To Linda,
a truly perceptive,
wise, and beautiful woman
Introduction to the
Paperback Edition
THE DAY It’s Nobody’s Fault: New Hope and Help for Difficult Children and Their Parents was published, I started a book tour that took me across our nation. I was able to meet and speak to thousands of parents of difficult children. I listened to their stories of struggling to find the right help for their children in distress, of the ignorance of teachers and even some health professionals. On almost every television show or radio program in which I participated, the interviewer would share a vignette about his or her own troubled child and that child’s success with medication. Unfortunately, the interviewers almost always shared these stories off the air—a clear sign that the stigma of mental disorders in children and adolescents is alive and well in the United States. Millions of children suffer unnecessarily in classrooms, on playgrounds, and at home. Their parents continue to be unfairly blamed for their problems. I heard a recent report of a six-year-old boy who broke into a house, stole a tricycle, and brutally beat an infant. The media immediately blamed his mother’s marital status, the family’s socioeconomic class, and the neighborhood as the cause of the boy’s aberrant behavior. The fact that he was probably suffering from a serious psychiatric illness was totally overlooked.
Even as more scientific data comes in about the safety and efficacy of medication in the treatment of mental disorders, the media remain resistant to reporting its positive effects. While we are becoming more accepting of depressed adults’ decision to take antidepressant medication, we largely fail to do so when a depressed adolescent’s mental well-being is at stake. I see this media bias—which naturally influences how parents consider the issue—even in the subtle use of language in coverage. Articles are more likely to refer to psychiatric medications as “drugs,” while antibiotics and even cancer chemotherapy are referred to as “medicines.”
The bias is still there, but the good news is that Americans are beginning to pay more attention to this issue. This year, Congress passed a bill giving parity or equality to mental illness. In other words, they are mandating that health insurers cover physical and mental illnesses equally. I applaud this act, because more and more research indicates that the no-fault brain disorders that I discuss in this book are as real as physical illnesses. A gene for Attention Deficit Hyperactivity Disorder has been identified. Research is being done to pinpoint the genes for depression, Tourette’s syndrome, and obsessive-compulsive disorder. Our understanding of how the brain works is expanding almost daily. Molecular neurobiology is helping researchers develop new models to understand how chemicals carry messages in the brain and affect our emotions and behavior. Pharmaceutical companies have finally recognized the unmet need of children and teenagers with depression and anxiety disorders. Today research is being conducted and data collected to obtain approval for new medicines that will help these kids and eliminate their needless suffering.
Years ago, I took my oldest son, Joshua, on a business trip with me. He was seven and spent the day in an excellent child care program run by the hotel. I spent the day attending conferences. In the late afternoon, we had the opportunity to walk on the beach together and talk. Josh was very happy about being away from school and spending time with me. He held my hand and said, “Can you imagine if we could do this every day?” Somewhat alarmed, I replied, “You mean stop going to school?” He said, “No, just hanging out and being in Florida.” I said, “You mean retire like Grandma and Grandpa?” He looked at me and said, “Dad, don’t you know how to imagine?” I never imagined when I entered child and adolescent psychiatry training that we would identify the genes and develop medicines that can change the way the brain works—and by doing so, save the lives of millions of children. We can be more hopeful than ever that new help will come every year to aid difficult children and their parents.
The publication of my book has given me a wonderful opportunity to work with different patient advocacy groups, members of Congress, and many in the mental health profession. If we can all continue to collaborate with and educate parents and teachers, we’ll be able to identify children with no-fault brain disorders sooner and get them the help they need to bring out their full potential.
There are dozens of stories in this book about people I have encountered during my many years of practicing psychiatry. I talk about many children and adolescents I’ve treated and parents I have counseled. On occasion I describe youngsters who have been cared for by my colleagues. The facts as I relate them here are accurate, but some of the details have been changed in an effort to keep the identities of all concerned private and confidential.
Acknowledgments
THE FIRST PERSON I want to thank is Kathleen Moloney, whose skills as an interviewer and writer helped make this book possible.
My thanks go also to my agent, Wendy Lipkind. I have thought about writing a book for years; Wendy persuaded me that there’s no time like the present. Fortunately my editor, Betsy Rapoport, had the same idea. Her enthusiasm and her words of encouragement have been much appreciated.
My colleagues in the Division of Child and Adolescent Psychiatry at Schneider Children’s Hospital were exceptional in their generosity and their understanding during all phases of this project. Many of them shared their wisdom and their experiences during the information-gathering period and offered valuable suggestions and honest appraisals as the book progressed. I am especially grateful to Joe Blader, Ph.D., Robert H. Dicker, M.D., Carmel Foley, M.D., David J. Ganeles, M.D., Stanley M. Hertz, M.D., Emily Klass, Ph.D., Michael H. Kronig, M.D., Marc W. Reitman, M.D., Mary V. Solanto, Ph.D., and Neil M. Smoke, D.O. I am thankful also to Howard Abikoff, Ph.D., Carmen Alonso, M.D., Keith Ditkowsky, M.D., Anita Gurian, Ph.D., Glenn S. Hirsch, M.D., Vivian Kafantaris, M.D., and Richard Morrissey, Ph.D., for sharing their experiences. Rona Novick, Ph.D., and Richard Gallagher, Ph.D., were especially helpful in making the principles of behavioral therapy understandable.
