Parents who have children with brain disorders tend to end up in hospital emergency rooms more often than the average parent—because of accidents, suicide attempts, and other crises—and they’re always saying things like, “Whenever there’s trouble in the classroom, my kid is bound to be in the middle of it.” Being with these kids is challenging and terribly demanding. “I’m not having much fun with my child. I love him, but I’m exhausted after being with him. And no one else can stand him” is a statement I hear quite often from my patients’ mothers and fathers. Many parents are embarrassed by the child’s behavior.
Even though they are nobody’s fault, there is a lot of parental guilt and blame attached to these disorders, and much of it comes about when parents are slow to notice a problem. One extremely conscientious mother of a boy with pervasive developmental disorder knew by the time her child was two years old that he needed some help, but she feels bad anyhow. She insists that she could have picked up the symptoms of PDD earlier if she had known what to look for. “Because of my son I got involved in a PDD program, and I saw babies who were four or five months old who were already showing signs of developmental delay. If I had known before what I know now, I would have taken him to the doctor much earlier than two.”
Another mother and father whose child I’ve treated reproach themselves for not being aware of their daughter’s depression. “She was so good at masking everything. She fooled us,” they told me. And they’re right. Some children, unable or unwilling or ashamed to ask for help, are masters at disguising the symptoms of their disorders.
A child should be evaluated by a child and adolescent psychiatrist if any of the items on this checklist describes his behavior for at least two weeks:
Stomachaches or headaches with no physical cause
Loss of interest in activities previously enjoyed
Change in sleep patterns
Change in eating patterns
Social withdrawal
Excessive anxiety or fearfulness upon separation from parents; refusal to sleep away from home or alone in his own bed
Refusal to go to school
Decline in school grades in several subjects
Persistent underachievement at school
Unacceptable behavior in the classroom
Aggressive behavior
Stealing, lying, breaking rules
Inability to speak to peers or adults other than family
Repetitive behavior; a child becomes overly upset if these actions are prevented or interrupted
Avoidance of objects or activities not previously avoided
Mood swings or a dramatic change in mood
A preoccupation with death or dying; suicidal wishes or threats
Change in personality, especially from cooperative to irritable or sullen
Odd or bizarre behavior or verbalizations
A tendency to confuse fantasy and reality
This checklist and the brief overview of a child’s developmental milestones are not meant to be alarming to parents, but I do hope that if you see that your child is not developing normally or that he’s exhibiting unusual behavior, you will be encouraged to do something about it. (Chapters 7 through 19 thoroughly examine the most common brain disorders in children and adolescents.) For example, if a child of two seems exceptionally uncomfortable with people, you should say, “You know what? My kid is supposed to be over this by now. Maybe I should talk to the pediatrician about it. Perhaps I’ll get him to recommend a child psychiatrist.” There’s nothing to be lost by getting some professional advice. The only thing better than prompt treatment of a disorder is the reassurance that nothing is wrong.
DISTRESS AND DYSFUNCTION
Schoolteachers have the three Rs: reading, writing, and ’rithmetic. Child and adolescent psychiatrists have the two Ds: distress and dysfunction. In deciding whether or not a child needs treatment for a disorder, we look for one or both of the Ds. If a child’s symptoms are not causing him or his parents distress or dysfunction, we watch and wait. Perhaps it’s not a disorder but the child’s style or an element of his personality. If and when the symptoms of a disorder increase and do cause distress or dysfunction, we establish a course of treatment, usually a combination of behavioral therapy and medication.
Child and adolescent psychiatrists are in the business of treating children who are sick, not medicating children who aren’t sick so that they can become more popular, perform better at a music recital, or turn a B + average into an A average. Since most children’s brain disorders are treated with medication and since all medications have some side effects, no physician is eager to put a child on medicine unless he really needs it. The first line of attack should be and is psychosocial intervention. Medication isn’t called for unless there is a diagnosable disorder.
Any physician must weigh the seriousness of a disease against the effects of the cure. Before he is treated with medication, a child has to be sick enough. If a boy bites his fingernails and the medicine to get him to stop doing it causes liver failure, we live with the chewed-up nails. After all, there’s no dysfunction involved, and the distress is only on the part of the parents. On the other hand, a girl who’s banging her head so hard and so often that she detaches her retinas needs a trial of medication to get her behavior under control, even with the risk of side effects.
Distress is not always obvious to spot in children. Some admit it, but many others deny that they’re in pain. Distress may manifest itself in any number of ways, many of them in conflict with the others: agitation, depression, social isolation, boisterousness, silence, sleeplessness, giddiness, sadness, and lots of others. Identifying dysfunction is a little more clear-cut. A child is dysfunctional if he doesn’t achieve and maintain developmental milestones; if he can’t or won’t go to school and pay attention; if he doesn’t have friends; or if he does not have a satisfying, loving relationship with his parents.
