects of the pandemic on young people’s mental wellbeing, but he never thought they would affect his own family. But in July 2020, Alex’s 19-year-old brother Llyr, who had been struggling with anxiety during lockdown, took his own life. This poignant film is his response.

Production & Filming Details

  • Presenter(s):
    • Alex George.
  • Director(s):
    • Candace Davies.
  • Producer(s):
    • Becky Houlihan … producer.
    • Peter Wallis-Tayler … executive producer.
  • Writer(s):
  • Music:
  • Cinematography:
  • Editor(s):
  • Production:
    • Dragonfly Film and Television.
  • Distributor(s):
    • BBC.
  • Release Date: 14 November 2021.
  • Running Time: 59 minutes.
  • Rating: Unknown.
  • Country: UK.
  • Language: English.

What are Child and Adolescent Mental Health Services (CAMHS)?

Introduction

Child and Adolescent Mental Health Services (CAMHS) is the name for NHS-provided services in the United Kingdom for children, generally until school-leaving age, who are having difficulties with their emotional well-being or are deemed to have persistent behavioural problems.

CAMHS are organised locally, and the exact services provided may vary, often by local government area.

Brief History

In Europe and the United States child-centred mental health did not become a medical specialty until after World War I. In the United Kingdom children’s and young people’s mental health treatment was for decades the remit of the Child Guidance Movement increasingly working after World War II with local educational authorities and often influenced by psychoanalytic ideas. Provision in NHS hospitals was piecemeal across the country and disconnected from the youth justice system. However opposition to Psychoanalysis with its pioneering research work into childhood and adolescence, which was poorly understood by proponents of the Medical model, caused the service to be abandoned in favour of evidence-based medicine and evidence-based education. This led to the eclipse of the multidisciplinary child guidance approach in the 1990s and a public policy-motivated formal take-over by the NHS.

The development of CAMHS within a four-tiered framework started in 1995. In 1998, 24 CAMHS Innovation Projects started, and the Crime and Disorder Act 1998 established related youth offending teams. In 2000 the NHS Plan Implementation Programme required health and local authorities to jointly produce a local CAMHS strategy.

In November 2008 the independent CAMHS Review was published.

From about 2013 onward major concerns have been expressed about reductions in CAMHS, and apparently increasing demand, and in 2014 the parliamentary Health Select Committee investigated and reported on provision. In 2015 the government published a review, and promised a funding increase of about £250 million per year. However the funds were not ring-fenced and as of 2016 only about half of England’s Clinical commissioning groups had increased local CAMHS funding. CAMHS funding remains a popular topic for political announcements of funding and the current aim is to increase funding to the level that 35% of young people with a disorder are able to receive a specialist service. Different models of service organisation are also advocated as part of this transformation.

In Scotland, between 2007 and 2016 the number of CAMHS psychologists had doubled, reflecting increased demand for the service. However in September 2020, 53.5% of CAMHS patients in Scotland had waited for an appointment longer than the 18 weeks target, and in Glasgow the average waiting time was 26 weeks.

131 new CAMHS beds were commissioned by NHS England in 2018, increasing the existing 1,440 bed base by more than 10%. 56 will be in London, 12 at Bodmin Hospital and 22 at St Mary’s Hospital in Leeds.

Service Framework

In the UK CAMHS are organised around a four tier system:

TierDescription
1General advice and treatment for less severe problems by non-mental health specialists working in general services, such as GPs, school nurses, social workers, and voluntary agencies.
2Usually CAMHS specialists working in community and primary care, such as mental health workers and counsellors working in clinics, schools and youth services.
3Usually a multi-disciplinary team or service working in a community mental health clinic providing a specialised service for more severe disorders, with team members including psychiatrists, social workers, board certified behaviour analysts, clinical psychologists, psychotherapists and other therapists.
4Highly specialist services for children and young people with serious problems, such as day units, specialised outpatient teams and in-patient units.

Specialist CAMHS – Tiers 3 and 4

Generally patients cannot self-refer to Tier 3 or 4 services, which are sometimes called specialist CAMHS. Referrals can be made by a wide range of agencies and professionals, including GPs and school nurses.

