People are increasingly aware of emotional health problems in children. Some children cannot sit still. Some cannot pay attention. Some do not engage in verbal, non-verbal, or social communication with others. Some seem withdrawn, depressed, angry, and violent. Some have mood swings that are unpredictable. With or without troubles in learning, parents are seeking help for these concerns earlier than ever.
Most parents of children with these concerns are very worried. Some of these represent serious problems and some do not. Parents are not clear about what should be done and how soon. There is a view that acting too early may create more problems than it solves. There is another view that acting early will allow for early interventions which minimize greater problems later. What can be done? What should be done? Is there a simple answer for this entire class of concerns?
As a general rule the notion that early intervention stems bigger problems later does not seem to be holding up when you look at just the problem itself. There are many myths about age and an optimum time for interventions. Retaining young first graders to address their “readiness” to learn reading (Morrison, 1997) is one example. A major problem with the passing of time is that it gives a child with significantly disturbing symptoms more time to be teased, misunderstood, and to develop negative opinions about himself as a learner.
There are two challenges in the category of emotional problems: 1) the symptoms, and 2) the possibility that parents have similar symptoms.
What are the symptoms of many childhood emotional problems? Being withdrawn is one; being irritable, being impulsive, being quick to hit, kick, scream, or cry, can all be related to childhood emotional disorders. All children display these from time to time. We eventually come to the understanding that emotional disorders are often just typical symptoms greatly distorted in terms of how often they occur (frequency), how bad they are (severity), and how long they last (duration) and how many different settings they occur in (pervasiveness).
There is a growing body of research that is demonstrating that many emotional disorders have a neurological cause and are genetic. The good news is that if the parents are aware of their history and know of relatives who have successfully treated these disorders, they are more comfortable with what needs to be done. The bad news is that if there is a clear familial history of a disorder in a family but the family does not accept that and has never treated it, they may not be able to see the symptoms.
COURSE OF ACTION:
The action plan is similar to other behavior problems. Identify the problem behavior. Set up a plan where you ask the child to stop the behavior. Include rewards for periods of time when the child successfully stops the behavior. Put in punishments for when the behavior occurs again. See if the problem goes away. If the problem behavior goes away it probably does not represent a neurological disorder. If it does not go away, two things could be wrong. One, you are not skilled at behavior modification and you need to study how to set up these plans properly; or Two, there is a problem that will need more attention.
I continue to marvel at how deeply entrenched the bias is that improper parenting causes most of these emotional problems. A family can have four children three of whom are well behaved and doing fine. When parents seek help for problems with one of their four the first assumption is that the parents have done something wrong with this one. They will drag the parents through endless counseling and parenting classes. They will stubbornly stick to this approach in the face of no improvement for far longer than should be. The helpers will be blind to the skills the parents showed with their other three children.
This is the legacy of some of the early founders of the field of Psychology. To promote a broad public acceptance of their science, they wrote to the general public as well as in their own journals. Many suggested that improper parenting was the basis of all emotional problems. This theme has persisted with many bitter consequences down to today. It has only been in the last few years that people have finally surrendered this wrong view in the area of autism. How many mothers have tortured themselves with the belief that a cold, unloving parenting style was supposed to have caused this disorder?
While it is true that even among all normal children some are more compliant than others, or easier to parent, if a parent has been successful at reward and punishment plans with some of their children, they probably understand how to use them for all their children.
If parents prefer to handle severe emotional problems with behavior modification first before resorting to other medical interventions, these plans can be very demanding. When research has shown them to work with serious emotional disorders, they were characterized by being clearly defined, frequently communicated, and rewards and consequences were administered frequently and extremely close in time to the behavior that triggered them.