TAKING CHARGE
“It’s been really hard,” said a father of a little boy with attention deficit hyperactivity disorder. “I was looking forward so much to being a dad, and when my son finally came along, I was incredibly happy and excited. I wanted to do millions of things with him—all the great stuff my dad did with me. I couldn’t wait to play catch and go camping and that kind of thing. Then I found out I was living with a holy terror who was an absolute pain in the neck to spend time with. I hate to admit it, but I was pretty disappointed.”
The father’s statement is extremely blunt, true, but he’s only expressing what many parents with problem children feel. When a baby is on the way, parents are expectant in more ways than one. They are excited, consumed with hopes and fantasies about what the child will look like and how he will be. Parents want their children to surpass them, to live better, more fulfilling lives than their own. They want them to be accomplished, beautiful, and happy. When parents are busy picking out layettes and narrowing down the list of possible baby names, they aren’t anticipating illness. Brain disorders—even no-fault brain disorders—are not what they have in mind.
Accepting the fact that a child has a brain disorder is never easy for parents, even those who do finally realize that they’re not at fault. It’s even harder to cope with the realization that a child’s problem is in his brain. After all, parents think optimistically, if the behavioral problem is caused by something environmental, perhaps the child will outgrow it. I’ve met some parents who are a little downhearted that it’s not their fault. “I was hoping that it was our divorce that was making our daughter so crazy,” another blunt parent said to me. “At least that way she would get over it in time.” After all, if bad parenting is what is causing a child’s disease, it stands to reason that good parenting can make it better.
Unfortunately, that’s not how it works. Parents don’t cause the disorders, and they can’t cure them either. However, mothers and fathers can and should take responsibility for seeing that their children get professional help, and the sooner the better. T
he sooner a child’s brain disorder is diagnosed and treated, the sooner he can get on with living a full, happy, satisfying life. And that, in the end, is what every loving parent wants.
CHAPTER 2
Brain Disorders and Personality
Several years ago I was part of a group of psychiatrists and other clinicians who studied the effects of the psychostimulant Ritalin on preschoolers with attention deficit hyperactivity disorder. One part of the study involved observing the children and their mothers at play before and after the child was given medication. A mother and child were left alone in a playroom full of toys and games for 25 minutes, and their activities were monitored—one of the walls was a two-way mirror—and videotaped.
The time allotted to mother and child was divided into three segments: 10 minutes of free play, 5 minutes of cleanup, and 10 minutes of structured tasks. During free play a youngster was allowed to play with whichever toy he chose, with no limit as to the number of toys or the kind of play. The mother was encouraged to play with him. The cleanup was to be done by the child, with the mother supervising the process if necessary. During the 10 minutes of structured tasks the child would sit at a table with his mother, and she would ask him to complete 40 tasks, or as many as the child could manage in the time allowed. The simple tasks—picking out circles, identifying the red triangles, pointing out everything that’s blue, and so forth—tested the child’s ability to distinguish colors and shapes. What we were really taking note of, however, was the child’s ability to focus, pay attention, and follow instructions. We were also interested in the interaction between mother and child.
I’ll never forget the day that Christopher, three years old, came in with his mother to be tested. Little Christopher had one of the most severe cases of ADHD most of us had ever encountered. He nearly tore up my office the first day I met him, climbing on the furniture, scribbling on the tables, and tossing books and papers around the room. I ended up having to hold him in my lap (quite firmly, I might add) in order to interview him, and even then our talk lasted only a few minutes. Not surprisingly, Christopher had long since been blacklisted by every babysitter in his neighborhood. My diagnosis was ADHD. Christopher’s parents agreed to let him take part in our study, and his mother brought him to the playroom a couple of days after our first appointment.
Christopher was by far the most impulsive, inattentive child who took part in our study. During the 10 minutes of free play the boy played with 61 different toys. (Children with a normal attention span may play with as many as five toys in ten minutes, but many three-year-olds will spend the whole time with only one toy.) In truth, he didn’t play with any of them; he’d just pick a toy up, throw it down, and move on to another. Christopher’s mother tried to get him to settle down, running after him and making a strenuous effort to engage him, but nothing worked. The video camera caught it all: Christopher running from toy to toy, not even pausing to look at a toy; mom following along, calling out, “Christopher! Come here! Look at the truck! Christopher! Here’s a beach ball! Don’t you want to play catch with Mommy?” The faster Christopher moved, the louder and more agitated the mother became. There was complete chaos in the room.
After the time for free play had elapsed, one of my colleagues went into the playroom and told the boy and his mother that it was time for cleanup. That’s when Christopher really went ballistic. He screamed, threw himself down on the ground, and categorically refused to have anything to do with picking up the 61 toys. Again the mother tried to get her son to follow orders. “Chris, honey, come on. Let’s clean up,” she said, first in a normal voice and then, as the boy’s behavior grew into a full-fledged tantrum, more loudly. The noise on the tape is deafening. After a minute of the tantrum we asked Christopher’s mother to handle the cleanup on her own.