The aim is to have a team led by a consultant psychiatrist, although other models exist and there is limited evidence of what system works best. It is suggested that there should be a consultant psychiatrist for a total population of 75,000, although in most of the UK this standard is not met.

The Tier 4 service includes hospital care, with about 1,450 hospital beds provided in England for adolescents aged 13 to 18. Typical conditions that sometime require hospital care include depression, psychoses, eating disorders and severe anxiety disorders.

The service may, depending on locality, include:

  • Art therapy.
  • Child psychiatry.
  • Clinical psychology.
  • Educational psychology.
  • Family therapy.
  • Music therapy.
  • Occupational therapy.
  • Psychiatric nursing.
  • Social worker interface.
  • Speech therapy.
  • Child psychotherapy.
  • Forensic CAMHS, working with young offenders or those at risk of offending.

Performance

As of December 2016, some young English people with eating disorders were being sent hundreds of miles away to Scotland because the services they required were not available locally. Not withstanding good care in Scotland it was said that being away from friends and family compromised their recovery. In response the government had adopted a policy of ending such arrangements by 2021, and had allocated a cumulative £150M to improve local availability of care. There are concerns that not enough is being done to support people at risk of taking their own lives. 1,039 children and adolescents in England were admitted to beds away from home in 2017-2018, many had to travel over 100 miles (160 kilometres) from home. Many had complex mental health issues frequently involving a risk of self-harm or suicide, like severe depression, eating disorders, psychosis and personality disorders.

In 2017-2018 at least 539 children assessed as needing Tier 3 child and adolescent mental health services care waited more than a year to start treatment, according to a Health Service Journal survey which elicited reports from 33 out of the 50 mental health trusts.

Book: CBT Toolbox for Children and Adolescents

Book Title:

CBT Toolbox for Children and Adolescents: Over 220 Worksheets & Exercises for Trauma, ADHD, Autism, Anxiety, Depression & Conduct Disorders.

Author(s): Lisa Phifer.

Year: 2017.

Edition: First (1st).

Publisher: PESI Publishing & Media.

Type(s): Spiral-bound, Paperback and Kindle.

Synopsis:

The CBT Toolbox for Children and Adolescents gives you the resources to help the children in your life handle their daily obstacles with ease. Inside this workbook you’ll find hundreds of worksheets, exercises, and activities to help treat:

  • Trauma.
  • ADHD.
  • Autism.
  • Anxiety.
  • Depression.
  • Conduct Disorders.

Written by clinicians and teachers with decades of experience working with kids, these practical and easy-to-use therapy tools are vital to teaching children how to cope with and overcome their deepest struggles. Step-by-step, you’ll see how the best strategies from cognitive behavioural therapy are adapted for children.

Book: Camouflage: The Hidden Lives of Autistic Women

Book Title:

Camouflage: The Hidden Lives of Autistic Women.

Author(s): Dr Sarah Bargiela.

Year: 2019.

Edition: First (1st), Illustrated Edition.

Publisher: Jessica Kingsley Publishers.

Type(s): Hardcover and Kindle.

Synopsis:

Autism in women and girls is still not widely understood, and is often misrepresented or even overlooked. This graphic novel offers an engaging and accessible insight into the lives and minds of autistic women, using real-life case studies.

The charming illustrations lead readers on a visual journey of how women on the spectrum experience everyday life, from metaphors and masking in social situations, to friendships and relationships and the role of special interests.

Fun, sensitive and informative, this is a fantastic resource for anyone who wishes to understand how gender affects autism, and how to create safer supportive and more accessible environments for women on the spectrum.

What is Oppositional Defiant Disorder?

Introduction

Oppositional defiant disorder (ODD) is listed in the DSM-5 under Disruptive, impulse-control, and conduct disorders and defined as “a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness” in children and adolescents.

This behaviour is usually targeted toward peers, parents, teachers, and other authority figures. Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit. It has certain links to Attention Deficit Hyperactivity Disorder (ADHD) and as much as one half of children with ODD will also diagnose as having ADHD as well.

