Seeking Help for Your Child
In changing children’s behavior, as a general rule, we want to start with interventions that are the least invasive and costly in terms of restriction of the child’s freedom (or yours), side effects, risks to the individual, time, and money. You don’t place a child in long-term psychotherapy or a psychiatric hospital because he swears too much or has tantrums. You don’t use medication, either—not only because these approaches have not been shown to be effective for swearing or tantrums but also because they bear other costs in time, side effects, stigma (at school, for instance, where regular trips to the nurse for medication can inspire comments from peers, different treatment from teachers, and the like), disruption of the child’s and the family’s life, and more.
As a point of departure, ask two questions in selecting interventions for yourself and your children. First, is there evidence to support the efficacy of the treatment? Most therapies have no solid scientific evidence to show that they work. Make sure you are getting one that has been studied. See the end of this chapter for further advice on how to do that.
Second, is this the first place to begin, or is a less costly, less invasive, less restrictive alternative available? Deciding when to refer a child to treatment is challenging for two main reasons. First, many people have psychiatric disorders or close approximations of them and yet are in the world, moving through normal life. Research consistently shows that one in five children, adolescents, and adults meets the criteria for at least one psychiatric disorder. This is a conservative estimate, because there is no clear-cut point that defines most disorders, and people who “just miss” meeting the criteria still have short- and long-term problems. With such a large proportion of the population meeting the criteria for psychiatric disorder, we must look not just for symptoms but also for signs that they interfere with the individual’s functioning in the world. This is why impairment and dangerousness are among the decision-making criteria I list below. Second, as part of normal development, many problems come and go routinely. Lying, stealing, stuttering, tantrums, oppositional behavior, anxiety and fear, sleeplessness, and excessive crying all emerge for many children as part of normal development. They can become significant problems, even for children who make up the “normal” sample (those not clinically referred for the problem). They’re not trivial. If they were to persist, many parents would no doubt seek help for their child. But these behaviors tend to come and go without being treated by professionals, sharply decreasing after a brief peak.
Lying. Studies show that approximately 30 to 40 percent of ten- and eleven-year-old boys and girls lie in a way that their parents identify as a significant problem. This age seems to be the peak, and the rate of problem lying tends to plummet thereafter and cease to be an issue.
Difficulty in Sitting Still. This is a significant problem for approximately 60 percent of four- and five-year-old boys, but decreases as they age.
Whining. Approximately 50 percent of boys and girls who are four or five years of age whine to the extent that their parents consider it a significant problem. This too decreases with age.
Fears. Before the age of five, the large majority of children go through phases in which they experience fear and anxiety. Common fears include darkness, monsters, small animals, or separation from an adult. Just because these fears occur in many children does not mean they are minor to the children experiencing them. They worry, cry, and lose sleep. Fortunately, most children lose these fears over time.
Delinquent acts. By adolescence, over 50 percent of males and 20 to 35 percent of females have engaged in one delinquent (illegal) behavior. Typically, this involves stealing or vandalism. For most children, it does not turn into a continuing problem.
Stuttering. Approximately 2.5 percent of children under the age of five stutter. The vast majority simply stop stuttering on their own, without treatment. The normal course for all of the above problems is to decrease significantly or disappear entirely over time. The challenge is deciding whether to intervene professionally. Let’s say your child is of just the “right” age to be afflicted by fears. That would argue for just comforting your child and waiting to see if the fears drop out on their own. But what if the child’s anxiety really means he is crying all night, cannot go to daycare or school, and cannot be easily comforted by a parent? If things are that bad, you should consider seeking professional help. Let’s consider some general criteria to help you make such decisions.
