Some parents find that the best response to a crisis in the family is action. One mother of a 13-year-old boy I’m treating for TS is constantly looking out for her son, clearing the path in front of him, but she is careful to stay behind the scenes, where her son can’t see her.
“The day before school opened, I went to the principal’s office and checked Philip’s schedule. I noticed some problems and asked the principal to make some changes. He said to me, ‘Oh, don’t worry. Phil can change it tomorrow.’ I said, ’No. You don’t understand. Phil can’t change things. When he sets these mistakes on his schedule, he’ll be too upset.’ I sat there until all the changes were made. The principal was great about it.”
Not all principals are great, of course, but this enterprising mother is politely unstoppable. Here’s more.
“Phil was going through a terrible time in sixth grade, so I wanted him to have a teacher who wouldn’t put too much pressure on him. I worked it out with the school in advance, but when he got to class on the first day of school, he had the wrong teacher, one I knew would be horrible for him. I marched in to talk to the principal, but they told me he couldn’t see anyone for two weeks. I said, very politely, That’s okay. I’ll just sit here and wait.’ And I did. He had no choice but to see me, and he did what I asked. I’m not an aggressive person; you can ask my husband. But my kid is too important for me not to go the extra mile. I mean, if my kid has to give a speech in class, he’s a nervous wreck until he’s called on and gets it over with. What’s wrong with asking a teacher to call on him first?”
As far as I can tell, there’s nothing wrong with the kinds of things that Phil’s mother routinely does behind the scenes. I’m in favor of parents’ protecting their children, of not putting a child in a position that will cause distress. For example, I advised another set of parents not to give their soon-to-be-13-year-old son, who had fairly serious TS, a traditional bar mitzvah celebration. The ceremony and the party afterward are stress-provoking for the most stalwart and brave boys; for this boy it would all be too much. Much to his relief—and theirs, I’m sure—the parents took the boy on a short trip instead.
Parents should be careful not to expect too much from their children, but they shouldn’t expect too little either. Children, even ones with a serious disorder like TS, have to make their way in the world, and that means learning to fit in and follow the rules. There are certain symptoms that a child with TS can’t control, even when he is appropriately medicated, but there are others that can be reined in. Like any child, a youngster with TS must understand that there are limits. It’s the parents’ job to set and enforce these limits, to help a child to function in polite society. Allowing a child to behave badly does him no service whatsoever.
Out there in the real world people may not enjoy looking at facial tics or listening to throat-clearing, but those behaviors are tolerable in society. What people can’t and won’t tolerate is someone who shouts obscenities or touches everyone’s food at the dinner table. A child must be told what will and will not be permitted. For example, a child who misbehaves in a restaurant should know that his actions have consequences.
“Look, this behavior is really unacceptable,” a parent might say. “You have to stop arguing with us and cursing when we go out to a restaurant.
“Well, I have no control over it,” the child might answer.
“Your mother and I think you can control it. If you feel you are going to yell and can’t control it, we think you should leave the table. If you can’t control yourself, you won’t be able to go out with us to dinner anymore.”
“But I can’t help it.”
“We think you can, and the doctor thinks so too. Here’s an idea: if you feel the need to scream, excuse yourself from the dinner table and go wait in the bathroom until the feeling goes away.”
I’ve spoken to parents who worry about punishing a child for behavior he can’t control, and I sympathize with their concerns. But there’s nothing punitive or even unreasonable about that exchange. A child is not being threatened with punishment because he can’t stop blinking or sniffing. He’s being asked to modify behavior that he can control. By the way, this process of setting limits should be honored by the extended family, including close friends and doting grandparents. No one should be permitted to sabotage the parents’ efforts. Everybody should know and abide by the rules.
Psychotherapy is not part of the standard treatment package for Tourette syndrome, but parent counseling or family therapy can be extremely beneficial for all concerned as a family tries to invent ways to cope with a disturbing, sometimes all-absorbing brain disorder. Parents of kids with TS need all the education and support they can get, and many find it by joining parent support groups or patient support groups, such as the Tourette Syndrome Association. The organization keeps its members up to date about the treatment of TS, publishes a regular newsletter, and sponsors various activities that bring together people whose lives are touched by TS. Once in a while they even arrange a movie screening. Their latest? Twitch and Shout, of course.
CHAPTER 14
Major Depressive Disorder
Until a month before I met her, Claire, 15 years old, had always been the life of the party. Attractive, bubbly, and smart, she made excellent grades, held down a job at a drugstore after school, and had an active social life, including a boyfriend. I first saw Claire just after the start of her junior year of high school. Her parents said that she hadn’t really been herself since she returned from a summer away at camp. She’d been having trouble concentrating on her studies, she quit her job at the drugstore, and her boyfriend broke up with her. She’d been having a lot of trouble sleeping. Her parents said she was snappish and short with them and spent most of the day in her room. “Everything is an effort. I don’t enjoy anything,” Claire told me when we first met.