Brief History

Oppositional defiant disorder was first defined in the DSM-III (1980). Since the introduction of ODD as an independent disorder, the field trials to inform the definition of this disorder have included predominantly male subjects. Some clinicians have debated whether the diagnostic criteria presented above would be clinically relevant for use with females. Furthermore, some have questioned whether gender-specific criteria and thresholds should be included. Additionally, some clinicians have questioned the preclusion of ODD when conduct disorder is present. According to Dickstein, the DSM-5 attempts to:

“redefine ODD by emphasizing a ‘persistent pattern of angry and irritable mood along with vindictive behavior,’ rather than DSM-IV’s focus exclusively on negativistic, hostile, and defiant behavior.’ Although DSM-IV implied, but did not mention, irritability, DSM-5 now includes three symptom clusters, one of which is ‘angry/irritable mood’—defined as ‘loses temper, is touchy/easily annoyed by others, and is angry/resentful.’ This suggests that the process of clinically relevant research driving nosology, and vice versa, has ensured that the future will bring greater understanding of ODD”.

Epidemiology

ODD, is a pattern of negativistic, defiant, disobedient and hostile behaviour, and is one of the most prevalent disorders from preschool age to adulthood. ODD is marked by defiant and disobedient behaviour towards authority figures. This can include: frequent temper tantrums, excessive arguing with adults, refusing to follow rules, acting in a way to purposely upset others, getting easily irked, having an angry attitude, and acting vindictive. Children with ODD usually begin showing symptoms around 6 to 8, although the disorder can emerge in younger children, too. Symptoms can last throughout the teen years. The pooled prevalence is approximately 3.6% up to age 18. There has been research to support that ODD is more common in boys than girls with a 2:1 ratio.

ODD has a prevalence of 1% to 11%. The average prevalence is approximately 3.3%. Gender and age play an important role in the rate of the disorder. In fact, ODD gradually develops and becomes apparent in preschool years; often before the age of eight years old. However, it is very unlikely to emerge following early adolescence. There is difference in prevalence between boys and girls. The ratio of this prevalence is 1.4 to 1 with it being more prevalent in boys than in girls, before adolescence. On the other hand, girls’ prevalence tends to increase after puberty. When researchers observed the general prevalence of oppositional defiant disorder throughout cultures, they noticed that it remained constant. However, the sex difference in ODD prevalence is only significant in Western cultures. There are two possible explanations for this difference which are that in non-Western cultures there is a decreased prevalence of ODD in boys or an increased prevalence of ODD in girls. Other factors can influence the prevalence of the disorder. One of these factors is the socioeconomic status. Youths living in families of low socioeconomic status have a higher prevalence. Another factor is based on the criteria used to diagnose an individual. When the disorder was first included in the DSM-III, the prevalence was 25% higher than when the DSM-IV revised the criteria of diagnosis. The DSM-V made more changes to the criteria grouping certain characteristics together in order to demonstrate that ODD display both emotional and behavioural symptomatology. In addition, criteria were added to help guide clinicians in diagnosis because of the difficulty found in identifying whether the behaviours or symptoms are directly related to the disorder or simply a phase in a child’s life. Consequently, future studies may obtain results indicating a decline in prevalence between the DSM-IV and the DSM-V due to these changes.

Signs and Symptoms

DSM-IV-TR) (now replaced by DSM-5) stated that a child must exhibit four out of the eight signs and symptoms to meet the diagnostic threshold for oppositional defiant disorder. These symptoms include:

  1. Often loses temper.
  2. Is often touchy or easily annoyed.
  3. Is often angry and resentful.
  4. Often argues with authority figures or for children and adolescents, with adults.
  5. Often actively defies or refuses to comply with requests from authority figures or with rules.
  6. Often deliberately annoys others.
  7. Often blames others for his or her mistakes or misbehaviour.
  8. Has been spiteful or vindictive at least twice within the past 6 months.

These behaviours are mostly directed towards an authority figure such as a teacher or a parent. Although these behaviours can be typical among siblings, they must be observed with individuals other than siblings for an ODD diagnosis. Children with ODD can be verbally aggressive. However, they do not display physical aggressiveness, a behaviour observed in conduct disorder. Furthermore, they must be perpetuated for longer than six months and must be considered beyond a normal child’s age, gender and culture to fit the diagnosis. For children under 5 years of age, they occur on most days over a period of 6 months. For children over 5 years of age they occur at least once a week for at least 6 months. It is possible to observe these symptoms in only one setting, most commonly home. Thus the severity would be mild. If it is observed in two settings then it would be characterised as moderate and if the symptoms are observed in 3 or more settings then it would be considered severe.

