Results tagged “Bipolar disorder” from Ψ Dare To Dream...

Pete Feigal sent me another set of stories now posted to Dare To Dream Forums. Pete has been a regular contributor. He is now blind, mostly wheelchair bound, but still one of the most inspirational speakers I've ever heard on the topic of recovery from disability.

Pete Feigal has been battling clinical depression for 30 years, and MS for the last 19. He has spoken nationally over 1400 times in the last 11 years for schools, colleges, prisons, corporations, churches, medical professionals and police forces around the nation. He is a native Minnesotan and has been, in his checkered past, a professional Shakespearian actor, an aviation and motorcycle artist, and a motorcycle drag racer.

He describes his newest contributions.

""Why There Are No 'Whys?'" came from all of the senseless killings we've had lately, and from when I'm asked to speak afterwards and people want to know "why."

"The Light That Failed" is a life-changing moment in my life, when I went totally blind almost exactly a year ago.

"Open Letter To A Friend With Depression." I'm contacted every day by folks that are looking for help, inspiration, resources, for themselves or a loved one.

"The Stars Are The Diamonds Of The Poor," is a two parter where I interviewed almost 100 folks with different struggles, esp mental illness, asking them for their insights about money, living without it, and what they've learned are the curses, but also the gifts."

Pete's web site
You can buy Pete's art!

There is some major progress in the treatment of persons with Bipolar DO - Mixed episodes. Bipolar DO-Mixed is characterized by less serious manic symptoms, or hypomania, and significant depressive symptoms occuring at the same time. As you might expect, having a high energy level, little impulse control, impaired judgment and significant depression is a miserable condition, prone to substance abuse, suicide ideation and serious attempts. Persons with BPDO-Mixed are more prevalent in my practice than any other subtype of the disorder. That fact could be an artifact of primary finding of the following studies.

Anti-depressants, when combined with mood stabilizers such as Lithium or Depakote, or atypical anti-psychotic medications like Abilify or Seroquel have been found to provide no more symptomatic relief for the depressive symptoms and a significant risk of increasing manic symptoms. The contradicts standard psychiatric practice which calls for treating mania with mood stabilizers or atypical anti-psychotic medications and the depression with anti-depressants.

Intensive psychotherapy has been found to be modestly helpful with persons with Bipolar DO-Mixed. These findings affirms my recent clinical findings that persons with Bipolar DO-Mixed can experience significant symptomatic relief and, perhaps more importantly, a budding sense of recovery based on personal responsibility and enhanced skills in managing moods.

Excerpts from a review of the research follow:

Mental illness is less understood than most people think. Common sense would have it that good parenting makes all the difference. It's just not that simple. The NY Times has a great series on "Troubled Children" that is well worth the read. The articles include some good background on the nature of mental illness and it's development.

Today six million American children have been diagnosed with a serious mental disorders, a number that has tripled since the early 1990's.

But that doesn't mean that the rates of illness have increased in the past few decades. Rather, it is the decease in stigma of seeking help and that more professionals and parents are willing to attribute problems with children to mental illness. ADHD and Bipolar illness is diagnosed with alarming frequency these days, clearly an indication of misdiagnosis in both the past and the present.

From the NY Times series:

Still, many psychiatrists believe that, although childhood bipolar disorder may be real in families like the Finns, it is being wildly over-diagnosed. One of the largest continuing surveys of mental illness in children, tracking 4,500 children ages 9 to 13, found no cases of full-blown bipolar disorder and only a few children with the mild flights of excessive energy that could be considered nascent bipolar disorder -- a small fraction of the 1 percent or so some psychiatrists say may suffer from the disease.

Moreover, the symptoms diagnosed as bipolar disorder in children often bear little resemblance to those in adults. Instead, the children's moods seem to flip on and off like a stoplight throughout the day, and their upswings often look to some psychiatrists more like extreme agitation than euphoria.

[...]The children in one group, a minority, have mood cycles similar to those of adults with bipolar disorder, complete with grandiose moods, and a high likelihood of having a family history of the illness. Those in the other group have severe problems regulating their moods and little family history, and may have some other psychiatric disorder instead.

[...]Last year in the United States, about 1.6 million children and teenagers -- 280,000 of them under age 10 -- were given at least two psychiatric drugs in combination, according to an analysis performed by Medco Health Solutions at the request of The New York Times. More than 500,000 were prescribed at least three psychiatric drugs. More than 160,000 got at least four medications together, the analysis found.

