It's n.o.body's Fault.

New Hope and Help for Difficult Children and Their Parents.

by Harold Koplewicz.

Introduction

NEW HOPE, NEW HELPTHE 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 pa.s.sion 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 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. 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. 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 n.o.body's Fault. It's n.o.body's Fault. One of the most important is One of the most important is no-fault brain disorder 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 n.o.body'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 Medication-there's another word you'll be seeing often in this book. Another is drugs 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 not taking drugs to treat a serious problem can often be more harmful than those a.s.sociated with taking the medicine. taking drugs to treat a serious problem can often be more harmful than those a.s.sociated 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 cla.s.s 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 cla.s.s 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 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 rea.s.sure the parents of these troubled kids and give them hope. 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 rea.s.sure 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.

PART ONE.

Living with a Child's

Brain Disorder.

The four chapters of Part One focus on what a no-fault brain disorder is and how it affects-directly and indirectly-the lives of children, their parents, their teachers, their friends, and the rest of the world. This section also explores the role of the health professional in the treatment of children's brain disorders.

CHAPTER 1.

It's n.o.body's Fault.

It's a typical day in early October. The school year has started, so I'm seeing quite a few new patients. The first child I talk to is William, age seven, who starts my day off with a real bang. William's motor just won't quit. He doesn't sit or even perch. He walks around my office, touching everything as he goes. At one point he sits behind my desk and spins in my chair. William's nickname at home is "The Magician," because he's always making things disappear. "He can lose his homework walking from the kitchen to the bedroom," his mother tells me.

After William comes Margot, nine years old and as quiet and sad as William is animated. Her parents tell me that Margot has trouble sleeping. For the last two months she's been getting up every night and crawling into bed with Mom and Dad. They give her warm milk, rub her back, and put her back in her own bed, but a short time later there she is again. Sometimes they find her asleep on the floor of their bedroom in the morning. When her parents leave my office so that I can speak to the little girl alone, Margot starts to cry. I tell her that Mom and Dad are waiting right down the hall. She begs me to let them stay just outside the door.

I see a lot of good-looking children in my line of work, but my next patient, 11-year-old Kenny, with his dark skin, dimples, and huge hazel eyes, would stand out in any crowd. Kenny has come to see me because his parents are worried that he might hurt himself. According to his mother and father, Kenny has always been conscientious and hardworking, giving "110 percent" to everything he does. His grades are excellent, he's a better than average athlete, and he has plenty of friends. Until recently he seemed fine. A few months ago, however, he turned cranky and irritable. One night not too long ago he became more upset than his parents had ever seen him; he said that he wished he were dead and locked the door to his room. He's been complaining of headaches almost every day.

"She's driving us crazy," said Delia's mother within seconds of crossing the threshold of my office in the midafternoon. Delia, 10 years old, didn't look look as if she could drive anyone crazy. She had a winning smile and a delightful personality. But she's been making demands at home that her parents can no longer meet. The ritual that she insists on at bedtime is the worst, her parents say. Every night she says, "I love you, Mom" and "I love you, Dad," and her parents have to say, "I love you too, Delia" right back. The problem is, they have to go through this exchange 20 or 30 times before Delia will let them turn off the light. A few nights ago they decided not to follow the script and sent her to bed with just one "I love you" apiece. Delia got hysterical. "She was obviously in real pain," her father told me. as if she could drive anyone crazy. She had a winning smile and a delightful personality. But she's been making demands at home that her parents can no longer meet. The ritual that she insists on at bedtime is the worst, her parents say. Every night she says, "I love you, Mom" and "I love you, Dad," and her parents have to say, "I love you too, Delia" right back. The problem is, they have to go through this exchange 20 or 30 times before Delia will let them turn off the light. A few nights ago they decided not to follow the script and sent her to bed with just one "I love you" apiece. Delia got hysterical. "She was obviously in real pain," her father told me.

My last patient of the day was Tobias, age 16, who looked, from a distance, like a typical teenager-baggy clothes, huge athletic shoes, single earring, surly expression. Up close I could see that he was pale and tired, and I soon learned that the bagginess of his clothes wasn't just the latest fashion; Tobias had lost a lot of weight. He just didn't feel like eating. In fact, he didn't feel like doing much of anything. "Everything's just so boring" more or less summed it up for him. He didn't make eye contact when we spoke. His parents told me that Tobias stays up until all hours of the night and then takes four-hour naps after school. He's also missed a lot of school.