Other colleagues made significant contributions as well. Michael Maloney, M.D., Katherine Halmi, M.D., and David Herzog, M.D., shared their considerable expertise on eating disorders. Steven Suomi, Ph.D., chief of the Laboratory of Comparative Ethology at the National Institutes of Health, let me observe firsthand the work he is doing on animal behavior and temperament and was a gracious host. Bennett Leventhal, M.D., was enormously generous with his knowledge of brain chemistry, and he, too, made suggestions about the work in progress.
Many friends and family members were supportive and understanding during this project, especially Dominick Abel, Virginia Anthony, Ken Burrows, Michael Carlisle, Gabrielle Carlson, M.D., Gail Furman, Ph.D., Erica Jong, Maureen Klesmer, Edith Koplewicz, Stanley Kutcher, M.D., Owen Lewis, M.D., Reina Marin, Ph.D., Brian Novick, M.D., Sally Peterson, Ph.D., A1 Ravitz, M.D., Peter Ross, Michael Strober, Ph.D., and Jamie Talan. I am deeply grateful to Margery Rosen for her generous and indispensable advice and support. Judith Schumer merits special thanks for helping with the title.
Jackie Eichhorn, my secretary in the office, did a great job of juggling my schedule so that I could find time for this project. Special thanks go to my assistant, Vera Connolly, who always makes my professional life run smoothly. The extra mile that she went, especially in putting together the charts and the “Resources and Support Groups” section at the back of the book, is much appreciated.
The heart of It’s Nobody’s Fault is, I believe, the stories of the children I’ve encountered over the years. I would not have been able to do those stories justice without the candid contributions of many of the parents of those kids. I am grateful to the many mothers and fathers who agreed to be interviewed
and gave so generously of their time, especially Karen Chapnick, Brooke Garber Neidich, Sherry Laniado, Nancy Morris, and Bernard Rosenblum.
Long before there was any thought of a book I was helped more than I can say by Donald Klein, M.D., and Rachel G. Klein, Ph.D., my mentors and good friends. It was they who set me on this path. I thank them both for their advice, their encouragement, and their inspiration.
Somewhere in the pages of It’s Nobody’s Fault I say that one of the most important things a child can do is choose the right parents. I made the best possible choice with mine. Roma and Joseph Koplewicz are remarkable people, and I thank them for everything.
Finally, on the home front I received indispensable wisdom and moral support from my wife, Linda Sirow. Some of my best insights about children come, directly and indirectly, from my three wonderful sons, Joshua, Adam, and Sam. I could not have done it—any of it—without my family.
Contents
Introduction to the Paperback Editon
Acknowledgments
Introduction to the First Edition
PART ONE
Living with a Child’s Brain Disorder
1. It’s Nobody’s Fault
2. Brain Disorders and Personality
3. The Doctor-Patient-Parent Relationship
4. The Art of Parenting a Troubled Child
PART TWO
DNA Roulette and the Role of Medication
5. The Chemistry of the Brain
6. The Great Medication Debate
PART THREE
No-Fault Brain Disorders
7. Attention Deficit Hyperactivity Disorder
8. Obsessive Compulsive Disorder
9. Separation Anxiety Disorder
10. Social Phobia/Shyness
11. Generalized Anxiety Disorder
12. Enuresis/Bedwetting
13. Tourette Syndrome
14. Major Depressive Disorder
15. Bipolar Disorder/Manic Depressive Illness
16. Schizophrenia
17. Eating Disorders
18. Conduct Disorder
19. Pervasive Developmental Disorder, Autism, and Asperger’s Disorder
Afterword
APPENDIX ONE
A Definition of Terms
APPENDIX TWO
Resources and Support Groups
APPENDIX THREE
Psychopharmacology at a Glance
Introduction to the First Edition
NEW HOPE, NEW HELP
THE FIRST TIME I knew I wanted to be a doctor I was about four years old, sitting in the office of my pediatrician over on Eastern Parkway in Brooklyn. If I close my eyes, I can still see his face and his friendly Norman Rockwell office, with the big brown leather furniture and a bowlful of lollipops on the desk. I wanted to grow up to be just like him.
It wasn’t until I was in medical school that I settled on psychiatry. I was working in a psychiatric community clinic headed by a man whose conviction and passion were so strong that he excited everyone around him. He was the first person I knew who took a “team” approach to treating mental illness. He talked about how medicine worked for certain disorders and psychotherapy worked for other disorders and how sometimes what was needed was a little bit of both. I was intrigued.
Then, in 1980, I read a book that changed my life. This book, Diagnosis and Drug Treatment of Psychiatric Disorders: Adults and Children, opened my eyes as nothing else had to the importance of diagnosis in the treatment of mental illness. What I read also made it quite clear that the role of medication in that treatment was indispensable. It sealed my fate.