Charlie, also 15, was reading aloud in English class one day, and right in the middle of A Separate Peace he burst into tears. When the teacher took him to see the guidance counselor, Charlie was inconsolable, and his parents had to be called to pick him up. Everyone who knew the boy was baffled by what had happened. He seemed to have everything going for him—he was nice-looking, a talented musician, a good athlete, and a nearly straight-A student—but when he came to see me, he was sleeping all the time. For the past two months he’d been eating very little, and his weight was plummeting. He had stopped playing baseball. He said that he woke up every morning thinking that life wasn’t worth living.
MOOD DISORDERS
Until about 15 years ago—the year that Charlie and Claire were born—it was generally accepted that children couldn’t be depressed, not clinically at least. The thinking was that the egos of children were not sufficiently developed to be affected by mood disorders. Today we know better. There is irrefutable evidence that major depressive disorder, or MDD, does exist in children and adolescents. In prepubescent children it’s quite rare, affecting only 1 to 2.5 percent of the population under the age of 12 and 2 to 8 percent of the population between the ages of 12 and 18. Among children it seems to affect boys and girls equally, but in the adolescent population females are more likely to have it.
Depression is the most common brain disorder in America; each year some 8 to 14 million Americans are recognized as suffering from clinical depression. One survey found that 19 percent of all adolescents had experienced an episode of MDD.
“It’s been raining all weekend. I’m so depressed.”
“That movie was so depressing.”
“I had such a depressing day at work today.”
“I can’t believe the Yankees lost again. I’m incredibly depressed!”
We’ve all heard comments like those. Most of us have made them ourselves. Depression is an overused word these days, describing our reaction to everything from a train crash to a failed soufflé. Of course, true clinical depression—MDD—is a lot more serious than a bad day at the office. It’s a serious mood disorder with very specifi
c symptoms, and it requires prompt, active treatment.
MDD may come and go, with occasional flare-ups; kids with MDD have their “ups and downs.” For example, Charlie, described earlier in this chapter, had his first depressive episode back in the first grade. His mother says she knew there was something wrong, but she had no idea what it was. Then Charlie got better and stayed that way until fifth grade, when he went through a month-long period of being agitated and all but impossible to live with. That too passed, and he was fine until that frightening incident in tenth-grade English class, the one that led his parents to my office. MDD doesn’t spring up overnight, although it may seem that way sometimes. Like a volcano, it simply lies dormant until some sort of crisis triggers the first episode.
Other children and adolescents suffer from dysthymia, a milder, more chronic form of depression, which should be distinguished from MDD. If MDD is like a full-blown infection, dysthymia is like a chronic virus—with a low-grade fever, some aches and pains, perhaps a mild headache. Kids with dysthymia get the “downs,” but they rarely experience any “ups.” One child who fits this description perfectly is Dominick, 16 years old. To hear his mother tell it, Dominick is a child who never seemed to get any joy out of life. He was the best student in his class and the star of the football team, but none of it seemed to make him happy. Getting an A on a test was incredibly important to him—he was completely focused and driven in his efforts—but when he got the A, there was no pleasure attached to the accomplishment. Dominick wasn’t morose, but he had no zest for life. “He never cries, but I don’t think I’ve ever seen him smile either,” his mother said. Recent studies show that dysthymia may well be a stepping-stone to MDD. Dominick is a likely candidate for clinical depression.
THE SYMPTOMS
Major depressive disorder in children and adolescents is characterized by at least two weeks of a nearly constant depressed mood severe enough to cause distress and dysfunction. (We look for the so-called depressed triad: feelings of hopelessness, helplessness, and worthlessness.) The two-week minimum requirement for symptoms rules out the many unpleasant events and situations that can and do cause people to be unhappy and even temporarily depressed, such as a divorce, a medical emergency, a family financial crisis, or any of a dozen other problems. (An important exception is bereavement. The period of mourning considered normal for a death in the family is two months.) If the depressed mood is not a result of MDD, it will wax and wane; it won’t be predominant for two weeks. In addition to the two weeks of depression, a child or adolescent with MDD will have at least four of the following symptoms: inability to concentrate, irritability and anger, marked fatigue, feelings of worthlessness, sleep problems, appetite disturbance, social withdrawal, restlessness, and decrease in libido. One final symptom of MDD that may be present is anhedonia: the inability to experience pleasure. Most youngsters have had their symptoms much longer than two weeks by the time they receive professional help.
MDD manifests itself differently in children and adolescents. Very young children may not necessarily look or act sad, although some will have downcast eyes or a blank expression. In fact, many children with MDD will seem more oppositional than depressed. They’ll be irritable and cranky; everything bothers these kids. Behavior disturbances such as hyperactivity, temper tantrums, and absence of normal play are not unusual. A small number of children, perhaps as many as a third, will have thoughts of suicide. They also often complain about various aches and pains,—headaches, stomachaches, even back troubles. Typically a depressed youngster will see his pediatrician or some other physician before finally making his way to a child and adolescent psychiatrist’s office.