Some Help with Signs and Signals
How does a parent or teacher know when to seek help? Most parents have worked out a rough routine for deciding when to take a child to the doctor for a physical ailment. A sniffle and cough, by themselves, probably don’t qualify. But add a fever and a rash, and most parents are likely to decide that this is something for a medical professional to look at. Add a stiff neck, and even the do-it-yourself holdouts may well call the doctor. You plug the data into your rough decision-making routine and out comes a judgment. That’s how you make your decisions when it comes to physical health, but deciding when a person has the mental health equivalent of a high fever that requires a visit to a professional is not so clear-cut a process. The data are less precise, since there’s no psychological equivalent of a thermometer, and in this area of health care, most parents tend not to have decision-making routines as ready to hand. But there are criteria you should look for to decide whether professional help beyond this book is needed. Look for any one of these:
Impairment. Does the child’s behavior interfere with meeting the usual role expectations at home or at school? Many children (and adults) have anxiety, fears, and tantrums, but does the problem interfere with going to school (or work) regularly? If so, that would be impairment. Early in life, at the toddler stage, when the child may be just at home with a parent or babysitter, there are not too many role requirements, so it is especially hard to tell then. However, because daycare is used for younger and younger children, parents receive more complaints now than ever before that their child is not fitting in. Impairment is a difficult criterion to apply at these early life stages, when the child ought not to be expected to do very much. Sleeping, growing, and learning (from exposure to parents and the world) are the key objectives. Any further role demands, like fitting in with many others in a daycare setting, can be a bit unrealistic. That said, if the child has to be regularly isolated in daycare or is repeatedly kicked out of preschool, this would qualify as impairment. Before the age of four or five, I would not seek any treatment unless there is something more stark (see below). After that, impairment as a criterion becomes more useful. Also, in some cases the behavior might well go away on its own, but the parents can’t afford to wait that long. For instance, we have seen two-year-olds at my clinic who have been kicked out of multiple daycare centers for hitting. The hitting may well be a passing phase, but that doesn’t matter to parents or daycare workers who have to deal with it. So hitting constitutes a sign of impairment here, even if it’s not necessarily a sign of a serious long-lasting problem.
Even if we raise the bar for impairment in the early stages of life, it may become clear to a parent as she or he interacts with a young child that something potentially troubling is happening. The child will not eat, for instance, or will not respond physically (an infant who pushes away, for example), does not make eye contact, and does not turn around to look when you say his name. The normal range can be wide at this age, so don’t panic, but you should probably visit a pediatrician just to bring up these concerns and get questions answered.
Change in behavior. A behavior may take on significance and become a problem because it represents a break from the usual pattern. Two different children might mope, tend to stay in their room, and not want to be with friends. For one child, this may be pretty much how she acts and has always acted, which is also, by the way, kind of like how her dad acts. For the other child, who is usually actively involved in things and pretty cheerful (when not giving the usual attitude, of course), moping and standoffishness mark a notable change. In the case of the latter child, a parent should be more alert to the possibility of depression. The change marks the behavior as clearly not a matter of temperament or enduring personality style, but something else.
Signs of distress. Is the child showing signs of stress that coincide with exposure to an event or stressor? Here I’m talking about, for instance, exposure to a disaster (anything from the grand scale, like a hurricane, down to something in the household, like a fire), domestic violence, death of a relative, peer bullying, sexual abuse, or even exposure to violent TV, be it CSI or news footage. The child may show lack of sleep, nightmares, anxiety, clinginess, or impairment as noted above. Many of the effects are transient, depending on the child and the nature of the event. If they do not go away or lessen after a few weeks (depending on the child and severity of the exposure to the event), consider seeking help.
Danger and risk of danger. Is the child’s behavior dangerous to himself or to others? This may involve aggressive behavior that could hurt others or self-injury that is not accidental, which runs a range from poking pins into his own arm to setting fires to attempting suicide. One of my cases is a nine-year-old boy who slaps his new infant brother across the face in exactly the way a woman rebuffing a romantic advance would slap a man in an old movie. Another one of my cases, an eleven-year-old boy, placed a pillow over his six-month-old infant sister, which could have resulted in suffocation. In case you think that’s not scary enough, he looked up at his mother, who had caught him in the act, and said, “Do you think she’s dead yet?” He was brought to the emergency room and then to the inpatient unit I was directing at the time. These are, of course, clear cases of danger to others requiring immediate attention, whatever the child’s intentions might be. If the baby is smothered, it doesn’t really matter whether it was the result of unwise play or malice aforethought. A child talking about killing himself or others must be taken seriously. The statements alone serve as a basis for seeking help or intervention. Sometimes, the decision is easy to make. A twelve-year-old boy was brought to my clinic because he kept telling a teacher he was going to kill her. This was not one event or just a statement made in a moment of rage. He was calm, methodical in his presentation, and noted that his father had guns he would bring to school one day. An eight-year-old girl said she did not want to live and just wanted to kill herself. Again, she said this repeatedly and not just when prompted by a moment of strong emotion (for example, /I’m so embarrassed, I could just kill myself/).
