It's Nobody's Fault (3 page)

There are millions of people who endure traumatic experiences—abuse, divorce, the death of a loved one, skipping second grade, and so on—without having to be treated for a psychiatric disorder. Naturally, all children are affected by the events of their lives. If a child is abandoned or beaten, it will most certainly change the way he looks at the world and reacts to it. If his parents get a divorce, it will unquestionably have an effect on him, probably a significant effect. But unless he has the brain chemistry that makes him vulnerable to a psychiatric disorder, the child will not end up with a disorder. By the same token, a brain disorder doesn’t miraculously disappear if the unpleasant environmental factors are altered.

Not all children develop at precisely the same rate, of course. Still, the developmental milestones that follow will give parents a rough idea of what to expect.

At
one month
a child will react to voices and be attentive to faces. By
four months
he’ll smile at people and respond socially to both familiar and unfamiliar people. At
six months
a child will sleep through the night. At about
age one
he’ll walk and say his first word, usually “Mama” or “Dada,” and he’ll have developed a clear attachment to a caretaker, usually but not necessarily the mother. Also at one year kids start “pretend play,” having tea parties with imaginary food and pretending, for example, that a toy cup is real.

At
two years old
a child can draw a circle, and he starts to use symbolism: a pencil represents a person, or a block becomes a chair. At the same time kids have “idealized representations”; they don’t like broken dolls or toys or anything that has something wrong with it. Kids develop empathy at about this time; if a child hears a baby crying, for example, he’ll say that the baby’s hungry or hurt. By the time a child is two, he’ll be comfortable around strangers with his parents nearby and capable of parallel play: two or more children playing in the same room at the same
time but not together. The kids may not speak or otherwise interact as they go about their tasks. Most two-year-olds have a hundred words in their vocabulary and speak in sentences of two words, such as “Big boy,” “More food,” or “Come here.” Girls usually have a more advanced verbal ability than boys, so a two-year-old girl probably will have a much more extensive vocabulary than a hundred words.

At around age
three
most children are toilet-trained, and they have a thousand-word vocabulary. They move on to reciprocal play, building sand castles together or engaging in some other mutually enjoyable activity. With reciprocal play there’s a connection between children, even if it
is
a fight. At three kids can sit for 20 minutes of story time or some other activity. By the age
of four
they stop wetting their beds at night and use complex grammatically correct sentences. At four a child can separate comfortably from his parents; he’ll be able to stay at a birthday party for an hour without his mother in the room. He will also be able to share toys, follow the rules of a game, and function in a group with minimal aggression. A four-year-old might be afraid of the dark or of animals, but that fear is usually transient.

At five years old
children like to hear stories read repeatedly and enjoy rituals throughout the day, such as having a snack as soon as they get home from school, playing with certain toys in the bath, and sleeping with the same teddy bear every night. At
six
kids have a vocabulary of about 10,000 words, and they learn to read. They frequently start to collect things—rocks, dolls, basketball cards, and so on—and may become fond of superheroes. At
seven
they may develop superstitions and rituals: step on a crack, break your mother’s back.

From age eight through adolescence, children focus on school performance. Competition and ambition become more important in their lives. Boys and girls begin to develop a value system based largely on the beliefs learned from their family. Their social sphere widens, and friendships begin to take on greater meaning.

The developmental milestones associated with adolescence are less specific in terms of age; there are basically five
developmental tasks
that must be accomplished by a youngster between puberty—approximately age 11 for girls and 12 or 13 for boys—and the end of adolescence, about age 22. There are enormous physical changes that take place during adolescence, especially hormonal fluctuations, and brain chemistry goes through changes as well.

The first task youngsters must accomplish is to
separate
from their parents. Naturally, this separation process doesn’t happen all at once; it comes about gradually, in steps, such as flirting with ideas that are different from those of their parents or favoring music and wearing clothes that adults hate. By age 22 a young person should be completely comfortable about being separate from his folks, regardless of geography. The second task that faces an adolescent is the
development of a network of friends.
At age 13 or 14 a child begins to find his peer group important. The greatest influences in his life remain Mom and Dad, but he’s influenced by his friends and shares intimacy with them. The third task is
sexual orientation.
Sexual fantasies usually start at puberty; by the age of 22 a young person, even one who is not sexually active yet, should know which gender arouses him sexually. Task number four is the
setting of educational and vocational goals.
At age 12 that means finishing a math project or learning the history of Syria. When a youngster is 17 or 18, his goal may be to get into college or find a job. By the time he’s 22, he should have a good idea of what he wants to be when he “grows up.” The fifth and final developmental task of adolescence is
adjustment to the physical changes
that take place during this period. It’s important for a child to adjust not just to the specific changes themselves but also to the fact that his changes are different from those of his friends and are taking place at a different rate.

Being mindful of the milestones of childhood and adolescence will help parents to identify problems their child might have. Parents should be on the lookout as well for specific abnormal behaviors that may indicate that a child has a psychological disorder. Some of them are: repetitive actions, such as tapping, hair-pulling, and hand-washing; unreasonable fears, such as not being able to sleep unless the parents are in the same room; agitation and excessive rigidity; nervousness about meeting people; motor or verbal tics; and extremely aggressive, disruptive behavior. The degree and the intensity of these symptoms are what really matter. Occasional lapses into peculiar behavior are not cause for concern.

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.

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.

“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.