Many psychiatrists and parents believe that such drug combinations, often referred to as drug cocktails, help. But there is virtually no scientific evidence to justify this multiplication of pills, researchers say. A few studies have shown that a combination of two drugs can be helpful in adult patients, but the evidence in children is scant. And there is no evidence at all -- "zero," "zip," "nil," experts said -- that combining three or more drugs is appropriate or even effective in children or adults.

Diagnosis is very complicated, largely because the whole concept is a rather crude way to explain all the varieties of behavioral disorders into a linear and causal model of mental illness that will facilitate treatment planning. Unfortunately, diagnosis and treatment is more like shaping Jello without a mold.

The human body doesn't work in a linear way. There is no simple way to describe a step-by-step process of disease development and no simply way to ensure an accurate way to prescribe treatment. Instead, the body, while a whole in itself, it is too complex to be thought of as one interacting system. The best we can do is break it up into parts and posit hypotheses about how parts might function. Our model of brain function, mental illness and treatment has fallen behind our knowledge. Worse yet, economics has pushed medicine to embrace a simple solution for a very complex problem. Giving a patient a pill sometimes works. It's so simple and cheap to do, if one pill doesn't work, another pill is offered, sometimes replacing the first, sometimes adding to it.

Frankly the state of our science doesn't really support the first pill, much less the second. There is growing evidence that therapy is as effective as the primary treatment or at least in combination with medications.

Psychotherapy has had it's own problem with linear thinking. There is more research on Cognitive Behavior Therapy, showing it as effective or more so than all other treatments, so the assumption is made that since the practice of CBT is "evidence-based", that it must be the treatment of choice. CBT is a simple straight forward process that can often be encapsulated into a manual. But there is no consistent evidence that CBT is any better than any other treatment. There is a dearth of meaningful comparison studies.

The problem is that mental health treatment is not amenable to meaningful research. Mental illness often has life long process of ebbs and flow where only part of the time is it "clinically" treatable, but it's roots and symptoms are pervasive throughout the lifespan. Studies are necessarily time limited. Treatments are offered most often for no more than six months and then outcomes are measured. Not surprisingly, treatment is demonstrated as disappointingly little more effective than "placebo". A placebo is a an intervention, such as giving the patient some helpful attention, which might reasonably be seen as helpful by a patient but there no reason to believe it should be as effective as the studied treatment. But the placebo is pretty effective itself, much more so than sitting on a waiting list for treatment.

Lets take a fresh look at the model of mental health, illness and behavioral science. Lets simplify the model from the biological realities but not so much as a singular linear model of one sequence of events producing an outcome. Actually, I've found it useful to conceive of the mind as having two main parts. One part is largely made up by the cortex, or the evolutionary most recently developed brain function. It's this part of the brain that is largely responsible for manipulating symbols, interpreting and remembering patterns of perceptions, and self-awareness and self-monitoring.

The cortex overlies a phylogenetically older part of the brain that largely makes up the autonomic nervous system. In this part of the brain, the body functions largely "automatically" with little interaction with the cortex. Here the heart is stimulated to beat, breath is maintained, pain sensors are monitored and automatic behaviors like walking and steering a car is monitored, largely without conscious awareness. Here is also the roots of our emotions, the biochemical and hormonal precursors to the thoughts whose symbolic representations we create to understand our emotions.

The cortex is the thinking part of the brain. The autonomic nervous system is the emotional and functionally analogic part of the brain. That part of us we imagine as "rational" or "logical" largely resides in the cortex. Those parts of us that are instantly compelled to act out of sheer emotion reside in the autonomic brain. Virtually all of our behavior is in fact the result of BOTH parts of the brain. So it is equally inaccurate to call our behaviors as rational manifestations or solely emotionally based. Our behavior is largely the result of both parts of us.

So, given this, its not surprising that there are times we wonder why we behave certain ways, or why we know we need to make a change, but mysteriously find ourselves unable to do so. While our awareness directs most functions of the rational cortex, we have relatively little "rational" control over the autonomic brain.

Traditionally, culture has attempted to explain this as a mind/soul duality. Judeo/Christian tradition posits that the primitive nature of humanity must be overcome by suppression of our autonomic impulses. Freud developed that concept into his scientific systemic model of the id (autonomic), ego (awareness), and superego (conscience). His concepts led to the idea that suppressed impulses caused problems, internal conflicts, that were manifested in dysfunctional behavior.

