THE BRAIN CHEMISTRY
Conduct disorder has not been widely studied, but the information that has been gathered indicates that certain children have a genetic vulnerability to this disorder. When that vulnerability is combined with certain high-risk environmental factors, such as poverty, parental neglect, marital discord, parental illness, parental alcoholism, and having a parent with antisocial personality disorder—the adult version of CD—the child’s chances of having the disorder are even greater.
The role of genetics in CD is less than crystal-clear. We do know that a vulnerability to the disorder is inherited. The chances that a child will have CD increase if one parent has it and go up even more if both parents have it. (If either of the parents abuses drugs or alcohol as well, the chances of CD in a child are greater still.) Twin studies have shown that if one twin has CD, the other is more likely also to have it if he or she is an identical twin rather than a fraternal twin. Adoption studies show that there is an increased risk for a child to have CD if both his adoptive and his biological parents have this disorder, further supporting the nature-plus-nurture “double whammy” theory.
Neuropsychological testing has shown that children and adolescents with CD seem to have an impairment in the frontal lobe of the brain, the area that affects their ability to plan, to avoid harm, and to learn from negative consequences. Another study demonstrates that the serotonin levels in the brains of children and adolescents with CD were even lower than the serotonin levels in the brains of children and adolescents with obsessive compulsive disorder.
THE TREATMENT
Conduct disorder is by far the most difficult disorder to treat in all of child and adolescent psychiatry. There is no one drug of choice for all the symptoms of CD and no one therapy that has an appreciable effect except in rare cases. When treating children with conduct disorder I, like every other child and adolescent psychiatrist, hope that in addition to the CD there is another disorder that we can treat. If CD is co-morbid with another disorder, we treat the other disorder first; if there is evidence of ADHD, for instance (and about half the time there is), we’ll prescribe Ritalin or sometimes Cylert. Dexedrine works well too, but we’ve found that kids with CD are more likely to sell their Dexedrine than to take it as prescribed. Once the symptoms of the other disorder have subsided, we’re often faced with a very different child. With luck the “new” child will be more responsive to medication or behavioral therapy or both.
If the child with CD does not have ADHD, we’ll probably give him Ritalin anyway, since Ritalin is effective in decreasing negative behavior (specifically aggression toward teachers and other kids) in children with CD. If Ritalin is not effective and the child is very aggressive, we may give him a trial of Lithium, which is used to reduce aggressive behavior in adult males. Also prescribed in the treatment of bipolar disorder in children and adolescents, Lithium alleviates the aggressive explosiveness that kids with CD sometimes demonstrate. (Because of the possible effect that Lithium may have on the thyroid, a youngster taking the medication will require blood monitoring.) If Lithium doesn’t work, we usually try Depakote, another medication used for bipolar disorder.
In addition to medication we recommend therapy for the child, specifically a cognitive behavioral approach that helps the child learn new ways to resolve conflict. This is a very active process, employing a lot of role playing and rehearsal. A child is taken through simulated or real events that involve conflict and encouraged to forget his usual responses—aggression and other forms of antisocial behavior—and learn new, nonviolent, socially appropriate ways to react to these events. This form of behavior modification basically gives the child a whole new way to behave and to respond to conflict of any kind. Because of its strong cognitive component (that is, it requires thinking), the program usually works better with adolescents than with young children.
When the diagnosis of a child with CD is in question or when it becomes necessary to get immediate control of a very aggressive child or adolescent, hospitalization will probably be called for. An out-of-home setting provides more intensive supervision and structure than anything that can be done while the child is living at home. Once the child has made significant progress, and provided his parents are cooperative, treatment can be continued on an outpatient basis.
Early detection and treatment are vital here. Every day care center in America should be on the lookout for obviously aggressive and out-of-control three-year-olds. Nothing is to be gained by watching and waiting to see if these kids will outgrow this behavior by the time they’re four or five or 10. By then their behavior will be even more sociopathic; also, they’ll do badly in school and won’t have any friends. Even more important, they’ll probably have parents who can hardly bear to be around them. If there is any chance of turning these kids around, it must be done in the early stages of the disease, before they’ve “progressed” from lying and shoplifting to assault and rape. Left untreated, these kids are at high risk for substance abuse, imprisonment, and death by unnatural causes.
PARENTING AND CD
In my practice I meet a lot of unhappy, angry, embarrassed, frustrated, helpless, hopeless, and overwhelmed parents. The ones who would take first prize in all categories were the mother and father of Edward, an 13-year-old boy being treated for conduct disorder. The parents adopted Edward at birth, and they had a few good years with their son, they said. By the age of three, however, Edward was already a terror. The parents, who are conscientious to a fault, looked for help right away, and over the years they had tried everything, including trials of medication, private schools, and family therapy. Still, a week doesn’t go by without an alarmed phone call from Edward’s teacher, saying that he beat up one of the other kids. The neighbors call too, to report that Edward stole the barbecue grill or urinated on the front lawn. Edward’s parents are at their wits’ end. They don’t know what to do next.