Sometimes, the decision to seek help is harder to make. I’m not saying that you have to haul your four-year-old to the emergency room because he mimics a cartoon character saying, /I could just die./ Context matters. A young child may make an isolated statement or two, but the child seems fine at home, at school, and when playing with friends, and the statements disappear after a couple of days. That’s one kind of context, and it would argue for just keeping an ear out for further statements. Another kind of reassuring context can be found in the minuscule suicide rate among the very young. But suicide attempts and suicide run in families, so that’s part of the context, too, and it argues for alertness. And if a twelve-year-old girl says the same thing, that’s different. Rates of suicide attempts and depression increase sharply with the onset of adolescence, especially for girls. Other context variables—not being involved with peers at school, the presence of a gun in the home, a “contagious” event in the media (a celebrity’s recent suicide, for instance) that might inspire imitation—make the statement gain in seriousness until it’s clear that you need to seek help for her. Danger to oneself or others is a special case in which you should err on the side of obtaining an evaluation. When in doubt, get a professional opinion.
Behavior in relation to age. One complexity in judging the behavior of children is that they’re changing so fast, presenting a moving target for your judgments about the relative seriousness of their problems. The behavior itself may not always be at issue; sometimes, it’s the behavior in relation to the child’s age. For instance, not being toilet trained by age three, four, or five is not a psychological calamity or even a problem, except that parents are sick and tired of changing diapers and don’t want to deal with it anymore. More specifically, for children of five and under, bedwetting is not very significant in relation to current or future adjustment, but after the age of ten it becomes a risk factor that may presage serious psychological problems later in life. It’s the same behavior, but the different age changes its meaning. Not being toilet trained by age ten or twelve predicts later aggression. The same is true of fears—of darkness, monsters, separation from a parent—all of which are a “normal” part of development for most children, even when those fears really do bother them. But the fears usually go away on their own. If they don’t, the same problem with fear in middle or later childhood (ages ten to twelve) could reflect a more serious anxiety disorder.
Unusual behaviors and extreme symptoms. Here we arrive at a far and often disturbing end of the area defined as problem behavior. Is the child reporting hearing voices that tell him to do dangerous or harmful things, or engaging in endless repetitive behaviors (for example, with toys or objects) for hours on end? We have had cases in which voices tell the child to hurt others or to set fires. Seeing things that aren’t there, believing that some spirit is controlling one’s mind—these can be significant signs pointing to a serious disorder. Moreover, and it’s worth repeating, it’s a serious disorder whether or not the children act on what the voices tell them to do. Again, a parent should look for departure from the everyday. Much of early childhood and normal development includes imaginary play, imaginary friends, dialogues between stuffed animals, and just plain talking to yourself, sometimes in different voices. That is all part of play, a critical aspect of context. A five-year-old muttering to himself in two or three different voices while playing with toy soldiers on the floor is quite normal. A twelve-year-old sitting by himself, muttering in different voices, bears closer attention, especially if it happens more than once.
When in Doubt Pediatricians, psychologists, and child psychiatrists are the first line of inquiry about how a child is doing. Pediatricians do not specialize in social, emotional, or behavioral problems and psychiatric disorders; their primary training is in medicine and physical health. But a large percentage of children (up to 40 percent) who are brought to them have psychological problems. Thus, pediatricians very often serve as parents’ first contact with specialists who can treat such problems or make referrals to mental health professionals. Psychologists and child psychiatrists are trained to provide systematic evaluation, meaning that they use various standard psychological measures to see how the child is doing in many areas of social, emotional, cognitive, and behavioral functioning. And they’re trained to look at different contexts—how the child is doing at home, in school, in peer relations—and assess any signs of trouble requiring follow-up. Sometimes this kind of evaluation is vitally important.
