Based on my years of clinical experience as a pediatrician, together with evidence offered by contemporary research in developmental psychology, genetics and neuroscience, I believe that supporting parents efforts to understand their child's experience of the world, to help him or her to make sense of whatever particular vulnerabilities he or she has, without labelling him or her with a disorder, is a better approach.
An article just published in The American Psychologist, Developmentally Sensitive Diagnostic Criteria for Mental Health Disorders in Early Childhood, a comment on my new Psychology Today blog and a family I recently saw has got me thinking further about this controversial issue.
I met with Joanne and Peter, parents of five-year- old Andrew, in my behavioral pediatrics practice (details,as always, have been changed to protect privacy) He was having increasingly inflexible and explosive behavior. They wanted to know "what to do" so he would stop getting upset about "little things." They described him as challenging since birth, a picky eater who had difficulty with loud noises. He could take hours to put on his socks because he hated the bumps.
Recently, he and his parents were at the playground and his younger sister fell and hurt herself. It wasn't anything major, but they had to leave suddenly without giving him usual warnings that made transitions less difficult for him. The result was that he was inconsolable for hours-unable to stop repeating, "Its not fair! I didn't get to go down the slide!" His parents tried to be patient and understanding, while simultaneously tending to their other child, but eventually Peter lost his cool. He yelled at Andrew and sent him to his room.
What prompted them to call me, after months of increasing frequency of similar scenes, was what happened next. Andrew kicked the wall and threw his toys. Then he began to call out,"I'm so sad!! I'm a bad person" I'm so sorry." It was his words that most frightened them. Joanne admitted to being worried that he might intentionally hurt himself. After a while, when she felt more comfortable with me, Joanne spoke of her own longstanding struggle with depression. There were other family members with similar difficulties. Both parents confessed their fear that Andrew was depressed.
Drawing on the research of Peter Fonagy and others, I sought to help Joanne and Peter in their efforts to help Andrew make sense of the world, to manage his inflexibility and sensory difficulties. It seemed to me, based on his history, that he had some biologically based genetic vulnerabilities. To them it seemed that he got upset about "little things." But it sounded from their description that at times for Andrew the world felt like an overwhelming and incomprehensible place. Joanne and Peter needed to help him learn to manage himself in the face of his particular challenges. Trying to reason with him when he was out of control did not work. I explained that at moments such as the playground incident, the higher centers of his brain were likely temporarily not working, and so Peter and Joanne hit a brick wall. They needed, in the heat of the moment, to find other means to help Andrew to regulate himself, even something as simple as going for a walk. Talking about what happened could come after he calmed down. Eventually their repeated efforts would give him the tools and language to regulate himself in these difficult moments.
Andrew's mother had a vivid memory of being taken to the psychiatrist as a child and given medication. She did not want Andrew to come to my office-to get the feeling that there was "something wrong with him." We agreed that they would try this new way of being with Andrew, and come back and see me in a few weeks to talk about what happened. Within a week or so of simply thinking differently about Andrew, he was more calm. Joanne and Peter felt more relaxed and sure of themselves. They found it easier to be with him and help him manage these moments of frustration.
Several weeks after this visit, I received the following comment on a blog post questioning the use of antipsychotics for young children. As a pediatrician I don't have the opportunity, other than stories from parents like Joanne, to hear adults describe their experience of being diagnosed and/or medicated, and I find these comments to be helpful. I quote him in full:
I was a so called HFA when I was a kid, "Aspergers Syndrome" they called it and was tortured on Risperdal.While I can't claim to know anything about this person, his wish to be recognized and understood, rather than labeled and medicated, comes through loud and clear. I wonder how many others have a similar experience without the opportunity to give voice to it until many years later.
Dropped out of school when I was 13 and finished my education on the
internet. Looking back I never fail to notice that 100% of my problem was not
that I was sick but that other people considered me so.I say leave them alone. I once bit myself and screamed cause someone was chewing paper (Couldn't stand paper, pencils, chalk, people bending their
hands and about 10 other things) and so what? Get me out of the room for a
minute and I'm fine. Any kid should have the right to take that over
permanent drug induced damage.
Those who advocate for a new system of diagnostic criteria for mental health disorders in early childhood are not advocating for use of medication in this age group. It is a reasonable concern, however, that a consequence of psychiatric diagnosis, in the age of intense marketing efforts of the pharmaceutical industry and limited access to quality mental health services, will be an increase in prescribing of psychoactive medications to young children. In fact, an article in today's New York Times Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy offers a close up look of the realities of the practice of psychiatry today.
Even putting the issue of medication aside, the label of mental health "disorder" may obscure parents efforts to truly understand their child's experience. It is this kind of understanding that Peter and Joanne are working towards. In the setting of such recognition and understanding, children, even those with Andrew's quirks and vulnerabilities, have the opportunity to develop a strong, healthy sense of self.