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 always screwing 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 associated with academic failure can last a long, long time. Riley, the 32-year-old manager of a parking garage, recently told me, with some embarrassment, 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 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 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 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.)
Kids with 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.)
The “overachiever” symptoms of 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 class. 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.)
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 Chapter 8.)
In some ways youngsters with 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 associated 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 Chapter 13.)
Ennresis/bedwetting causes kids to feel ashamed, inadequate, and insecure and usually makes them avoid situations in which their disorder will be discovered, such as camping, pajama parties, and sleepover dates—all social activities that most young people enjoy. The effects may be felt for a long time. A 20-year-old man who’s had untreated enuresis his entire life (he kept thinking he would “work through it”) says he has never had a satisfying relationship with a woman. He had a girlfriend he was crazy about, but it didn’t work out. He would have sex with her, he told me, but, because he didn’t want to fall asleep, for fear of wetting the bed, he always got up and went home right afterward. His girlfriend, convinced he was thoughtless and uncaring, broke it off. The young man was convinced he’d never get married. (Chapter 12 focuses on enuresis.)
Having major depressive disorder has a formidable effect on how a youngster experiences and relates to the rest of the world. Teenagers with MDD tend to avoid going to school and being with other people, so they may fall behind academically, miss out on dating, and may not have a chance to develop friendships. Their hopelessness—the “glass is half-empty” approach to life—and their social isolation put them at greater risk for suicide. (MDD is the subject of Chapter 14.)
Kids with bipolar disorder have difficulty in every sphere of their lives: school performance is impaired; friendships are difficult to maintain; and their relationship with their parents is disturbed and filled with conflict. All of these problems have a huge impact on self-esteem. As time goes by, they are at serious risk for substance abuse and suicide. (For more about bipolar disorder, see Chapter 15.)
Adolescents with schizophrenia experience a deterioration of their personality; they become increasingly unresponsive and unable to initiate and maintain activities and friendships. Delusions and hallucinations play a more important part in their lives than the rest of the real world, and they may lose touch. (Chapter 16 focuses on schizophrenia.)
Like OCD, eating disorders—anorexia nervosa and bulimia—involve secrecy and activities that are all-consuming of time and energy. An adolescent girl with an eating disorder is limited in her ability and her inclination to interact with her friends and participate in age-appropriate activities. (Eating disorders are covered in Chapter 17.)
Children with conduct disorder have problems developing meaningful relationships—being devious, dishonest, and aggressive doesn’t usually make children popular—and a lot of difficulty keeping up with their studies at school. The dropout rate for kids with CD is high, as is the likelihood of substance abuse. Not surprisingly, their employment opportunities are limited, and their chances of ending up on the wrong side of the law are better than even. (Conduct disorder is discussed in Chapter 8.)
Children with autism find it difficult or impossible to communicate—many can’t speak, and others use language in peculiar ways—to learn, or to relate in any meaningful way to their parents or anyone else. Often avoided or ostracized by their peers for being so unusual, children with this and other pervasive developmental disorders suffer tremendous blows to their self-esteem. (PDD, autism, and Asperger’s Disorder are covered in Chapter 19.)
TEACHER’S PEST
Aside from his mother and his father, the most important adult in a child’s life is his teacher. Just as it is essential for a youngster’s well-being and self-esteem that he be cherished and highly regarded by his parents, it is crucial that he be well thought of by his teacher. When a child has a brain disorder that adversely affects his behavior in the classroom, he may be out of luck; even the most patient and understanding of t
eachers cannot always give him the positive reinforcement he needs.
Another study I was involved in illustrates just how hard it can be for a teacher to deal with a problem child. This time we were interested in finding out how teachers react to the behavior of their students. Our first challenge was to track down the very best teacher we could find—someone conscientious, caring, patient, creative, and skillful at getting the best out of children. We ended up in a grammar school in the Bronx with Ms. Leonard, a veteran first-grade teacher everyone said was the best in the business. When we asked Ms. Leonard if she would help us out, she agreed to leave her own class for a day and teach another group of first-graders a few miles away in Manhattan. We asked her to conduct the class as she usually did, but with two provisions: she was to ignore any negative behavior on the part of the children and praise all positive behavior.
Unbeknownst to Ms. Leonard, one of the kids in her temporary classroom was six-year-old Vincent, who had been diagnosed with ADHD but had not yet started taking medication for the disorder. Also in the classroom that day was a blind observer—someone who monitors behavior without knowing why. We asked our blind observer to monitor Ms. Leonard’s reactions to four of the children in class, one of whom was Vincent. Every time any of the four children did or said anything, either positive or negative, the observer was to make a note of the child’s behavior and describe the teacher’s reaction to it in one of three ways: ignore, criticize, or praise.
Vincent hit the ground running that morning. Before class had even begun, he pulled the hair of the girl in front of him so hard she started to cry. Then he tripped one of his classmates on his way up to the blackboard. When Ms. Leonard gave instructions, he ignored most of them. Ms. Leonard, who richly deserved her reputation as “super-teacher,” was flawless in her almost impossible mission. All day long she ignored all the bad things that Vincent did—shouting out, getting up from his seat, and so on. The behavior of the rest of the class was fine for the most part, and she praised and thanked each child who did something positive.
At about two o’clock in the afternoon, when the school day was just about over, Ms. Leonard handed out some papers to the first person in each row and asked the children to take one and pass the rest back. For the first time that day, Vincent did as he was asked, but Ms. Leonard did not praise him for his positive behavior. The blind observer made a note of the action and the reaction of the teacher. “Ignore,” he wrote. Soon thereafter class was dismissed.
