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Anxiety Disorders
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Pain Management

by Mary A Fristad and Jill S Goldberg Arnold
The Guilford Press, 2003
Review by Roy Sugarman, Ph.D. on Mar 1st 2005

Raising a Moody Child

At first glance, this is a guide for parents who are confronted with a child who is always in a mood of sorts. The "Moody" bit on the cover is in red, but in reality the title should have been "How to cope with depression and bipolar disorder: Raising a moody child", since the emphasis is on severe mood presentation as a mental illness in children.  On further reflection, a more adequate title would be "Mood disorders in children: what they are and what you can do about them".

Far from being a resource in do-it-yourself as a parent, this book is a psycho-educational tool designed to help lay people enter the world of professional help when their child is failing to think rationally, act with purpose, and deal effectively with the environment.

So here is a parental nightmare, the "Bad Kid" and here is the information about how you go about getting help, even if it scares you to see your kid's personality, mood, spirit, psyche, individuality, caste as pathology of a lasting, serious kind. As the book notes early on, each successive generation appears to be producing more and more mentally ill children, with a few comments on why this must be.  These include some ideas about toxic environs, dietary changes, increasing stress in family life, use of stimulant or antidepressant medication, and better detection capacity in mental health professionals.  The book sets off thus by saying that if your child has such-and-such a presentation, then one must consider they are ill and need medication and therapy of various types, all of which are then explained in some detail in very easy to understand language.  That is, if you are not sitting sobbing over the book as you find out that little Spence is not just being difficult, you are not a lousy parent: he is ill with some mental disorder process on the go that for some reason is more prevalent at this time in our history than previously, and that he probably inherited from us, his parents.

Case vignettes abound, pretty much with the same details, but different names:

  • Johnny (8 years old) is behaving badly
  • Parents don't know what to do
  • Take child to medical person
  • Child is diagnosed as Bipolar
  • Child is given medication
  • Parent goes to psychologist to learn how to cope with self and Johnny.
  • Therapy is not curative but helps you cope with fact child is ill.

To this end Part I of the book entails learning about what it is that is wrong with your child, namely that their difficult, temperamental and impossible behavior is likely to reflect on a DSM-IV illness, and the essential issue of getting a good evaluation and then good treatment.  Part II revolves around the idea of treatment, based on medicine and therapy.  Part III is when the nitty gritty arrives, in the form of helping your child cope.  The philosophy put forward is that by then you will have laid a critical foundation for helping by accepting the complexity of mood symptoms and syndromes, and how to get the most from the treatments discussed, including all of the major classes of drugs, alternative drugs, psychologist based therapies, ECT and the like. Ten major issues are raised with respect to managing:

  1. Shrug off blame and take action
  2. Be realistic
  3. Don't over or under-regulate
  4. Keep it simple
  5. Be flexible
  6. Choose your battles
  7. Become expert problem solvers
  8. Be good communicators
  9. Name the enemy
  10. Share the joy and the pain.

All good solid advice?

·        The first part: the idea here is that self-blame and guilt can blind you to the origins of your child's problems, or that the problem exists at all.  Let's say that after a divorce, your child is miserable; the psychologist will be able to perhaps diagnose them as adjustment disorder with depressed mood, and treat this.  The parent will then have the epiphany that the child's unhappiness is really a problem, not Dad's fault, and then begin appropriate treatment which in this case means engaging the parent into activity with the child to end their illness, or sorry, perhaps that was to make them happier, I forget.

·        Part two: now that the label is that of "mood-impaired child" one has to be reasonable, and mood disorders vacillate in severity, knowing what to expect from a child recovering from this disorder is best left to the advice of the clinician. Obviously there are good tips for parents about decreasing expectations, good advice in all, but at the bottom is the invocation to believe, namely to accept that the child has an illness from which he or she needs to recover and move on accordingly.  All the good advice in this book seems to demand the sine qua non that is a biopsychosocial approach, and that the point of departure is that these are illnesses like any other with the appropriate names.

·        Part three: Nothing more here than a plea for consistent parenting without too many or no rules, a Goldilocks clause if ever there was one.

·        Part four: as it sounds, their motto is simplify, simplify, simplify, or actually, create categories encompassing many rules and coagulating them into one for each group, rather than be confusing.

·        Part five: Just what it says, again, from the point of view of vacillating presentations.

·        Part six: More of the flexibility rule here, but introducing the very nice rule about negotiation versus an attempt at draconian parenting, just about forgotten or ignored by every parent I have seen as a professional.

·        Part seven: Here, one is expected to become expert at problem solving.  What this means is a seven-step approach to tackling conflict.  Identify the problem, decide who needs to know, define the possible solutions with the child involved as well, work out the pro's and cons, pick a solution and try it, evaluate if it worked, and try again if it doesn't from the solution list.  Seems like solid stuff.