The structured tasks were a total washout. Christopher would not even sit at the little table, let alone pick out red triangles and blue circles. His mother put him in the chair, but he kept getting up and running around the room. Mom kept trying—“Christopher! Come on! Let’s sit down and play some games!” she cried, over and over again—but nothing worked. The mother became increasingly frustrated; she knew that Christopher was capable of accomplishing the tasks, but nothing she did could persuade him to sit down and do it. When the 10 minutes were up, the little boy had not completed one task. The mother was exhausted.
Almost exactly a month later Christopher and his mom came back to do the test again, but by this time the boy was taking 40 milligrams of Ritalin a day. Again, the whole thing was captured on videotape. During free play Christopher chose a Fisher-Price toolbox, and he and his mother sat on the floor playing with it, and only it, for the full 10 minutes. It was so quiet in the playroom that we had to adjust the microphones. “You really like this toy, don’t you, Chris?” the mother asked softly. “Yes, I love it,” the boy answered. Their conversation was lively and pleasant. Cleanup took only a few seconds; there was just the one toy to put away, and Christopher did it as soon as he was asked. Finally, during the structured-tasks portion of the test the youngster sat at the table with his mother and completed 32 of the 40 assignments. The interaction between the two of them was a pleasure to watch; there was give-and-take and lots of laughter. Voices were never raised.
A few months later I had occasion to show the two videotapes of Christopher and his mother—before and after—to a small group of medical students who were doing a rotation in child psychiatry. We asked the students, who knew nothing at all about the study, what they thought had happened in the month between sessions. All of the students came to the same conclusion: the mother was taking medication. “In the first tape she’s a mess. She’s practically driving the kid crazy, constantly yelling at him and giving him a hard time,” one med student said. “She’s so much calmer and quieter on the medication.”
It’s true: on the second tape the mother is quieter and calmer, thanks to medication, but she’s not the one taking it, of course. The medication that brought on the changes in the mother’s attitude and behavior, not to mention the tone and the decibel level of her voice, is her son’s Ritalin. The “new” Christopher, the one who pays attention and enjoys laughing and playing and talking to his mother, is so much more pleasant to be with that his mother can’t help being pleasanter right back. And the cycle continues from there. The mother’s yelling and nagging are converted to praise and approval, and the child flourishes. The more his mother likes him, the more likable he becomes, not just to his mother but to everyone else around him as well. After a time, even the babysitters may have a change of heart.
I’ve described this study at length not to emphasize the effectiveness of Ritalin in the treatment of ADHD—I do that in Chapter 7—but to open a discussion of how a child’s brain disorder affects the way he and the rest of the world interact. Christopher’s ADHD did a lot more than make him impulsive and inattentive. It made him unpleasant and unlikable, even to the people who love him most. It made people avoid him, yell at him, and refuse to baby-sit for him. Furthermore, being constantly criticized and yelled at and infrequently praised probably made Christopher’s situation even worse. One of the things we learned in our study is that the mothers of children with ADHD don’t praise their children as often as other mothers do, even when the children do something eminently praiseworthy. The mothers of kids with ADHD are more attuned to their children’s negative behavior than to their positive behavior; this is not surprising, since there’s usually so much more of the negative than the positive.
Although it may not seem so, Christopher is one of the lucky ones. He was only three years old when his brain disorder was discovered and treated. He’d had a couple of years of negativity out there in the world, but it had been largely contained within the family. He hadn’t started school, so he had not had a chance yet to alienate his teachers and annoy his classmates. With the help of the Ritalin and his conscientious parents we hope he never will.
A PERSONALITY IS BORN
<
br /> Children are born with certain personality traits, which determine how they will behave in the world, how they will learn, and how they’ll interact with others. Even newborn infants have personalities; intelligence, humor, and all the other elements that make up a personality are largely determined in the womb. But that is by no means the whole story. A child’s personality development is affected, sometimes very strongly affected, by the environment in which he grows up. A child who is naturally cheerful and optimistic will not remain upbeat for long if the world is constantly giving him or her downbeat messages. Neglected and abused children find it more than a little difficult to maintain the sunny dispositions they were born with. In the same way, having a brain disorder has crucial and sometimes long-lasting effects on a child’s personality development.
When Mario, an eight-year-old boy, came to see me, I asked him what he thought his problem was. “I’m a bad boy,” he answered. “What do you mean you’re a bad boy?” I asked. “I get into trouble all of the time,” he explained. “Do you want to get into trouble all the time?” I asked. “I don’t know if I want to, but I do. I’m just bad,” Mario replied. At the ripe old age of eight, Mario is already convinced that he is a failure. Traveling through life surrounded by people who are forever impatient or enraged is bound to have an impact on a child’s personality.
It's Nobody's Fault Page 3