I’d like to say that I was able to give them an easy solution to their problem, but that wouldn’t be true. Treating conduct disorder, which Edward clearly had, is never easy. We treated Edward with Ritalin, and we started him in therapy; at 13 the child was a good candidate for the cognitive behavioral approach. We also added yet another element of this “team” approach to the treatment of CD: parent training, in which a therapist works with parents to help them understand the disorder and gives them strategies for making the other parts of the treatment more effective. Normally this means asking parents to learn how to discourage their child’s negative behavior—temper outbursts, destructiveness, refusal to follow the rules, and so on—and to reward desirable, socially acceptable behavior. Punishments are nonviolent, of course, and usually involve the loss of privileges, such as watching television or playing outside. Rewards are stars and check marks that can be traded in for something a youngster particularly values. Parents must monitor their child’s behavior regularly and stand ready to intervene promptly with either positive or negative reinforcement.
This is not as easy as it might sound. Kids with conduct disorder are tough, and parents should be prepared for a labor-intensive, time-consuming treatment. For these mothers and fathers there’s no such thing as being “off duty.” Frequently these children, when faced with new rules and regulations, become even more defiant, and that makes the training program even more challenging for even the most motivated, devoted parents. And the changes usually come a lot more slowly than anyone would like. In my experience the program takes at least a year.
CHAPTER 19
Pervasive Developmental Disorder, Autism, and Asperger’s Disorder
Terry, 11 years old now and getting along quite well, has had developmental problems ever since he was two. He grunted and pointed, but he didn’t speak, and his mother wasn’t sure he understood what was being said to him. For a while his parents thought he was deaf, but they had him tested and discovered that his hearing was fine. He slept badly from the beginning too, and his behavior was always a little off. There were a l
ot of temper tantrums. When Terry wanted something, he couldn’t express himself, so he’d throw things. He wasn’t any good at throwing, either, even when he got older. His coordination was terrible. He couldn’t run or throw a ball like the other kids. When he did eventually speak, he could barely be understood. At 11, Terry has been seeing various specialists for nearly nine years.
Clara, age three and a half, is a spectacularly beautiful little girl—big blue eyes, blonde hair, pink cheeks. The day I met her, her mother had dressed her up like a little doll. Clara didn’t speak or make eye contact. According to her parents, she never did. She screamed, though. If she didn’t get what she wanted right away, she would let loose the most bone-chilling shrieks, sometimes for hours at a time. Clara didn’t interact with me the way a typical three-or four-year-old usually does. There was no connection between us. She wouldn’t play. She didn’t respond to, “Can you say hello?” or “Please pick up the doll.” When I asked her to wave bye-bye, she stared right through me. I offered her a piece of candy, but she wasn’t interested. Her parents say that all Clara will eat, literally, is food from McDonald’s—a hamburger for breakfast, french fries for lunch, and another burger for dinner. Every morning they drive to the golden arches for Clara’s daily rations.
Bobby is twenty years old and has been my patient since he was ten. His parents claim he was always an “odd duck” and he didn’t seem to need people. Bobby had been in a special school program for many years, and he was doing quite well. Every day Bobby took a city bus to his school, and he never missed his stop. In fact, he had committed the entire bus system to memory. Bobby’s IQ was 128—well above average—and his grades were quite good all the way through high school. After graduation, he found the perfect job: managing the flow of checks in a local bank. He had to take three buses to get to the bank—no problem whatsoever for Bobby, of course. He was absolutely terrific at his job. He never missed a day, and he never, ever made a mistake.
DEVELOPMENTAL DELAYS
Most parents know a little something about the milestones of child development—when a child should walk, talk, use the toilet, and so forth. Many parents take these things for granted, not even realizing how fortunate they are to have children who are right where they should be, just like clockwork. Terry’s, Clara’s, and Bobby’s parents don’t have the luxury of such thoughts. Their children have pervasive developmental disorder, PDD. Terry’s case is relatively mild; today he is quite high-functioning, and with continued work he will probably go to college and maybe even get married. Clara’s prospects are not so bright. Clara has autism, the most severe form of PDD. With treatment and a lot of hard work she may well be able to hold a job of some sort, but it’s unlikely that she’ll ever be independent or have a family of her own. Bobby has Asperger’s Disorder. He had no significant delay in his language or his cognitive development but always had social difficulties and repetitive behaviors.
THE SYMPTOMS
Regardless of the severity of the disorder, all kids with PDD have serious impairments in several areas of development, especially language and communications skills and social interactions. Sometimes physical coordination will be impaired and the child will exhibit strange behavior. The development may be uneven—a child will be strong in one area and very weak in another—but overall these kids are weak in many spheres of development. That’s what makes this disorder pervasive. Reports indicate that approximately 1 percent of the population has PDD; most people with PDD are diagnosed after the age of three.