DISORDERS OF THE BRAIN.

William, Margot, Kenny, Delia, and Tobias, like all the other children described in these pages, have many things in common. All of them have brain disorders; all of them have responded well to treatment, including medication; and all of them have parents who care. Their parents have something in common too. When they first brought their children to see me, virtually all of them thought, or at least suspected, that what was wrong with their children was their fault. Those worried, guilt-ridden parents couldn't be more wrong. What's troubling their children is n.o.body's fault. n.o.body's fault.

According to a report issued recently by the Inst.i.tute of Medicine, one quarter of the United States population is under the age of 18, and at least 12 percent of those under 18 have a diagnosable brain disorder. That's 7.5 million children and adolescents-boys, girls, rich, poor, black, white-with psychiatric disorders. That's roughly 15 million parents who feel guilty about it.

One of the reasons parents think that they're to blame for their children's emotional and behavioral problems is that people are always telling telling them that they are. Teachers, relatives, friends, even strangers aren't the least bit reluctant to share their opinions with the parents of troubled kids. The mother of Freddy, a six-year-old boy I was treating for attention deficit hyperactivity disorder, summed it up very well when she said, "My husband and I have gotten a lot unsolicited advice, and just about all of it has been bad. First people said all Freddy needed was discipline, and they blamed his illness on us. If I would just quit my job and stay home with him, he'd be fine. My sister thinks that Freddy has problems because I weaned him at three months. She breast-fed her two girls until they were nine months, and they're fine. My husband works long hours, so my family blames him too, saying that Freddy would be okay if my husband would take him to more baseball games. People made us feel like negligent, uncaring parents." them that they are. Teachers, relatives, friends, even strangers aren't the least bit reluctant to share their opinions with the parents of troubled kids. The mother of Freddy, a six-year-old boy I was treating for attention deficit hyperactivity disorder, summed it up very well when she said, "My husband and I have gotten a lot unsolicited advice, and just about all of it has been bad. First people said all Freddy needed was discipline, and they blamed his illness on us. If I would just quit my job and stay home with him, he'd be fine. My sister thinks that Freddy has problems because I weaned him at three months. She breast-fed her two girls until they were nine months, and they're fine. My husband works long hours, so my family blames him too, saying that Freddy would be okay if my husband would take him to more baseball games. People made us feel like negligent, uncaring parents."

Old ideas die hard. Until 20 years ago there was a general belief that early childhood traumas and inadequate parenting were responsible for childhood psychiatric disorders. Although we know better today, that antiquated way of thinking is still supported by many mental health professionals, perpetuated by the media, accepted as gospel by too many teachers and other school officials, and espoused wholeheartedly by well-meaning relatives. People who wouldn't dream of blaming parents for a child's other diseases-asthma or diabetes or multiple sclerosis, for example-don't hesitate to embrace the notion that a child's behavioral difficulties are caused by working mothers, overly permissive parents, or absent dads.

The fact is, when a child has a brain disorder, it is not not the parents' fault. It is also not the fault of teachers or camp counselors or the children themselves. A brain disorder is the result of what I call "DNA Roulette." In the same way a child comes into the world with large ears, a tendency to go gray in his twenties, or, like Kenny, beautiful hazel eyes and deep dimples, a child is born with a brain that functions in a particular way because of its chemical composition. (The chemistry of the brain is explained at length in the parents' fault. It is also not the fault of teachers or camp counselors or the children themselves. A brain disorder is the result of what I call "DNA Roulette." In the same way a child comes into the world with large ears, a tendency to go gray in his twenties, or, like Kenny, beautiful hazel eyes and deep dimples, a child is born with a brain that functions in a particular way because of its chemical composition. (The chemistry of the brain is explained at length in Chapter 5 Chapter 5.) It is brain chemistry that is responsible for brain disorders, not bad parenting. It is brain chemistry that is responsible for brain disorders, not bad parenting.