It is not easy for parents to set up these kinds of behavior modification plans. This requires a high degree of objectivity and most parents are too emotionally involved with their children to be highly objective. They have problems identifying target behaviors, and they have problems arranging meaningful rewards and punishments that work. They also have problems issuing the consequences quickly and frequently. I cover these barriers to families using Behavior Modification very specifically elsewhere (Weingartner, 1999). Often it helps to have someone else oversee your efforts with behavior modification. They can provide a different point of view that will be helpful. This is important because you are going to decide whether or not to go on to further evaluation based upon whether or not this works.
There are a host of mental disorders that have an age of onset sometime in childhood and that have these kinds of symptoms. Childhood Depression, Bi-polar Disorder, Tourette’s Disorder, Anxiety Disorders, Autism, Aspergers, Attention Disorders, Psychotic Disorders are just some. Nearly all of these can be improved with two broad classes of interventions: medication, and psychosocial interventions. Psychosocial interventions can include: counseling, skill training, parenting training, behavior modification, and other therapies.
CHILDHOOD BIPOLAR DISORDER:
If a family wishes to pursue medication for symptoms of emotional problems, some care should be observed in one specific area. There is an emerging view that Bipolar Disorder can begin in childhood. This is new. The problem is that the symptoms of all of these emotional disorders can look alike in the early stages.
If, for example, a child is irritable and quick to blurt out protests, this could be due to childhood depression, it could be due to attention-deficit hyperactivity disorder, or other disorders. If a parent has seen no improvement in these symptoms, in spite of their efforts to punish them or reward the avoidance of them, they may take the child to a professional for a medical treatment. The selection of which medication to start with is probably more important than was earlier believed.
TRIAL MAY BE ERROR:
Since so many different disorders can potentially be starting at these ages, there is almost a sense of trial and error to this selection of medications. If the child is actually going into Bipolar Disorder, some of the early medications in this trial and error process can be very harmful (Papolos, 1999). So let us take a closer look at Childhood onset Bipolar Disorder here. A few symptoms that raise questions about the possibility of Bipolar Disorder are: 1) wide rapid swings in mood from being silly or giddy to being gloomy and sluggish. 2) rages that occur from very minor irritants. 3) overreaction to stress. 4) night terrors, and others.
If some or all of these occur it would be wise to pursue a thorough evaluation before beginning any medication treatment. There is building evidence that antidepressants (used with childhood depression), and possibly even stimulants (usually used with ADHD) might make the swings in mood in Bipolar disorder worse. Families that have gone down this path before have repeatedly said that it was a mistake to jump to the other medications (antidepressants or stimulants) first. The view is that the mood sings must be stabilized with medications more commonly used with Bipolar disorder first. Then, once the mood swings are stabilized, if additional medications are needed for inattention, etc. they can be added at that time and not the other way around.
If a family is not certain from this information, they can also look into their family history. If there is a history of family members treated for Bipolar disorder this would be a huge cautionary flag before rushing into some medications for other symptoms. Find a competent child psychiatrist, neurologist, or other child specialist and pursue a thorough evaluation first.
The course of these disorders is not always clear. Some of these disorders may require a brief course of medication and then improve over time. Others may require a long course of medications and the medications may have to be changed from time to time. Others may respond to some fine tuning of household rules or practices. In most cases, however, you will need professional supervision of these interventions to improve their effectiveness.
Most of these disorders are very manageable. Most people go on to highly successful, productive lives after encountering them, learning about them, doing what needs to be done about them. They are frightening at first. No one would choose to have one, but most of them can and are overcome if accepted and dealt with appropriately.
Morrison, Frederick J., & Griffith, Elizabeth M. Nature-Nurture in the Classroom: Entrance Age, School Readiness, and Learning in Children. Developmental Psychology; Volume 33(2); 1997; 254-262.
Papolos, Demitri F.; Papolos, Janice D. The Bipolar Child: The Definitive and Reassuring Guide to Childhood’s Most Misunderstood Disorder. 1999; New York; Broadway Books.
Weingartner, Paul L. (1999). ADHD Handbook for Families A Guide to Communicating with Professionals. Washington, DC, Child and Family Press.