I think it's much more useful to think of the body as a functional whole that emerged from millions of years of natural section into a amazingly effective organism. I'd rather assume that ALL parts of us are as necessary to survival as any one. On an experiential basis, this requires a leap of faith. Ambivalence is an uncomfortable condition. Our mind is known to do all sorts of convenient fictional explanations of motives and their behavioral manifestations in attempt to maintain an illusion of rationality. One such example is cognitive dissonance.

In order to make use of our incredibly effective brain, we must be aware of as many of it's manifestations as is possible. We must recognize and be able to put into words emotions as complex and varied as our thoughts. We must also accept the fact that our thoughts and emotions OFTEN contradict each other, but in a real and very personal sense, both are right. Both parts of the brain learn their reactions. They also are born with reactions characteristic of the genes they inherit. Environmental insults, such as neuro-toxins and brain trauma can alter both parts of the brain structurally and functionally.

My assumption is that we function best when we make the most of everything we have. Marsha Linehan in developing Dialectical Behavior Therapy, took a similar view. The "Wise Mind" was conceived of as a combination of "Emotion Mind" and "Rational Mind". This all may seem simplistic and convenient thinking, but from a clinical stand point, the concepts work quite well.

Cognitive learning is the most available for change. We think, therefore we do. If we change how we think, we change what we do. However, everyone knows from their last New Year's resolution that it's not that simple for the many behaviors we want to change.

Our culture has developed the concept of "character" to explain how some people can change and others cannot. Character is largely thought to be genetically determined. That makes the non-thinking part of us to be very difficult and unlikely to change. Indeed, that has been the bias of psychiatry for many years. Diagnostically, Personality Disorders are roughly equivalent to the common concept of character. Though, psychological developmental models have demonstrated that nurture has quite a bit of influence over nature, it is still largely assumed personality is unchangeable. Medicare and many other insurance companies won't pay for treatment based on a diagnosis of a Personality Disorder.

But we do know from Behavior Theory that even reflexive behavior like salivating, heart rate and emotions can be learned and unlearned. Personality Disorders are assumed to be so pervasive and embedded in lifestyle and biochemistry to be largely untreatable. However, those of us who have worked a lot with persons with personality disorders know that they can change with knowledge and sustained effort and lifestyle change.

Personality Disorders seem to emerge from unfortunate childhood events, child abuse, neglect, or trauma, especially repeated trauma and chaotic lifestyles in the parents or caregivers. Parents with personality disorders beget children who grow up similarly impaired. While the actual behavioral style and sensitivity to the environment may well be genetically determined, the behavior is largely learned by emotional conditioning.

In Behavior Theory, a strong emotion creates a unique learning sequence. Elicit a strong emotion, with say a loud noise, the person will be strongly motivated to do something. They may jump in a startle response. But the person will also learn approach or avoidance behavior, based on the valence of the emotion, rewarding or punishing. Then, when you pair a neutral environmental stimulus with the intense emotion, eventually, just the neutral stimulus acquires the emotion eliciting effects of the original.

When a child grows up in a chaotic environment, she experiences strong emotions all the time. She is likely to also learn approach and avoidance behaviors in a way that is often random associated with unrelated environmental events. She is said to have learned "superstitious" behavior. Unlearning this behavior is a major challenge. That is because emotional learning is in a way "hardwired" in the autonomic brain. Representations of the environment are paired with an emotional responses outside of her cognitive awareness. She develops persistent bad habits that over time pile up into patterns of dysfunctional behaviors and can become a Personality Disorder.

Treatment of a Personality Disorder must address the behavior, often manifested in a characteristic lifestyle, the thoughts and attitudes of the individual, and the emotional responses that together drive the behavior. The basic paradigm of therapy becomes conditioned emotional responses described above and must be repeated over and over again, with the cooperation of the individual during periods of withering emotions. Not surprisingly, few volunteer for this sort of treatment until things become intolerable. The other problem, is that few clinicians offer this sort of treatment. Despite it's grounding in Behavior Therapy, this is not mainstream CBT. DBT covers some of the same ground, but the experiential notion of making changes in the context of strong emotions seems to be absent.

