A Troubled Child Is Not 'Sick'

Excerpted from
Normal Children Have Problems, Too: How Parents Can Understand and Help
By Stanley Turecki, M.D., Sarah Wernick, Ph.D.

Emotional problems are fundamentally different from physical ones. If your child has a sore throat, and her physician suspects a strep infection, the diagnosis can be confirmed by a throat culture that looks for a particular germ. Once the cause is identified, the doctor can prescribe a specific medication that attacks the organism and produces a cure.

The situation is not at all the same with human feelings and behavior. Emotional problems rarely have a simple cause; the difficulties result from complex interactions among biological, psychological, and social factors. Though a psychiatric diagnosis may sound scientifically precise, it's based upon reported feelings and a clinician's subjective interpretations of what he or she observes.

Here's an example: Andy, age eight, is running into difficulties at home and school because of his high activity level, poor concentration, and impulsive behavior. This cluster of characteristics has been labeled and relabeled over the past fifty years, with terms like "hyperkinetic syndrome," "minimal cerebral dysfunction," and "hyperactivity."

Today's professionals generally follow the terminology and guidelines of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is published and periodically updated by the American Psychiatric Association. In the early 1980s, the DSM-III term "attention-deficit disorder" (ADD) became widely accepted, only to be followed by further confusing changes in nomenclature and diagnostic criteria. The latest version, DSM-IV, lists eighteen characteristics of inattention, hyperactivity, and impulsivity, and relates them to four different types of "attention-deficit/hyperactivity disorder" (ADHD). (To all intents and purposes, parents and many professionals use the terms ADD and ADHD interchangeably.) A child can receive a clinical diagnosis if he or she displays at least six signs of inattention and/or at least six signs of hyperactivity-impulsivity. These symptoms must be present in two or more situations (such as home and school) for at least six months "to a degree that is maladaptive and inconsistent with developmental level."

That sounds very precise, but what does it really mean? All eighteen criteria are open to subjective interpretation-for instance: "Often fidgets with hands or feet or squirms in seat," "Is often easily distracted by extraneous stimuli," and "Often loses things necessary for tasks or activities." It's not hard to imagine that different observers would reach different conclusions about the same child, depending on what they regard as normal and what they consider "often" or "easily." Indeed, there is wide state-to-state variation in the diagnosis of ADHD, as indicated by the number of prescriptions of Ritalin, a drug commonly used to treat these children. Current estimates put the incidence of ADHD at 3 to 10 percent. In no other country in the world is the diagnosis made so freely.

After I met with Andy, his parents asked me anxiously if their son had ADHD. But this is not like determining if Andy does or does not have chicken pox. Here's what I told them:

I don't have a simple Yes "or "No" answer for you. A child's activity level, impulsiveness, and distractibility can range from very low lo extremely high. Andy certainly is at the higher end of the spectrum. But there's nothing magical about having six symptoms for six months. Suppose he s had five symptoms for five months: Would that really change the fact that he's having problems because he's very active and easily distracted, and that he could use some help?

I'm not suggesting that diagnostic terms and criteria be discarded. They're useful for research, for improved accuracy of observation, and as a shorthand for communication between professionals. I use them myself-though I interpret the criteria very strictly and require behavior to be extreme. But I'm deeply concerned that diagnostic labels are increasingly applied to normal individual variations in behavior and development. Over the past couple of decades, in sequential editions of the Diagnostic and Statistical Manual, the number of mental disorders has nearly quintupled Indeed, the present edition defines pathology so broadly that most of us could find ourselves within its pages.

Accompanying this change has been another that worries me: Because of pressures for achievement, especially among middle-and upper-middle-class families, having a truly average child no longer seems acceptable. Increasingly, teachers approach parents about minor problems and suggest testing; more and more children are labeled "learning disabled."

There's a real risk that medical labels-as opposed to simple descriptions in everyday language-can stigmatize a child and turn him into a "case." If that happens, it's all too easy to focus on symptoms and what's wrong with the child, instead of looking at him as a whole person Treatments narrowly aimed at the "condition" can miss important dimensions of the youngster and his life.

Daunting medical terms may scare us away from commonsense solutions and into premature professional investigations and treatments. Parents sometimes arrive in my office with test results in folders two inches thick. These tests are often time-consuming, expensive, and emotionally draining; even worse, they can leave the parents confused and the child worried that there is something wrong with him. I'm not saying that professional help should be avoided-obviously, it can be enormously beneficial. Rather, we should realize that in many situations, simple, practical measures can be tried before going on to more complex interventions.

Seven-year-old Ned illustrates this point. He is a skinny child who gets frequent colds. He is behind the rest of his second-grade class in reading; he's often inattentive and occasionally disrupts lessons by calling out. Because he's small for his age and not well-coordinated, he does badly at soccer and other team sports. His classmates tease him, and he's developed a nervous blink.

Some professionals might recommend that Ned have a complete evaluation. This could include not only a thorough medical examination and routine blood tests, but also consultations with a neurologist, occupational therapist, educational psychologist, allergist, and child psychiatrist. Days of testing might yield such recommendations as tutoring with a specialist in learning disabilities, medication for hyperactivity, occupational therapy to correct poor coordination, dietary changes, or psychotherapy.

Ned's mom and dad are caring parents who would spare no effort to help their son. However, I think they would do better by approaching his problems another way first. The extensive evaluation could be put on hold. They could meet with his teacher and suggest that simple measures be tried first. Perhaps they could help Ned with homework if the teacher gave them a few guidelines; certainly he would benefit from more structure at home. Maybe the teacher could seat him in the first row of the classroom to reduce distractions and teasing. They could improve his self-confidence by encouraging activities in which he will be successful-piano lessons are a possibility since he's musically inclined. Having taken these and other similar steps, they could wait and see what happens. If the situation doesn't improve in a few months, professional evaluation and assistance would be appropriate.