These patterns of behaviour result in impairment at school and/or other social venues.

Aetiology

There is no specific element that has yet been identified as directly causing ODD. Researchers looking precisely at the etiological factors linked with ODD are limited. The literature often examines common risk factors linked with all disruptive behaviours, rather than specifically about ODD. Symptoms of ODD are also often believed to be the same as CD even though the disorders have their own respective set of symptoms. When looking at disruptive behaviours such as ODD, research has shown that the causes of behaviours are multifactorial. However, disruptive behaviours have been identified as being mostly due either to biological or environmental factors.

Genetic Influences

Research indicates that parents pass on a tendency for externalising disorders to their children that may be displayed in multiple ways, such as inattention, hyperactivity, or oppositional and conduct problems. Research has also shown that there is a genetic overlap between ODD and other externalising disorders. Heritability can vary by age, age of onset, and other factors. Adoption and twin studies indicate that 50% or more of the variance causing antisocial behaviour is attributable to heredity for both males and females. ODD also tends to occur in families with a history of ADHD, substance use disorders, or mood disorders, suggesting that a vulnerability to develop ODD may be inherited. A difficult temperament, impulsivity, and a tendency to seek rewards can also increase the risk of developing ODD. New studies into gene variants have also identified possible gene-environment (G x E) interactions, specifically in the development of conduct problems. A variant of the gene that encodes the neurotransmitter metabolising enzyme monoamine oxidase-A (MAOA), which relates to neural systems involved in aggression, plays a key role in regulating behaviour following threatening events. Brain imaging studies show patterns of arousal in areas of the brain that are associated with aggression in response to emotion-provoking stimuli.

Prenatal Factors and Birth Complications

Many pregnancy and birth problems are related to the development of conduct problems. Malnutrition, specifically protein deficiency, lead poisoning or exposure to lead, and mother’s use of alcohol or other substances during pregnancy may increase the risk of developing ODD. In numerous research, substance use prior to birth has also been associated with developing disruptive behaviours such as ODD. Although pregnancy and birth factors are correlated with ODD, strong evidence of direct biological causation is lacking.

Neurobiological Factors

Deficits and injuries to certain areas of the brain can lead to serious behavioural problems in children. Brain imaging studies have suggested that children with ODD may have hypofunction in the part of the brain responsible for reasoning, judgment, and impulse control. Children with ODD are thought to have an overactive behavioural activation system (BAS) and an underactive behavioural inhibition system (BIS) (both discussed here). The BAS stimulates behaviour in response to signals of reward or non-punishment. The BIS produces anxiety and inhibits ongoing behaviour in the presence of novel events, innate fear stimuli, and signals of non-reward or punishment. Neuroimaging studies have also identified structural and functional brain abnormalities in several brain regions in youths with conduct disorders. These brain regions are the amygdala, prefrontal cortex, anterior cingulate, and insula, as well as interconnected regions.

Social-Cognitive Factors

As many as 40% of boys and 25% of girls with persistent conduct problems display significant social-cognitive impairments. Some of these deficits include immature forms of thinking (such as egocentrism), failure to use verbal mediators to regulate his or her behaviour, and cognitive distortions, such as interpreting a neutral event as an intentional hostile act. Children with ODD have difficulty controlling their emotions or behaviours. In fact, students with ODD have limited social knowledge that is based only on individual experiences, which shapes how they process information and solve problems cognitively. This information can be linked with the social information processing model (SIP) that describes how children process information to respond appropriately or inappropriately in social settings. This model explains that children will go through five stages before displaying behaviours: encoding, mental representations, response accessing, evaluation, and enactment. However, children with ODD have cognitive distortions and impaired cognitive processes. This will therefore directly impact their interactions and relationship negatively. It has been shown that social and cognitive impairments result in negative peer relationships, loss of friendship, and an interruption in socially engaging in activities. Children learn through observational learning and social learning. Therefore, observations of models have a direct impact and greatly influence children’s behaviours and decision-making processes. Children often learn through modelling behaviour. Modelling can act as a powerful tool to modify children’s cognition and behaviours.