After class we reviewed the events of the day with Ms. Leonard and congratulated her for her overall handling of the class and for her patience and restraint in the face of Vincent’s impossible behavior. Then we asked her about her slip at the end of the day.
“At about two o’clock, when you asked the kids to pass the papers back, did you notice that Vincent followed instructions?” the interviewer asked her.
“Yes, I noticed,” said Ms. Leonard.
“Oh, we were thinking you might have missed it,” said the interviewer.
“No, I definitely saw him do it.”
“But you didn’t praise the behavior,” the interviewer said. “Remember? You were supposed to praise the kids whenever they did something positive.”
“Yes, I remember,” Ms. Leonard replied. “But after the terrible way that child had behaved all day long, there was no way I was going to say anything nice to him!”
My colleagues and I could do a hundred more studies and dozens of more tests, but one thing is already crystal clear: brain disorders affect a child’s behavior in many ways, directly and indirectly, and a child’s behavior affects the way he is regarded and treated by the outside world. The longer a child goes without treatment, the more damage will be done to his self-esteem and his prospects for success. If Ms. Leonard, superteacher, can’t say anything nice to poor little Vincent, nobody can.
CHAPTER 3
The Doctor-Patient-Parent Relationship
As I’ve said before in these pages, a child’s brain disorder is not his or her parents’ fault, but making sure that the youngster is cared for, promptly and properly, is their responsibility. One of the most important decisions that parents of children with brain disorders make in fulfilling this responsibility is choosing a child and adolescent psychiatrist.
There are other health care professionals besides child and adolescent psychiatrists who help troubled children, of course; psychologists, social workers, speech therapists, tutors, and others also play vital roles in helping these kids. Still, the first person a child with a suspected brain disorder should be examined by is a psychiatrist. That assertion leaves me open to accusations of bias, I know, but I’ll stand firm in my conviction that in dealing with no-fault brain disorders, child and adolescent psychiatrists make the best diagnosticians. If a child has an ear infection or a stomach virus, he belongs in his pediatrician’s office. If his problem is behavioral, he should consult a child and adolescent psychiatrist.
Because they are physicians—M.D.s—child and adolescent psychiatrists are able to evaluate all aspects of a child’s development and behavior (including neurology, psychology, language, speech, and hearing), to make a diagnosis, and to recommend a course of treatment. If the recommended treatment includes medication, psychiatrists are able to prescribe the medicine and monitor its effects. If behavioral therapy is called for, psychiatrists can either do the job themselves or send a child to someone else more suitable. If other help is necessary, such as tutoring, speech therapy, social skills training, cognitive behavioral therapy, or family therapy, a psychiatrist is in an excellent position to direct the parents and child to the appropriate expert.
CHOOSING A CHILD AND
ADOLESCENT PSYCHIATRIST
Of course, not all child and adolescent psychiatrists are the same, and finding one who is suitable for the child and acceptable to you may take some time and effort. Consumer Reports doesn’t cover the field of psychiatry, so parents in need of a child and adolescent psychiatrist will have to do their research the old-fashioned way, by asking for recommendations and checking out credentials.
Most pediatricians will be glad to point interested parents toward a good child and adolescent psychiatrist. School psychologists, principals, and guidance counselors may be able to help you as well, and the same goes for other parents whose children have similar problems. Parents’ support groups (listed near the end of this book, in Appendix 2) are also an excellent resource, as are medical schools and university-affiliated medical centers. The American Academy of Child and Adolescent Psychiatry, a professional organization, fills requests for referrals across the nation all the time; it offers not just names but a physician’s credentials as well.
Credentials are important. Parents owe it to themselves and their children to learn something about the training of the psychiatrist who is going to treat their child. Parents should look for someone trained and board-certified in child and adolescent psychiatry; this means that a physician has completed at least five years of training in general psychiatry and child and adolescent psychiatry as well as rotations in neurology and pediatrics or internal medicine, after which he passed an extensive written and oral exam in child and adolescent psychiatry. It is also useful to find out where the physician’s training took place. Like doctors, some hospitals have a better reputation than others. Parents who aren’t comfortable asking the psychiatrist about training and the reputation of a hospital may get the information from their child’s pediatrician.
THE INTERVIEW
Many parents like to interview child and adolescent psychiatrists before their children are evaluated. Spending time talking to the doctor can satisfy parents in two important ways: first, you get a sense of the psychiatrist’s breadth of skills; and second, you get a feeling for how well the psychiatrist communicates. A child and adolescent psychiatrist, like all physicians, should speak to you in language you can understand. I have little patience with any caregiver whose attitude is, “This is far too technical f
or you to understand. Why don’t you let me, the expert, handle this?” Parents should be comfortable not only with what the psychiatrist has to say but also with how he says it.
There’s a good chance that parents faced with this kind of decision are venturing into new, uncharted territory, and they need to be informed and reassured every step of the way. One way to accomplish this is to ask the child and adolescent psychiatrist how he works right up front. Don’t be shy about asking questions: What is the procedure for making a diagnosis? Who will be involved? How many sessions will it take? The doctor should be able to give you an idea of the time and expense involved in the diagnostic evaluation.
It pays for parents to be as specific as possible about what is troubling their child. A description of a child’s symptoms—“My daughter follows me from room to room and won’t let me out of her sight,” a parent might say, or “My son refuses to go to school,” or “My child seems really depressed,” or “He has these terrible temper tantrums all the time”—followed by, “How do you think you might approach the problem?” should give you the lay of the land in short order. Sometimes it makes sense to be even more specific about a child’s disorder, asking such questions as:
“My son has tics. Have you ever treated Tourette syndrome?”
“Do you specialize in children with attentional problems?”
“My kid has a real language difficulty. Are you the right person for that?”
It's Nobody's Fault Page 4