In teenagers the symptoms of MDD tend to be a little different, more like those of depressed adults. Depressed mood, diminished ability to concentrate, sleep, and appetite disturbance, sensitivity to rejection, a feeling of being weighed down, and thoughts of suicide are common symptoms. Depressed adults often undereat and undersleep; teenagers are more likely to overeat and oversleep. A lot of depressed adolescents sleep in the middle of the day, coming home from school and taking a nap. Then they wake up at seven or eight o’clock in the evening, grumpy and irritable. After having something to eat—probably not with their parents and the rest of the family—they’re wide awake until three o’clock in the morning and have trouble waking up the next day for school. Sleep disturbance is a vicious circle.
Depressed teenagers often have an additional symptom: mood reactivity. These youngsters are able to cheer up when they are in a positive interaction or environment. Chad, a 16-year-old boy I treated for MDD, was chronically irritable. He didn’t eat much, showed no interest in television, and couldn’t concentrate on his schoolwork. That was when he was home alone or with his family. When his friends came over, his mood would brighten; sometimes he seemed almost happy. His father was baffled and angry. “He must be doing this on purpose,” he said. “How can he be so pleasant when his friends come and so miserable the rest of the time?”
Depressed teenagers may also be very sensitive to rejection and may have a tendency to be histrionic, with extreme reactions to real or imagined slights. One 16-year-old girl with MDD whose boyfriend broke a date with her went up on the roof of her house and threatened tojump off. She stayed up there for hours, feeling completely despondent. She told her mother and father that life wasn’t worth living if her boyfriend didn’t love her. The fact that he had canceled their date because he had to study for a test made no difference.
The irritability associated with MDD can lead to very erratic, even violent behavior. A 14-year-old boy named Gerard was brought in to see me after pulling a knife on his father. Gerard had been having problems at school—skipping classes on a regular basis and behaving badly when he did attend. On the days he didn’t go to school, he would just lie in bed all day, mostly sleeping but occasionally watching television. He hardly ate at all. He had no social life, no friends. One evening his father lost patience with Gerard and told him he had to go to school or else, and Gerard became enraged. That’s when he reached for the knife, after pounding on and then overturning the kitchen table. When I interviewed him, Gerard wasn’t forthcoming about his symptoms at first except to say he was tired all the time. All he would tell me about the episode with the knife was: “My father made me mad.”
THE DIAGNOSIS
It is highly unlikely that anyone watching Gerard turn over that table and grab that kitchen knife would describe him as depressed. The word depressed summons up images of a weepy, withdrawn child. By the same token, when a child or an adolescent does look unhappy or withdrawn or demonstrates any of the other symptoms associated with clinical depression, there are many possible explanations besides MDD. Before making a diagnosis of major depressive disorder, a child and adolescent psychiatrist must take a detailed history by interviewing the child, the parents, and the teachers. Then he must systematically consider and rule out all the other possibilities, bearing in mind that co-occurent conditions are very common with MDD.
It’s not uncommon for kids with MDD also to have an anxiety disorder, especially separation anxiety disorder (discussed in Chapter 9) and social phobia (Chapter 10). Studies have shown that nearly half of the children diagnosed with MDD will have an anxiety disorder as well. Leonard, a 16-year-old boy I treated for MDD, was originally diagnosed with social phobia. When I first met him, Leonard told me that he had been feeling unhappy for five years. The other kids think he’s weird, and he’s afraid to talk to people at school, he told me. He would like to have friends, but he doesn’t know how. Leonard’s mom and dad have their own theories. Dad says that the problem is that Leonard has always had low self-esteem. Mom says it all started because Leonard is the smallest kid in his class, and that makes him feel inadequate. One thing I learned during that first visit was that lately Leonard has been having a lot of trouble sleeping. He’s been suffering from both initial insomnia (trouble falling asleep) and middle insomnia (waking up in the middle of t
he night). Both sleep disturbances are common symptoms of MDD.
Major depressive disorder may sometimes look a lot like attention deficit hyperactivity disorder too (see Chapter 7). Not too long ago I saw a little eight-year-old boy who was sent to me by a neurologist because of his disruptive behavior at home. He behaved himself at school well enough, but after school he would bang on the walls of his bedroom until he made holes in them. Almost anything would set him off. He was agitated and cranky all the time, and he had many physical complaints. Nothing gave him pleasure. When his parents didn’t give him his way, he went ballistic. My eventual diagnosis was MDD.
Yet another relative of MDD is CD: conduct disorder (Chapter 18). Jamie, a 16-year-old boy, came in because he was irritable, fresh, and always getting into trouble both at home and out in the world. He was terrific at sports and a very good artist, but his academic achievement left a lot to be desired. He frequently cut classes and had lots of fights after school. A psychologist had given Jamie’s parents the diagnosis of CD, and there was no question that Jamie had it. It turned out that he also had MDD. (Depressed kids are often regarded as oppositional because of their irritability.) It took me a few weeks to find out that Jamie was also feeling, in his words, empty. “I felt like nothing. I felt like: Why move? Why get out of my chair?” he told me. It’s important to remember that teenagers Jamie’s age, and particularly those considerably younger than Jamie, don’t necessarily speak the language of MDD. They don’t say they’re depressed or blue or gloomy or morose or any of the many words an adult might choose. Empty was the closest Jamie could get.
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