Traditional psychoanalytic therapy has used "abreaction" for many years. Crisis intervention theory also had a similar concept. But neither of these models claim that the method is effective with long standing chronic psychopathology. Marsha Linehan's DBT is the one of the few treatments that claim to be effective with personality disorders, especially borderline personality disorder. Although Linehan's model continues the tradition of encouraging suppression of excessive emotion by teaching incompatible behaviors, it does encourage patients to be "mindful" of their emotions and to combine them with rational thought for wisdom.

Why aren't more people doing this? There is several reasons. There is little recent theoretical formulations beyond Linehan's that support this approach. Current concepts of crisis intervention emphasize stabilization as the goal. In fact, virtually all the insurance company criteria for termination of mental health treatment call for stabilization of symptoms, rather than permanent behavior change! This is the same reasoning that got psychiatry stuck on handing out pills first.

Medication is often a helpful option. But given the recent highlight on suicidality with anti-depressants, side-effects of all medications, especially anti-psychotics, psychotherapy seems a prudent course to start and use medication adjunctively, rather than the other way around.

There is an important new research study on treatment of schizophrenia. They have found delayed or interrupted treatment is associated with permanent lost brain function and less success in recovery. That is indeed my clinical experience with schizophrenia and bipolar disorder. Any kind of chronic brain dysfunction makes permanent changes to brain structures and functioning. PTSD has been associated with permenent changes in emotion intensity and increased difficulty in emotion regulation. Chemical abuse has been associated with brain changes as well.

When the brain is involved, respond quickly, ask for help and persist to be sure the treatment is effective. Anything less will cost you in brain function. This applies to any serious mental health or neurological problem.

Psychiatric Weekly

In summary, it appears that there are benefits to be gained by identifying psychotic exacerbations early and bringing effective treatment to bear quickly (Table).11 If patients do not respond within the first 2 weeks to the initially prescribed antipsychotic, consider switching antipsychotics until you find something that works. When patients respond, our work is not finished. Optimize the response. Try to reduce psychopathology to a minimum. Attend to side effects; think of this task in terms of how you would feel if you had to take a medication every day for the rest of your life. Repeatedly inquire about patients' judgments as to their need for medication and the value of the medications they are presently taking. Treat their viewpoints with respect, express your point of view on these issues with clarity and persistence, and make it clear that their feeling better is the goal for both of you.

There is news today of a new study about mental health problems in prison and jails. The information shows a much bigger problem than previously reported.

MSNBC.com

More than half of America's prison and jail inmates have symptoms of a mental health problem, the Justice Department estimated Wednesday. But fewer than one-third of those with problems are getting treatment behind bars. The study by the department's Bureau of Justice Statistics also found the incidence of symptoms much higher among women than men.

Compared to inmates without symptoms, these mentally troubled prisoners were more likely to have been jailed before, to get into a fight behind bars, to have been physically or sexually abused in the past and to have drug problems, the bureau said. But troubled inmates were no more likely to have used a weapon during their offense (37 percent for troubled and nontroubled state prisoners) and only slightly more likely to have committed a violent offense (49 percent of state prisoners with symptoms but 46 percent among inmates without problems).

The results are "both a scandal and national tragedy," said Michael J. Fitzpatrick, executive director of the National Alliance on Mental Illness, a national grass-roots organization dedicated to improving the lives of the mentally ill. "The study reveals that the problem is two to three times greater than anyone imagined." Fitzpatrick said the results indicate "that the mental health system is failing -- long before people enter the criminal justice system and after they leave it." He said more resources devoted to mental health treatment on the outside would avoid "enormous costs shifted onto our police, courts, jails and prisons at all levels."

[...]Fred Osher, health service policy director in the criminal justice program of the Council of State Governments, noted that previous studies that focused on those diagnosed as mentally ill found fewer troubled inmates -- closer to 20 percent.

The mental health system has been called in "crisis". The use of that term is misleading. The problem has been with us forever, we are just starting to figure out why so many people are in jail and prison. Services for mental health have always been under funded. Previous studies and a Frontline public television report prompted a previous post on this topic.

Mental health problems and criminality have common roots. I've written about this topic before.

The US has one of the highest rates of incarceration of any country in the world. At year end 2002, 1,440,655 prisoners were under the jurisdiction of State or Federal correctional authorities. Four years later, that number is estimated at 1.8 million. In 2001, about 592,000 State prison inmates were released to the community after serving time in prison. (DOJ). Of the more than half a million offenders released every year, nearly 70% of them return to prison within three years.