At conception a child receives genes from his parents, half from his mother and half from his father. As parents with more than one child know very well, those genes aren't donated in exactly the same configuration every time. A child's precise genetic makeup is largely determined by chance. Genetic messages from both parents come together to create many different combinations. If that DNA Roulette wheel stops spinning on a "lucky" number, the brain works properly and the child is normal. If not, the brain is dysfunctional. There is no reason for parents to feel guilty about their child's psychiatric disorder. There's nothing that any of us can do about our genes. The good news is that there is a lot we can do to treat the problems that genes can cause in our children.

Over the past two decades genetic influences in psychiatric disorders among adults have been fairly carefully studied, but science has only recently begun to focus attention on brain disorders in children and adolescents. Still, the studies that we do have are quite persuasive. Studies comparing the frequency of brain disorders in identical twins (who share the exact same genetic makeup) to the frequency of brain disorders in fraternal twins (who are only as genetically similar as any siblings) show that if one twin had a psychiatric disorder, the other twin was more likely to have it too if he or she was an identical rather than fraternal twin. The conclusion: many childhood psychiatric disorders have a genetic component. Adoption studies that investigated the genetic influences of psychiatric disorders in children who were raised from a very early age by adoptive parents, and compared their incidence of psychiatric disorders with both their biological and their adoptive parents, came to the same conclusion.

Animal models, especially those conducted with Rhesus monkeys, who have a 94 percent genetic similarity to humans, also support the theory that brain chemistry is genetically transmitted. In studying the neurochemistry of these animals and their reactions to stress and other environmental factors, experts have established in yet another way that nature is a stronger force than nurture. Of course, nurture does play a part in determining how a child will feel and behave. An unfavorable environment, in which a child is abused or unloved, certainly will have a detrimental effect. If that child begins life with a brain that is vulnerable to a disorder, a demoralizing environment is strike two.

THE FINE ART OF STORYTELLING.

"Right after my daughter Serena was born, I was very sick. I spent most of the first year of her life in bed. I gave the baby as much attention as I could, but I was way too sick to be the kind of mother I wanted to be. Serena was difficult as a baby, and over the years she got much worse. There were a lot of problems with her behavior. When she was four, we took her to a child psychiatrist, who told us that Serena had separation anxiety disorder. He said it was probably caused by my not being available to her when she was an infant. If I hadn't gotten sick, she probably would have been completely normal. One part of me didn't believe what the doctor said. It isn't as if I abandoned her or anything. But I felt tremendous guilt anyway. I cried for a week."

Serena's psychiatrist wasn't the first person to make up a story to explain away a child's problem, and he won't be the last. People do it all the time; they see a set of symptoms and create a story around them. What's the rationale of this disorder? they ask. What has happened in this child's life to explain this abnormal behavior? Traumatic birth, adoption, illness, parents' divorce, strong mother, weak mother, an overachieving older sister-all of these and many more have been used to rationalize children's psychiatric disorders. One mother told me that her 10-year-old son wet his bed every night because he had skipped second grade. The impossible behavior of a nine-year-old with obsessive compulsive disorder was attributed to the fact that the little boy, who was always bossing people around, was simply imitating his father, the CEO of a Fortune 500 company.

Even when these ingeniously fabricated stories make a small amount of sense, science is all but ignored. The psychiatrist who told Serena's mother that it was her sickness that brought on Serena's separation anxiety disorder was forgetting the fact that many children with sick mothers-or no mothers, for that matter-do not not end up with SAD. What's more, there are many children with SAD whose mothers have never spent a single day in a sickbed. People who become convinced that A causes B often lose sight of the facts. For example, it is widely believed that bulimia is the result of s.e.xual abuse, but there is little evidence to support this theory. s.e.xual abuse is a common phenomenon, and bulimia is a common disorder; it stands to reason, therefore, that there will be a substantial number of women with bulimia who have been s.e.xually abused. That still doesn't prove a cause-and-effect relationship. Many women who have been s.e.xually abused don't have bulimia or any other disorder, and many women with bulimia have not been abused. end up with SAD. What's more, there are many children with SAD whose mothers have never spent a single day in a sickbed. People who become convinced that A causes B often lose sight of the facts. For example, it is widely believed that bulimia is the result of s.e.xual abuse, but there is little evidence to support this theory. s.e.xual abuse is a common phenomenon, and bulimia is a common disorder; it stands to reason, therefore, that there will be a substantial number of women with bulimia who have been s.e.xually abused. That still doesn't prove a cause-and-effect relationship. Many women who have been s.e.xually abused don't have bulimia or any other disorder, and many women with bulimia have not been abused.