·        Part eight: Being a good communicator here applies to anyone. The tips involve listening without correcting what the child asserts are issues, or concerns, or feelings. Next is to ask if your child wants to hear the solution you propose before you do it, choose your battle and then talk directly to the child about your concerns, make small issues into big ones so they don't become real big ones, emphasize the positive, and give negative feedback in a calm, unemotional voice, make more positive than negative comments, remember the body language, and avoid playing 20 questions, that is, don't pester the kid about what is going on inside.

·        Part nine involves labeling symptoms of illness as symptoms of illness, rather than as personality traits (that are their fault presumably, or yours).

·        Part ten involves sharing the pain with others so there is less of a burden by sheer division of load.

Chapter nine embarks on providing coping skills for moody children, and the first one offered is that of a "tool kit". In this kit are the tools to enable children to escape the internal pressure generated by the putative illness, in four categories, namely physical, creative, social, and R&R.  Building up the items in the kit involves the parent and child sitting together and co-creating in each category so that there are a few, age- appropriate devices to call upon in each of the four categories.

Dividing up the overwhelming tasks is offered next, namely avoiding the child choking on an everyday task that feels impossible, by dividing the whole into digestible chunks, each a goal unto itself as opposed to going for the full Monty in one hit, a kind of scaffolding or graded competition approach Vygotsky would have approved on, baby steps in rehabilitation.

Managing mania by putting a brake system into place is a way of avoiding the crash and burn effect when too much is started out on, with ending all of it satisfactorily beyond the capacity when the kid flames out: putting on the brakes early means more is completed with less open ends smoldering away and letting the child feel diminished by the weight of unfinished business.

In keeping with ideas of intrinsic reward, helping the child reach its own solutions is also preferred to the answering of questions. In the same vein, choosing which parent has the best capacity in defined situations and letting them deal with that situation is also advised, kind of like "just wait until the specialist comes home".

Sleep hygiene enforcement is encouraged, as well as adopting a pre-emptive strike position by identifying antecedents of behaviors, and thus acting early on rather than later, when the problem has taken hold and running along nastily. In this scenario, triggers are important to identify and avoid or contain. Signals that something is about to get nasty are the time to intervene surreptitiously and thus limit the public confrontation. And of course, finally, this all goes to early warning and the prevention of relapse.

This last point is perhaps hardly emphasized. Although the book acknowledges early on that treatment is necessary, there is only passing acknowledgement of the recidivism rate in major depression and bipolar disorders, without too much comment on why this should be so in such an authoritative work.  Part of the dreadful burden is that there is the presumption of recurrence and only little attention paid to recovery as a consumer doctrine.

The tenth chapter is devoted to then working with the other psychosocial venue for depression, the environment of the school in which the symptoms play themselves out, affecting performance and the opinions of others.  Loss of interest, fatigue, concentration, agitation and retardation, poor judgment, speed of inward and outward speech, and then of course secondary factors such as peer problems and social isolation are noted. In here too are the problems caused by side effects of medication, the act and process of taking medication in a public venue, all create their own problems.  Attention to the role of the stigmata of diagnosis might have been nice here, but is not dealt with, in any event not until some 40-50 pages later.

A collaborative but realistic approach to interacting with the school over these issues is adopted, clearly a reasonable approach.  Ideas surface with regard to specialized attention from qualified teachers, and rights to receive special attention under the laws of the USA.  The role of various school specialists is discussed, namely school psychologists, OT's, principals, teachers, social workers, special ed coordinators, physical therapists, speech language pathologists, and so on is introduced.  Methods are proposed for getting such services allocated.

A host of examples follow of parents and schools getting creative.

Chapter Eleven speaks of crisis management, referring to safety issues, the need to predict and think ahead, the role of the ER and the police, and staying ahead of the game again in mania, and avoiding the exacerbation of the already parlous situation.  Managing suicide attempts is obviously important, and gets some attention here.

Part IV now turns to helping the family live with the mood disorder (not the child, "living with a mood disorder" is the term used.

Focusing initially on a "negative family cycle", the authors refer to the cycle of parents trying to help, then feeling jaded and losing a sense of efficacy, withdrawing and becoming punitive, feeling guilty and over compensating, burning out and withdrawing and fighting amongst each other and so on, until the cycle is punctuated by intervention. Interventions are described, or rather attitudes proposed to deal with avoiding the perpetuation of this cycle.

In dealing with the stigma, the idea of social isolation is also addressed, and rightly so. However, this is clearly a personal and variable decision, so little real guidance can be given on who to tell and who to avoid, and why.

The next chapter deals more specifically with the same question, but more narrowly with regard to the siblings and their adjustment to the child's condition. As in brain injury, the impact on siblings is seldom addressed directly.