In reaction to the problem of the "career criminal", the states and federal legislators passed tough new mandatory sentencing laws. The prison population as a result has grown precipitously. Now virtually every prison in the US is overcrowded. There is evidence that overcrowding "creates competition for limited resources, aggression, higher rates of illness, increased likelihood of recidivism and higher suicide rates." In addition, the cost of incarcerating an ever increasing population is skyrocketing, for the most part made up of non-violent offenders.

[...]We live our lives based on experiences we've had over our lifetime and the skills we learn and abilities with which we are born. People who behave in anti-social ways have learned that this behavior has advantages over socially acceptable behavior. Many of the studies reviewed in Hare's book reflect a poor relationship between parent and child, an absent or ineffective father figure, and abusive, inconsistent and/or neglectful child rearing. Children who grow up anti-social witness a disproportionate level of violence and perhaps most importantly, a level of chaos and absence of a perception of fairness and justice in their lives. They learn that their behavior in the long run doesn't change anything, delay of gratification just produces more pain. So short-term gain is chosen as the primary motivator. And the child's own self-interest is considered above all other considerations.

The study, by the Bureau of Judicial Statistics, a division of the Department of Justice, is done periodically. Previous reports found focused on only previously diagnosed inmates finding only 20%, similar to the current study based on recent history. The new study suggests that inmates are overwhelmingly under diagnosed. That's not particularly surprising since much so called "criminal behavior" is also associated with mental illness. An untrained eye in law enforcement is not likely to see what are often subtle differences that could only be verified by a formal diagnostic assessment by a mental health professional experienced in forensic mental health. Here are some key excerpts from the study:

At midyear 2005 more than half of all prison and jail inmates had a mental health problem, including 705,600 inmates in State prisons, 70,200 in Federal prisons, and 479,900 in local jails. These estimates represented 56% of State prisoners, 45% of Federal prisoners, and 64% of jail inmates. The findings in this report were based on data from personal interviews with State and Federal prisoners in 2004 and local jail inmates in 2002. Mental health problems were defined by two measures: a recent history or symptoms of a mental health problem. They must have occurred in the 12 months prior to the interview. A recent history of mental health problems included a clinical diagnosis or treatment by a mental health professional. Symptoms of a mental disorder were based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).

• More than two-fifths of State prisoners (43%) and more than half of jail inmates (54%) reported symptoms that met the criteria for mania.


• About 23% of State prisoners and 30% of jail inmates reported symptoms of major depression.


• An estimated 15% of State prisoners and 24% of jail inmates reported symptoms that met the criteria for a psychotic disorder.


• Female inmates had higher rates of mental health problems than male inmates (State prisons: 73% of females and 55% of males; local jails: 75% of females and 63% of males).


• About 74% of State prisoners and 76% of local jail inmates who had a mental health problem met criteria for substance dependence or abuse.


• Nearly 63% of State prisoners who had a mental health problem had used drugs in the month before their arrest, compared to 49% of those without a mental health problem.


• State prisoners who had a mental health problem were twice as likely as those without to have been homeless in the year before their arrest (13% compared to 6%).


• Jail inmates who had a mental health problem (24%) were three times as likely as jail inmates without (8%) to report being physically or sexually abused in the past.


• Over 1 in 3 State prisoners and 1 in 6 jail inmates who had a mental health problem had received treatment since admission. State prisoners (18%), Federal prisoners (10%), and jail inmates (14%) most commonly reported that they had used prescribed medication for a mental problem in the year before arrest or since admission.


• To meet the criteria for major depression, inmates had to report a depressed mood and decreased interest or pleasure in activities, along with 3 additional symptoms of depression. In order to meet the criteria for mania, inmates had to report 3 symptoms during the 12-month period. For a psychotic disorder, 1 symptom of delusions or hallucinations met the criteria.


• About half reported a family member incarcerated, 15% higher rate than none MI.


• Past physical or sexual abuse more prevalent among inmates who had mental health problems State prisoners who had a mental health problem (27%) were over two times more likely than those without (10%) to report being physically or sexually abused in the past. Jail inmates who had a mental health problem were three times more likely than jail inmates without to have been physically or sexually abused in the past (24% compared to 8%).