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.

NORMAL DEVELOPMENT.

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 one month a child will react to voices and be attentive to faces. By a child will react to voices and be attentive to faces. By four months four months he'll smile at people and respond socially to both familiar and unfamiliar people. At he'll smile at people and respond socially to both familiar and unfamiliar people. At six months six months a child will sleep through the night. At about a child will sleep through the night. At about age one 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. 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 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. 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 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 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 is a fight. At three kids can sit for 20 minutes of story time or some other activity. By the age a fight. At three kids can sit for 20 minutes of story time or some other activity. By the age of four 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. 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 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 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 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 seven they may develop superst.i.tions and rituals: step on a crack, break your mother's back. they may develop superst.i.tions and rituals: step on a crack, break your mother's back.

From age eight through adolescence, children focus on school performance. Compet.i.tion 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 a.s.sociated with adolescence are less specific in terms of age; there are basically five developmental tasks developmental tasks that must be accomplished by a youngster between p.u.b.erty-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. that must be accomplished by a youngster between p.u.b.erty-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 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 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. 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 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 s.e.xual orientation. s.e.xual orientation. s.e.xual fantasies usually start at p.u.b.erty; by the age of 22 a young person, even one who is not s.e.xually active yet, should know which gender arouses him s.e.xually. Task number four is the s.e.xual fantasies usually start at p.u.b.erty; by the age of 22 a young person, even one who is not s.e.xually active yet, should know which gender arouses him s.e.xually. Task number four is the setting of educational and vocational goals. 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 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 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. 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: repet.i.tive 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 cla.s.sroom, 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 embarra.s.sed by the child's behavior.

Even though they are n.o.body'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 cla.s.sroom Aggressive behavior Stealing, lying, breaking rules Inability to speak to peers or adults other than family Repet.i.tive 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 rea.s.surance 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 do cause distress or dysfunction, we establish a course of treatment, usually a combination of behavioral therapy and medication. 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. 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. 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 are excited, consumed with hopes and fantasies about what the child will look like and how he will be. Parents want their children to surpa.s.s 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 antic.i.p.ating illness. Brain disorders-even no-fault brain disorders-are excited, consumed with hopes and fantasies about what the child will look like and how he will be. Parents want their children to surpa.s.s 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 antic.i.p.ating illness. Brain disorders-even no-fault brain disorders-are not not what they have in mind. 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 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. 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. The 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 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 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 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. 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 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 a.s.signments. 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. 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 a.s.signments. 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 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." 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 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 att.i.tude 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. 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 att.i.tude 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 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 of the negative than the positive. 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 cla.s.smates. With the help of the Ritalin and his conscientious parents we hope he never will.

A PERSONALITY IS BORN.

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.

Mario is by no means the only child I've encountered with low self-esteem. I see kids every day who think they're bad or stupid or incompetent, who are convinced that they're a thorn in the side of their teachers and a severe disappointment to their parents. "My dad thinks I'm a real screw-up," 10-year-old Ross told me. "He's right. I am am always s.c.r.e.w.i.n.g up." It's easy to understand what has brought Ross to this sad conclusion. His short life has consisted of one negative experience after another. He's known little else. always s.c.r.e.w.i.n.g up." It's easy to understand what has brought Ross to this sad conclusion. His short life has consisted of one negative experience after another. He's known little else.

THE LONG-TERM EFFECTS.

OF A BRAIN DISORDER.

Mario and Ross both had attention deficit hyperactivity disorder, ADHD, the most common and most studied of all children's brain disorders. There's a great deal of evidence to suggest that ADHD affects every aspect of a child's life: school, friendships, and family. School is an unpleasant place for these kids, filled as it is with demands and tasks that seem impossible. Some 25 percent of all children with ADHD drop out of high school (as opposed to 2 percent of those kids without ADHD). Obviously, that makes their prospects for employment less than ideal.