Environmental Factors

Negative parenting practices and parent-child conflict may lead to antisocial behaviour, but they may also be a reaction to the oppositional and aggressive behaviours of children. Factors such as a family history of mental illnesses and/or substance use disorders as well as a dysfunctional family and inconsistent discipline by a parent or guardian can lead to the development of behaviour disorders. Parenting practices not providing adequate or appropriate adjustment to situations as well as a high ratio of conflicting events within a family are causal factors of risk for developing ODD.

Insecure parent-child attachments can also contribute to ODD. Often little internalisation of parent and societal standards exists in children with conduct problems. These weak bonds with their parents may lead children to associate with delinquency and substance use. Family instability and stress can also contribute to the development of ODD. Although the association between family factors and conduct problems is well established, the nature of this association and the possible causal role of family factors continues to be debated.

In a number of studies, low socioeconomic status has also been associated with disruptive behaviors such as ODD.

Other social factors such as neglect, abuse, parents that are not involved, and lack of supervision can also contribute to ODD.

Externalising problems are reported to be more frequent among minority-status youth, a finding that is likely related to economic hardship, limited employment opportunities, and living in high-risk urban neighbourhoods. Studies have also found that the state of being exposed to violence was also a contribution factor for externalizing behaviours to occur.

Diagnosis

For a child or adolescent to qualify for a diagnosis of ODD, behaviours must cause considerable distress for the family or interfere significantly with academic or social functioning. Interference might take the form of preventing the child or adolescent from learning at school or making friends or placing him or her in harmful situations. These behaviours must also persist for at least six months. Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD. Other common comorbid disorders include depression and substance use disorders.

Management

Approaches to the treatment of ODD include parent management training, individual psychotherapy, family therapy, cognitive behavioural therapy, and social skills training. According to the American Academy of Child and Adolescent Psychiatry, treatments for ODD are tailored specifically to the individual child, and different treatment techniques are applied for pre-schoolers and adolescents.

Children with oppositional defiant disorder tend to exhibit problematic behaviour that can be very difficult to control. An occupational therapist can recommend family based education referred to as Parent Management Training (PMT) in order to encourage positive parents and child relationships and reduce the child’s tantrums and other disruptive behaviours. Since ODD is a neurological disorder that has biological correlates, an occupational therapist can also provide problem solving training to encourage positive coping skills when difficult situations arise, as well as offer cognitive behavioural therapy (CBT).

Psychopharmacological Treatment

Psychopharmacological treatment is the use of prescribed medication in managing oppositional defiant disorder. Prescribed medications to control ODD include mood stabilisers, anti-psychotics, and stimulants. In two controlled randomised trials, it was found that between administered lithium and the placebo group, administering lithium decreased aggression in children with conduct disorder in a safe manner. However, a third study found the treatment of lithium over a period of two weeks invalid. Other drugs seen in studies include haloperidol, thioridazine, and methylphenidate which also is effective in treating ADHD, as it is a common comorbidity.

The effectiveness of drug and medication treatment is not well established. Effects that can result in taking these medications include hypotension, extrapyramidal symptoms, tardive dyskinesia, obesity, and increase in weight. Psychopharmacological treatment is found to be most effective when paired with another treatment plan, such as individual intervention or multimodal intervention.

In one case, a 16-year-old boy was given oestrogen at an L.A. juvenile jail due to allegedly having ODD due to somewhat elevated testosterone levels, developing gynecomastia and requiring breast reduction surgery as a result.

Individual Interventions

Individual interventions are focused on child-specific individualised plans. These interventions include anger control/stress inoculation, assertiveness training, and child-focused problem-solving skills training programme, and self-monitoring skills.

Anger control and stress inoculation help prepare the child for possible upsetting situations or events that may cause anger and stress. It includes a process of steps they may go through.

Assertiveness training educates individuals in keeping a balance between passivity and aggression. It is about creating a response that is controlled, and fair.

A child-focused problem-solving skills training programme aims to teach the child new skills and cognitive processes that teach how to deal with negative thoughts, feelings, and actions.

Parent and Family Treatment

According to randomised trials evidence shows that parent management training is most effective. It has strong influences over a longer period of time and in various environments.

Parent-child interaction training is intended to coach the parents while involving the child. This training has two phases. The first phase being child-directed interaction, whereby it is focused on teaching the child non-directive play skills. The second phase is parent-directed interaction, where the parents are coached on aspects including clear instruction, praise for compliance, and time-out for noncompliance. The parent-child interaction training is best suited for elementary-aged children.

Parent and family treatment has a low financial cost, which can yield an increase in beneficial results.

Multimodal Intervention

Multimodal intervention is an effective treatment that looks at different levels including family, peers, school, and neighbourhood. It is an intervention that concentrates on multiple risk factors. The focus is on parent training, classroom social skills, and playground behaviour programmes. The intervention is intensive and addresses barriers to individuals’ improvement such as parental substance use or parental marital conflict.

An impediment to treatment includes the nature of the disorder itself, whereby treatment is often not complied with and is not continued or stuck with for adequate periods of time.

Comorbidity

ODD can be described as a term or disorder with a variety of pathways in regard to comorbidity. High importance must be given to the representation of ODD as a distinct psychiatric disorder independent of conduct disorder.

In the context of oppositional defiant disorder and comorbidity with other disorders, researchers often conclude that ODD co-occurs with an ADHD, anxiety disorders, emotional disorders as well as mood disorders. Those mood disorders can be linked to major depression or bipolar disorder. Indirect consequences of ODD can also be related or associated with a later mental disorder. For instance, conduct disorder is often studied in connection with ODD. Strong comorbidity can be observed within those two disorders, but an even higher connection with ADHD in relation to ODD can be seen. For instance, children or adolescents who have ODD with coexisting ADHD will usually be more aggressive, will have more of the negative behavioural symptoms of ODD and thus, inhibit them from having a successful academic life. This will be reflected in their academic path as students.

Other conditions that can be predicted in children or people with ODD are learning disorders in which the person has significant impairments with academics and language disorders in which problems can be observed related to language production and/or comprehension.

What is Resignation Syndrome?

Introduction

Resignation syndrome (also called traumatic withdrawal syndrome or traumatic refusal; Swedish: uppgivenhetssyndrom) is a possibly factitious, dissociative syndrome that induces a catatonic state, first described in Sweden in the 1990s. The condition affects predominately psychologically traumatised children and adolescents in the midst of a strenuous and lengthy migration process.

Refer to Pervasive Refusal Syndrome (PRS).

Young people reportedly develop depressive symptoms, become socially withdrawn, and become motionless and speechless as a reaction to stress and hopelessness. In the worst cases, children reject any food or drink and have to be fed by feeding tube; the condition can persist for years. Recovery ensues within months to years and is claimed to be dependent on the restoration of hope to the family.

More recently, this phenomenon has been called into question, with two children witnessing that they were forced by their parents to act apathetic in order to increase chances of being granted residence permits. As evidenced by medical records, healthcare professionals were aware of this scam, and witnessed parents who actively refused aid for their children but remained silent at the time. Later Sveriges Television, Sweden’s national public television broadcaster, were severely critiqued by investigative journalist Janne Josefsson for failing to uncover the truth. In March 2020, a report citing the Swedish Agency for Medical and Social Evaluation, SBU, said “There are no scientific studies that answer how to diagnose abandonment syndrome, nor what treatment works.”

Signs and Symptoms

Affected individuals (predominantly children and adolescents) first exhibit symptoms of anxiety and depression (in particular apathy, lethargy), then withdraw from others and care for themselves. Eventually their condition might progress to stupor, i.e. they stop walking, eating, talking, and grow incontinent. In this stage patients are seemingly unconscious and tube feeding is life-sustaining. The condition could persist for months or even years. Remission happens after life circumstances improve and ensues with gradual return to what appears to be normal function.

Nosology

Refusal syndrome and pervasive refusal syndrome shares common features and etiologic factors; however, the former is more clearly associated with trauma and adverse life circumstances. Neither is included in the standard psychiatric classification systems.

Pervasive refusal syndrome (also called pervasive arousal withdrawal syndrome) has been conceptualised in a variety of ways, including a form of post-traumatic stress disorder, learned helplessness, ‘lethal mothering’, loss of the internal parent, apathy or the ‘giving-up’ syndrome, depressive devitalisation, primitive ‘freeze’, severe loss of activities of daily living and ‘manipulative’ illness. It was also suggested to be on the ‘refusal-withdrawal-regression spectrum’.

Acknowledging its social importance and relevance, the Swedish National Board of Health and Welfare recognised the novel diagnostic entity resignation syndrome in 2014. While others argue that already-existing diagnostic entities should be used and are sufficient in the majority of cases, i.e. severe major depressive disorder with psychotic symptoms or catatonia, or conversion/dissociation disorder.

Currently, diagnostic criteria are undetermined, pathogenesis is uncertain, and effective treatment is lacking.

Causes

Resignation syndrome appears to be a very specialised response to the trauma of refugee limbo, in which families, many of whom have escaped dangerous circumstances in their home countries, wait to be granted legal permission to stay in their new country, often undergoing numerous refusals and appeals over a period of years.

Experts proposed multifactorial explanatory models involving individual vulnerability, traumatisation, migration, culturally conditioned reaction patterns and parental dysfunction or pathological adaption to a caregiver’s expectations to interplay in pathogenesis. Severe depression or conversion/dissociation disorder has been also suggested (as best diagnostic alternatives).

However, the currently prevailing stress hypothesis fails to account for the regional distribution (see Epidemiology) and contributes little to treatment. An asserted “questioning attitude”, in particular within the health care system, it has been claimed, may constitute a “perpetuating retraumatization possibly explaining the endemic” distribution. Furthermore, Sweden’s experience raises concerns about “contagion”. Researchers argue that culture-bound psychogenesis can accommodate the endemic distribution because children may learn that dissociation is a way to deal with trauma.

A proposed neurobiological model of the disorder suggests that the impact of overwhelming negative expectations are directly causative of the down-regulation of higher order and lower order behavioural systems in particularly vulnerable individuals.

Epidemiology

Depicted as a culture-bound syndrome, it was first observed and described in Sweden among children of asylum seekers from former Soviet and Yugoslav countries. In Sweden, hundreds of migrant children, facing the possibility of deportation, have been diagnosed since the 1990s. For example, 424 cases were reported between 2003 and 2005; and 2.8% of all 6547 asylum applications submitted for children were diagnosed in 2004.

It has also been observed in refugee children transferred from Australia to the Nauru Regional Processing Centre. The Economist wrote in 2018 that Doctors without Borders (MSF) refused to say how many of the children on Nauru may be suffering from traumatic withdrawal syndrome. A report published in August 2018 suggested there were at least 30. The National Justice Project, a legal centre, has brought 35 children from Nauru this year. It estimates that seven were suffering from refusal syndrome, and three were psychotic.

What is Pervasive Refusal Syndrome?

Introduction

Pervasive refusal syndrome (PRS), also known as pervasive arousal withdrawal syndrome (PAWS) is a rare hypothesized paediatric mental disorder. PRS is not included in the standard psychiatric classification systems; that is, PRS is not a recognised mental disorder in the World Health Organisation’s current (ICD-10) and upcoming (ICD-11) International Classification of Diseases and the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Refer to Resignation Syndrome.

Purported Signs and Symptoms

According to some authors, PRS symptoms have common characteristics with other psychiatric disorders, but (according to these authors), current psychiatric classification schemes, such as the DSM cannot account for the full scope of symptoms seen in PRS. Purported symptoms include partial or complete refusal to eat, move, talk, or care for oneself; active and angry resistance to acts of help and support; social withdrawal; and school refusal.

Hypothesized Causes

Trauma might be a causal factor because PRS is repeatedly seen in refugees and witnesses to violence. Viral infections might be a risk factor for PRS.

Mechanism

Some authors hypothesize that learned helplessness is one of the mechanisms involved in PRS. A number of cases have been reported in the context of eating disorders.

Hypothesized Epidemiology

Epidemiological studies are lacking. Pervasive refusal syndrome is reportedly more frequent in girls than boys. The average age of onset is purported to be 7-15.