Autism is a very rare disorder (it occurs about five times in every 10,000 live births, with a boy-girl ratio of 4 to 1) but widely studied. Some say that there are more people doing research on autism than there are people who have the disorder. People, not just psychiatrists and medical researchers, seem to be fascinated by this bizarre, inexplicable disease. Television shows and movies are filled with characters who have autism: a doctor’s son on St. Elsewhere, a victim on Law and Order, and, of course, the movie Rain Man. Most of them don’t exactly conform to the facts of the disease, but the true symptoms of autism don’t always make for good theater.
Autism is a congenital disorder—that is, a child is born with it—characterized by severe impairment in the areas related to communication, social interaction, and the ability to use play and abstract thinking. The essence of autism is a lack of interest in people and a failure to appreciate and make use of the nuances of social interplay. Kids with autism don’t respond to the subtle social cues that are obvious to most youngsters. A child with autism will know when his parents are very angry or very happy, for example, but he’s not able to detect anything in between. The difference between a grimace and a friendly smile of greeting will be lost on him, and voice inflections will mean little or nothing. Children with autism understand black and white, but they don’t usually understand gray. Subtleties are wasted on them.
Language deficits are a major component of this disorder. Only half of all children with autism will develop functional speech. Children with autism commonly have echolalia, which is the repeating of the words or phrases they have heard. They misuse pronouns and invent new words. The tone, pitch, accent, and cadence of their speech are abnormal. They have trouble sequencing (putting a story in order so that it makes sense) and encoding (storing information that has an emotional component). About 75 percent of all children with autism are also mentally retarded to some degree. The key difference between Asperger’s disorder and other types of pervasive developmental disorder is language acquisition. Kids with Asperger’s disorder have no significant delay in language: they have less echolalia and fewer pronoun reversals, and therefore initially may often not be identified as having a problem.
Children with autism may have strengths, though, especially in such skills as putting together puzzles or constructing objects. A very small number of people with autism—the Dustin Hoffman character in the movie Rain Man, for instance, who was fantastic with numbers and had memorized all the statistics about airline accidents—have phenomenal abilities in particular areas, such as memory, calendar calculations, and art.
Many kids with PDD and especially autism have attentional problems and exhibit repetitive behaviors. They may also be impulsive and hyperactive, often to the point of being self-destructive. I once treated a 14-year-old boy who would pick at his own skin until it bled. He’d also bang his head and his legs against brick walls until he’d break a bone or knock himself unconscious.
THE DIAGNOSIS
When PDD is suspected, we concentrate on getting as much information as possible about a child’s history, his behavior, and his abilities, looking to parents, teachers, and anyone else who has spent time with the child. Long-term baby-sitters, grandparents, and other relatives can sometimes be very valuable historians. In taking a history we pay special attention to delays and deviations from normal development, especially in the child’s acquisition and use of language and his social interactions. We check the family medical history, looking for language or social communication difficulties, a neurological disease or psychiatric disorders, particularly PDD or autism. The child’s pediatrician does a complete physical, including a neurological examination. Psychological testing can help in the diagnosis by giving us an assessment of the child’s social skills, language skills, and intelligence. Children with PDD will have higher performance scores than verbal scores. Because of their relatively normal language development, kids with Asperger’s disorder are diagnosed later than children with autism or PDD.
An official diagnosis of autism is rarely made until a child is 18 months old, but often the disorder can be detected much earlier. Autism can appear from birth all the way up to 30 months. Babies with autism don’t make eye contact and don’t even want to be held. Even in the crib they may show a tendency toward repetitive actions. Other children will be fine in infancy but will start to show signs of autism later. Typically, they don’t pick up language when they should. At age three or four children with
autism will have significant delays in all developmental areas, especially language. They’ll be unable to make distinctions between people and objects in their environment, and they won’t get or give pleasure during social interactions.
What may at first seem like autism in a child may be developmental language delay; language problems often lead to problems in communication and in some social interaction. However, children with language delay, unlike those with autism, engage in imaginative play and usually have normal social interactions with their family and friends. They don’t exhibit the same abnormal patterns of language as those typical among children with autism.
THE BRAIN CHEMISTRY
PDD is a complex disorder that probably involves variations in the structure of the brain; that is, the brain was not put together correctly, so there are some chemical abnormalities, ones that will probably never be repaired. As I mentioned earlier, there have been many studies of autism, so most of the information we have about the causes of PDD have to do with its most severe form.
Twin studies support the belief that autism is genetic; the concordance rate of the disorder is 91 percent in identical twins and 0 percent in fraternal twins. Family studies reveal that if one child in a family has autism, the likelihood that his brother or sister will have the disorder is increased. Studies of the brains of children with autism indicate that there is something wrong with how the brain processes certain information, especially sounds and language. Neuroimaging techniques and autopsies show that there are abnormalities in the cerebellum.
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