The stigma a.s.sociated with academic failure can last a long, long time. Riley, the 32-year-old manager of a parking garage, recently told me, with some embarra.s.sment, that he had dropped out of school in the ninth grade. "School was like prison to me," he said. "I couldn't sit still. I couldn't do the work. I couldn't wait wait to get out of there." Riley went on to tell me that he still doesn't read books, and he can't even sit through most movies. "I'm just not very intelligent," he concluded. He's wrong about being unintelligent. Riley reads two newspapers every day, runs a busy garage, and has great people skills. He's clearly smart. However, his early failures in school-a result, I believe, of untreated ADHD-left a mark on his self-esteem that may well be indelible. (See to get out of there." Riley went on to tell me that he still doesn't read books, and he can't even sit through most movies. "I'm just not very intelligent," he concluded. He's wrong about being unintelligent. Riley reads two newspapers every day, runs a busy garage, and has great people skills. He's clearly smart. However, his early failures in school-a result, I believe, of untreated ADHD-left a mark on his self-esteem that may well be indelible. (See Chapter 7 Chapter 7 for more about ADHD.) for more about ADHD.) All of the other no-fault brain disorders have secondary effects on a child's life as well, especially performance and self-esteem. A youngster with separation anxiety disorder separation anxiety disorder will be reluctant to leave the comfort and solace of home, where his parents are, so his ability to make friends will be impaired. He'll miss out on many positive experiences, such as parties and sleepover dates. Later on the disorder may limit his college and job choices. ( will be reluctant to leave the comfort and solace of home, where his parents are, so his ability to make friends will be impaired. He'll miss out on many positive experiences, such as parties and sleepover dates. Later on the disorder may limit his college and job choices. (Chapter 9 focuses on SAD.) focuses on SAD.) Kids with social phobia social phobia, fearful of being mocked, will avoid social situations and with time will become socially incompetent. Many opportunities, both romantic and professional, will be lost. We live in a verbal world, and people who don't make themselves heard are at a distinct disadvantage; they often are thought to be "stupid" or "hostile" or both. (Social phobia is discussed in Chapter 10 Chapter 10.) The "overachiever" symptoms of generalized anxiety disorder generalized anxiety disorder may seem beneficial at first blush, but children with GAD, unable to relax or enjoy life, are often tiresome and irritating-not the most popular kids in the cla.s.s. Not being liked by peers is intensely demoralizing, and it may lead to depression, especially if the disorder continues into adulthood. (GAD is the subject of may seem beneficial at first blush, but children with GAD, unable to relax or enjoy life, are often tiresome and irritating-not the most popular kids in the cla.s.s. Not being liked by peers is intensely demoralizing, and it may lead to depression, especially if the disorder continues into adulthood. (GAD is the subject of Chapter 11 Chapter 11.) Obsessive compulsive disorder has a tremendous effect on a child's personality because of the secrecy and shame that usually are components of the disease. A child who spends all of his time hiding his irrational obsessions and compulsions from other people-even those people closest to him-shuts himself off from the world. OCD is time-consuming; it limits a child's ability to experience and enjoy other activities. It may also keep him away from his studies. Ashamed and guilty about his behavior, he doesn't let himself be open and honest with other people. Naturally that kind of covert behavior makes it difficult for the youngster to establish satisfying relationships. One adolescent girl I treated for OCD told me that she feels as if she's faking it all the time. Kids with OCD carry a very heavy burden. (For more about OCD, see has a tremendous effect on a child's personality because of the secrecy and shame that usually are components of the disease. A child who spends all of his time hiding his irrational obsessions and compulsions from other people-even those people closest to him-shuts himself off from the world. OCD is time-consuming; it limits a child's ability to experience and enjoy other activities. It may also keep him away from his studies. Ashamed and guilty about his behavior, he doesn't let himself be open and honest with other people. Naturally that kind of covert behavior makes it difficult for the youngster to establish satisfying relationships. One adolescent girl I treated for OCD told me that she feels as if she's faking it all the time. Kids with OCD carry a very heavy burden. (For more about OCD, see Chapter 8 Chapter 8.) In some ways youngsters with Tourette syndrome Tourette syndrome have an even weightier load to bear than children with OCD, because many of them are hiding something even worse: they think they're freaks. The motor and phonic tics a.s.sociated with TS are hard to disguise, so people with this disorder often become homebodies. They don't want to go out in public for fear of being stared at or mocked for what they themselves regard as "crazy" behavior. Again, love, marriage, and fulfilling employment may elude them because they keep their distance from other people. (TS is described fully in have an even weightier load to bear than children with OCD, because many of them are hiding something even worse: they think they're freaks. The motor and ph