Finally, in the last chapter, turning to the carer, some advice is given on caring for the carer, again, a neglected tradition here and in brain injury too.  The major focus is on combating isolation, meeting your own needs as a carer, respite care and the sharing of parental responsibility and duties, and finally but most important, the preservation of the couple as a unit are all focused on.  The idea of managing stress and taking advantage of the free diversions available such as exercise and nutrition all are noted. Attitudes are targeted, such as remaining hopeful (despite the bad news earlier, one sentence refers to the idea of new treatments), avoiding the martyr role, recognizing negative feelings and grieving are briefly addressed.

Overall the book, despite a little confusion in the title, covers what is know about the affective disorders in children, and gives a fair amount of detail and advice about what to do.  It covers the obligatory areas, but the same conundrums that drove parents to buy such a helpful book will still remain:

  • Are we to accept these are illnesses for which one needs medicine
  • What about recovery without recidivism
  • How reliable, valid, consistent are these diagnostic categories, and why the increasing burden, what is wrong with society
  • Why the exceptional bad press about giving medication to children, making it worse, increasing restless actions and creating more problems
  • If stress in daily living appears to be a factor, what are schools and educators doing to lighten the load
  • How do I deal with people at school knowing my kid is mentally ill
  • How do I deal with the guilt of passing on genes that I must now admit made my kid sick?

Without trying to be, this book follows the standard approach in medicine that kids are sick, will be sick, must be given medication for the most part, that these illnesses are pretty much there for life, and we need to accept that this is it for life mostly, and if we don't, it's a form of abuse.

 

My own practice over the years has been filled with parents who would not accept the validity of diagnosis, took the illness on head on and refused medication or DSM-IV labels, spent heaps of time on various therapies such as family and behavioral therapy, and even when the child was struggling, refused to go the medication roundabout and changed their family structure, life, eating and sleeping habits.

Here are two professors of psychiatry presenting their experience and their model with mostly success, writing in a fairly banal way of human experiences that are dreadful, and really making the point that these are largely incurable illnesses.  Does this not beg the question to which the answer is that the treatment paradigms followed in the model are not quite acceptable to many, and that there are other views?

Treatment research in other modalities has high levels of success; the evidence base for CBT in the hands of a good therapist speaks of treatment being efficacious in 80/90% of cases.  Family therapy models are still showing good evidence bases in alcohol related illness and other conditions, and these after all emerged in the 50's and 60's in response to the failure of therapies that placed illness inside the body of the patient, particularly in adolescence, and what was then called 'juvenile delinquency'.

Many cultures across the world have a different view of such illnesses, often with very high rates of recovery.  We all accept that there must be a vulnerability that encodes somehow from genes, but how does this affect treatment and the application of biopsychosocial paradigms that still see the process as one of intracorporeal illness?

So while many parents in western societies will find this book and its wealth of carefully considered information and advice comforting, many others will find it disquieting, and reject its implications, which is a pity.  Many others will investigate its chapters and find not enough in the "what can I do to address these issues directly" arena without resorting to an acceptance of a diagnosis of some putative mental illness, and the administration of pills that clearly have received some nasty press.

I think most parents will have serious questions to ask their professionals, and that the general mistrust of psychiatrists will continue, with the same parents rejecting the presumption of medical illness in these extreme kids.  The press will continue to present the case that medication is dangerous and that how and why it works when it does is little understood, especially with Black Box warnings for children.

The argument in the book often is that too little or too much serotonin epitomizes the depressed or manic patients, so where is the blood test for serotonin? Indeed, if there were just too little we should get more, but perhaps that would make us nauseous or cardiotoxic and it's the way in which it is available around the synaptic cleft etc etc; but parents don't need to know those arguments, and in any event there is dopamine, noradrenaline, too much or too little, where, and why, obviously this is not known and the book should make that more plain, without getting into GABA, Glutamate, or excitotoxicity.

The confidence expressed in the book is not there in the literature, and parents within range of a TV or newspaper will know there are raging controversies around the views in the book.

Having said that, Fristad and Goldberg Arnold have closed a gap in the market, tried to mainline the exceptionally moody and troubled kid as a diagnosis entity, and coax parents into moving past questioning, healthy or not, the reality of these as illnesses, and into taking action.

I am not sure that is always fair comment, but if you can overlook these philosophical issues, then the parents may calm themselves down and in reading the book accept that so much is indeed known, and that there is some system of amelioration out there, even if acts of faith, if not leaps of faith, have to be contemplated.

I for one remain as cautious of the psychiatric view of childhood illnesses as ever, and the process of diagnosis, as so little is known.  Now, what is known is in one book, and within its genre, it's the best I have seen.

 

 

© 2005 Roy Sugarman

 

Roy Sugarman, PhD, Clinical Director: Clinical Therapies Programme, Principal Psychologist: South West Sydney Area Health Service, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia.