Controversially, Dr. Biederman and his colleagues find that nearly a quarter of the children with ADHD who are evaluated at their clinic also meet their criteria for bipolar disorder, the new name for manic-depression, once thought quite rare in children. The bipolar diagnosis carries with it the implications of a lifelong disabling pyschiatric disorder requiring perpetual drug treatment with medications like lithium, Depakote (an anticonvulsant) and Risperdal (an antipsychotic drug). The Harvard clinic's very high rate of diagnosis has led other doctors to question how typical these patients are compared to the general community. Critics have challenged the diagnostic thresholds of Biederman and his partners, alleging that it may be easier to be diagnosed with bipolar disorder of childhood in Boston than anywhere else in the world.

To be sure, the art of psychiatric diagnosis in children remains a very inexact science and in practice most doctors follow an algorithm of treatment using the safest drugs first. Children with the bipolar diagnosis have most often failed to improve with conventional psychotherapeutic interventions such as play therapy or parent effectiveness training. Drugs with relatively safer side effect profiles like Ritalin, Adderall or Prozac have either been insufficient or completely ineffective in controlling symptoms of these very difficult children. In fact these kids at the Boston clinic are often taking two, three and even four psychiatric drugs at the same time.

Greene openly acknowledges in his book that most of the children he treats are taking one or more psychiatric medications. He feels the medications are necessary just to allow his approaches to begin to work. The behavioral problems of children he treats, says Greene, are biological in nature, stemming from the children themselves. He believes the children's poor behavior is the result of their genetically derived temperaments -- behavior that is felt to be inherent to the children themselves and not the result of environment or experience.

Greene specifically avoids the debate over the psychiatric diagnosis of bipolar disorder in these children, which, given the controversy, is probably wise. But he puts a particularly negative spin on personality qualities that could be described neutrally as intense, determined, persistent or coping poorly with transitions. In "The Explosive Child" these qualities are defined as inflexible, stubborn and explosive -- coincidentally core descriptors of bipolar child behavior.

	The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children By Ross W. Greene Harper-Collins 326 pages Nonfiction Buy it Print story E-mail story

In Greene's analysis, parenting and school experience have little to do with the development of these children's problems. Greene absolves parents of causing the problems: a welcome relief for parents who generally feel guilty and responsible no matter what benevolent theories are offered for their children's behavior. Nevertheless, Greene correctly starts out by telling parents they will have to be the agents of change in improving their kid's behavior whether or not the child is taking medication (he or she usually is).

(Like many other child-oriented experts, Greene has found that the old Freudian-based models of play therapy, which were meant to allow children to express themselves safely in order to resolve inner conflicts, simply do not work in helping children learn to self-control. Most family therapists have known this for years, but treating children only with play continues in most community mental health practices with hopeless regularity.)

By the time parents have reached the Harvard clinic, no doubt they feel that they've tried everything. Many of them have tried behavioral modification programs yet their children continue to exhibit tantrums and outrageous behavior over trivialities. Greene tells them that behavior modification will not work with these children because the kids' brains make them "incapable" of responding to normal rewards and punishments. The children quickly move into a "vapor lock" sense of inchoate rage, which makes reasoning, as well as the "timeout," a useless learning exercise.

Greene nicely captures the inner thoughts of these intense and persistent children. He does a lovely job of elucidating the thinking of an 11-year-old girl who goes bananas simply because her mother wants to prepare waffles for the girl's younger brother. This little girl believes with all her heart that these waffles have her name on them. They belong to her even though she's told no one about her convictions. She argues, screams and knocks down chairs while her mother pleads that since the girl has already had her waffles, it's only fair to give the last two to her brother.

Most doctors would recommend ending this kind of exchange early before it escalates -- if necessary, with the immediate loss of some privilege or going to timeout. But Greene asks the mother to capitulate or negotiate with her daughter's otherwise outrageous demands in order to avoid having the girl "melt down." He feels the meltdown -- the frequent rages and temper tantrums -- constitutes the most destructive aspect of the explosive child for both the family and the children themselves. He says that these episodes lead to increasing feelings of despair and desperation for all the parties involved. Greene's goal is somehow to have the parents keep the child hanging onto reason even though -- to me -- it appears to be "rewarding" outrageous behavior.

Greene proposes that parents divide all conflictual challenges into "three baskets." In reverse order, basket C has the parents deciding that the waffles aren't worth fighting about at all. "OK, honey, I won't prepare them for your brother if it's that big a deal to you." He feels most conflicts parents take on with their kids can actually be put into basket C without too many ill effects.

Basket B is for issues that are not easily dropped but call for negotiating, distraction, rationalization -- anything to keep the kid talking and not flaming out. "Since you've already eaten your waffles this morning, what if we went out and bought some more right after school? How would that be?" The idea here is that the child will eventually be mollified by the offer and that by the time school is out, she will have forgotten how important the waffles were to her in the morning.

Order "Mothers Who Think: Tales of Real-Life Parenthood" from the editors of Mothers Who Think.