Just about the time I became a child and adolescent psychiatrist, I also became a father for the first time, so I discovered for myself how it feels to be a parent. I understand what it’s like to want the best for a child and how frustrating it is not to be able to make the world perfect for a son or daughter. I also know that the last place on earth a parent wants to be with a child is a doctor’s office. I’ve heard parents describe the feeling they get when they find out that something is wrong with their child—“a sinking feeling in the pit of my stomach,” they say—and I know what they mean. Parents have told me that there is a special pain attached to receiving unwelcome news from a child psychiatrist, and I can appreciate those feelings as well. Most parents don’t need an excuse to feel anxious or guilty about their children. Hearing that a child has psychological problems automatically pushes many mothers and fathers into guilt overdrive.
Over the years I’ve read many studies about genetics, but now that I’m the father of three, I’ve learned something firsthand. My wife and I have three sons, and while the boys are remarkably similar in some ways—they look very much alike, for instance—they couldn’t be more different in others. One is left-handed, and the other two lead with their right hands. They have very different social skills, anxiety levels, and abilities when it comes to sports, art, and learning. Their temperaments are not at all alike. The genes of their parents combined to make a baby three times, and each time the results were different. In these pages I call this phenomenon DNA Roulette. By the time you have come to the end of this book, I hope you’ll have a full understanding of what DNA Roulette means.
There are other terms you’ll see often in It’s Nobody’s Fault. One of the most important is no-fault brain disorder, by which I mean that the disorders examined here—attention deficit hyperactivity disorder, separation anxiety disorder, depression, social phobia, Tourette syndrome, and all the others—exist not because of what a child’s parents do but because of how his brain works, the brain that he was born with. As I’ll explain, a child’s brain disorder is not his parents’ fault. It’s nobody’s fault.
However, finding the right treatment is a parent’s responsibility. Parents don’t make their children sick, but it is their job to do everything possible to see that their kids get better. The good news is that there is much that can be done to do just that, much more today than even a decade ago. Most of the advances in the treatment of no-fault brain disorders have come in psychopharmacology, the use of medication to treat the symptoms of a no-fault brain disorder. Medication—there’s another word you’ll be seeing often in this book. Another is drugs, a word that stops a lot of parents cold. Many, perhaps even most, of the mothers and fathers who bring their kids to my office have a problem with the idea that their child might have to take drugs to treat a disorder, for a period of months or even years. They worry about side effects and fear that they’ll somehow “lose” their child if he’s under the influence of medication. What I hope I make clear in this book is that the role of medication in treating no-fault brain disorders is incredibly important. The side effects of not taking drugs to treat a serious problem can often be more harmful than those associated with taking the medicine.
One of my first patients as a psychiatric resident was Ned, a boy I don’t think I’ll ever forget. He was about nine years old when his mother brought him to see me. He had been having a terrible time in school; his performance was poor, and his teacher was complaining about his behavior. He didn’t have much of a social life either. None of the other kids in the class wanted to play with him, and their parents didn’t like having him around.
After making a diagnosis of attention deficit hyperactivity disorder, I prescribed medication for Ned (a small dose of Ritalin twice a day) and saw him once a month for nearly a year. We talked about what was going on in his life—his parents were going through a particularly unpleasant divorce—and worked on improving his social skills and self-esteem. After the year was up I saw him only every few months, to monitor his progress. His improvement was remarkable in every way. His grades were terrific, he had lots of friends, and his parents said it was a joy to be with the “new Ned.”
A few years after I first saw Ned, he invited me to his elementary school graduation. He was getting a class prize for the best science project, and he wanted me to hear his acceptance speech. Ned said that his mother was having a party
at the house afterward, and he wanted me to be there too. I told him that I would really like to be there, but I had a few questions.
“Where do you think I should sit?” I asked him.
“Well, if you sit with my mom or my dad, the other one will be jealous,” he answered. “Maybe you could sit with my friends’ parents.”
“Okay. And how should I introduce myself?” I asked.
This question was clearly harder than the first one.
“We can tell people you’re my veterinarian,” the boy ventured.
“But you don’t have any pets,” I said.
“I’ll say I used to have a bird with a wing that was broken. But then you fixed it, and it flew away.”
I told him that I didn’t think that making up a story was a good idea, and he agreed to think about it.
Graduation day came, and I stood at the back of the room and listened to Ned’s speech. I wasn’t able to go the family party, so after the ceremony Ned took me over to meet his grandparents. “This is Dr. Koplewicz,” he said. “He’s my… my friend.” True to his word, the youngster had come up with a description of our relationship without making anything up. After meeting the family I stayed for a while, watching as Ned, clutching his award, talked animatedly to his friends and family.
When I think about my role in Ned’s life, or in the lives of any of the children I care for, the image I always come back to is roadblocks, impediments on the path that keep these kids from getting where they want and need to go. It’s my job to help them climb over those roadblocks or push them out of the way. I say to them, “Look, there’s a way of getting from here to there. I’m going to show you how.” I give them the tools they need to clear the path. Along the way I try to reassure the parents of these troubled kids and give them hope.
That’s what I’ve tried to do in this book as well. I hope that parents and other readers will come away with new hope for their difficult, troubled children and will be inspired to do everything in their means to get their children the help they need in order to lead happy, fulfilling lives.
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