• Among State prisoners who had a mental health problem, nearly half (49%) had a violent offense as their most serious offense, followed by property (20%) and drug offenses (19%) (table 8). Among all types of offenses, robbery was the most common offense (14%), followed by drug trafficking (13%) and homicide (12%). An estimated 46% of State prisoners without a mental health problem were held for a violent offense, including 13% for homicide and 11% for robbery. About 24% of State prisoners without a mental problem were held for drug offenses, particularly drug trafficking (17%).


• Almost an equal percentage of jail inmates who had a mental health problem were held for violent (26%) and property (27%) offenses. About 12% were held for aggravated assault. Jail inmates who had a mental health problem were two times more likely than jail inmates without a mental problem to be held for burglary (8% compared to 4%). Use of a weapon did not vary by mental health status.


• The proportion of State prisoners who had used prescribed medication for a mental health problem since admission to prison rose to 15% in 2004, up from 12% in 1997 (table 15). There was little change in the percentage of inmates who reported an overnight stay in a hospital since admission (around 3%), or in the percentage who had received professional mental health therapy (around 12%).

Three-quarters of female inmates in State prisons who had a mental health problem met criteria for substance dependence or abuse. Female State prisoners who had a mental health problem were more likely than those without to --

• meet criteria for substance dependence or abuse (74% compared to 54%),


• have a current or past violent offense (40% compared to 32%),


• have used cocaine or crack in the month before arrest (34% compared to 24%),


• have been homeless in the year before arrest (17% compared to 9%).


• report 3 or more prior sentences to probation or incarceration (36% compared to 29%),


• report past physical or sexual abuse (68% compared to 44%),


• report parental abuse of alcohol or drugs (47% compared to 29%),


• report a physical or verbal assault charge since admission (17% compared to 6%).

The study report also included baseline information about mental health problems in adults for comparison purposes. Here is a summary:

As I said, the problem is not new, the recognition of the problem is an encouraging sign. The news reports quote the need for better mental health services to prevent crimes. That would certainly help. But the problem is bigger than that. From another previous post on the topic:

The US has one of the highest rates of incarceration of any country in the world. At year end 2002, 1,440,655 prisoners were under the jurisdiction of State or Federal correctional authorities. Four years later, that number is estimated at 1.8 million. In 2001, about 592,000 State prison inmates were released to the community after serving time in prison. (DOJ). Of the more than half a million offenders released every year, nearly 70% of them return to prison within three years.

In reaction to the problem of the "career criminal", the states and federal legislators passed tough new mandatory sentencing laws. The prison population as a result has grown precipitously. Now virtually every prison in the US is overcrowded. There is evidence that overcrowding "creates competition for limited resources, aggression, higher rates of illness, increased likelihood of recidivism and higher suicide rates." In addition, the cost of incarcerating an ever increasing population is skyrocketing, for the most part made up of non-violent offenders.

[...]Children who grow up anti-social witness a disproportionate level of violence and perhaps most importantly, a level of chaos and absence of a perception of fairness and justice in their lives. They learn that their behavior in the long run doesn't change anything, delay of gratification just produces more pain. So short-term gain is chosen as the primary motivator. And the child's own self-interest is considered above all other considerations.

Much the same could be said about people who grow up with mental health problems. The rates of child abuse and neglect due to chemical abuse by parents, and a chaotic lifestyle leads to the next generation at risk. From a previous post:

The correctional system we have is a complete failure. The only thing that works is locking people up for life. Truly, we as a society can't afford to lock up more than 2% of our total population at any one time. We need another solution. Career criminals are seldom caught. When they are, it's after more than a dozen offenses. Punishment will never be assured because we can't afford to lock them all up. We need a solution to the problem, not an over-sized band-aid.

The problem of crime [mental illness] and drug abuse originates in childhood. Years of research has shown that parents with chaotic lifestyles produce children with chaotic futures. Until we improve our parenting skills across the board, we will have to live with incredible crime and incarceration rates. We need to be teaching parents-to-be the skills beginning in junior high rather than assuming that parents pass on this skill to their children. Teaching parents-to-be how to nurture a quality attachment their children is critical. But it is also necessary to train parents-to-be emotion management skills and how to systematically teach those skills to their children. Competent parenting requires knowledge about emotion management and how to solve behavioral problems. My local school includes "Character Education" in it's curriculum. Creative approaches can be acceptable to both sides of the political spectrum. Improving parenting skills is critical to retrieving what has become a chronic underclass living a chaotic drug infested lifestyle.