For example, a ten-year-old girl was referred to me because she was very disruptive at home and her parents could not manage her. Also, she couldn’t sleep at night and seemed perturbed. The parents brought her to our clinic, and we did an evaluation, which included separate meetings with the parents and child. The evaluation revealed that she had many tantrums as part of home routines (such as eating and going to bed) and high levels of anxiety, as the parents had indicated. However, unbeknownst to the parents, she was clinically depressed and had very extensive suicidal thoughts—not just passing fancies but frequent thoughts, and a plan to kill herself with pills from her mom’s medicine cabinet. She had, in fact, attempted suicide with a high dose of her mother’s pills in the previous week, which had made her very sick. The parents just thought she was ill and let her stay home from school. We alerted the parents to this in the middle of the evaluation, suggested inpatient hospitalization for an evaluation, and then arranged at that moment for the girl to be admitted. Another case involved a twelve-year-old boy who was doing very poorly at school because he got into many fights and wouldn’t do any assigned work, be it in class or homework. Full evaluation revealed that he also met criteria for ADHD. The dominant symptoms were hyperactivity and inattentiveness. We began treatment at our clinic to address many of the behavioral problems, but we also encouraged his parents to work with a child psychiatrist with whom we consulted to consider a regimen of stimulant medication. Within ten days, the child was on medication and doing much better at school and at home.
Getting Help: Leads and Contacts
This section will necessarily be partial and open-ended, but there are some guidelines to bear in mind as you research the best way to get help for your child. The first step is to find out what you can about the problem your child might have. Don’t just Google the problem and click on whatever links you might find there. The Internet is filled with misinformation about clinical problems and effective treatment. You must go to a source where the information has been provided by or screened by professionals. The Web pages listed below are reliable sources that meet these criteria. Currently, there’s no Good Housekeeping Seal of Approval for websites’ accuracy, but the federal government and other organizations mentioned below go to special lengths to present the latest and most accurate facts and findings. The many professionals and others who offer services to treat particular problems are not all alike. Different psychologists, psychiatrists, social workers, family therapists, pastoral counselors, and others may all take different approaches to the same problem. Yes, you will want to start by making sure that the person you choose is a professional who is credentialed and licensed in the state in which he or she practices. But that’s not enough, so it’s your responsibility to ask questions and get second opinions. High on your list of questions to any professional should be What is the treatment you provide for my child’s problems? How long have you been providing this treatment? Has this particular treatment been studied and does it have scientific evidence in its favor? What are treatment options other than the one you provide? There’s a delicate point to navigate here. Many of the treatments offered in clinical practices are not based on evidence of their effectiveness. It’s likely that if you’re seeking treatment for your child, you will encounter a warm, persuasive, reasonable, well-intentioned professional who has the requisite credentials, seems like a good person, and otherwise meets your expectations. The waiting room will look right. The office will look right. There will be framed certificates from suitably impressive and accredited institutions of higher learning and professional organizations. But none of this—/none/ of it—guarantees that you will get worthwhile treatment. You need to be a critical consumer of psychological services, as critical you would be when buying a car or a house. You have to find out if there’s any evidence that the therapy provided by this professional actually works, and if the therapy is recognized as the treatment of choice. Ask. If you don’t like the answer, ask somebody else. Even if you do like the answer, ask somebody else. It’s a rare professional who will say, “I do this kind of therapy, but there are other therapies, which I don’t use, that are even more effective and that have scientific research behind them.” You will have to find such things out for yourself.
I won’t list Web addresses, because they tend to change, but the information below is intended to at least get you started. (And you can start with a look at my website— http://www.childconductclinic.yale.edu/ — which has links to others.) For information about children’s mental health and treatment services, go to the websites of the National Institutes of Health, the American Psychological Association, and the American Academy for Child and Adolescent Psychiatry. If you’re trying to find therapists for children or families, you can try the websites of the National Register of Health Services Providers in Psychology or the Association for Behavioral and Cognitive Therapies, or you can ask the psychological association in your state (for example, the California Psychological Association, New York Psychological Association, or Illinois Psychological Association). Type the state followed by “Psychological Association” in your favorite search engine and the site will come up. It’s also your responsibility to find out if there’s good evidence for a particular treatment’s effectiveness. The Cochrane Library, which can be found online, provides rigorous reviews of evidence related to medical and psychological treatments.