Growing minds

One of the toughest parts of raising children is helping them leap the emotional and intellectual hurdles of life. As parents, we try to ease their pain when friends snub them. We console them when their fears keep them awake at night. We scold them when they behave badly, and counsel them after they forget their homework or lose something of value.

Cute girl looking concerned, pensiveCourtesy of apdk via Flickr.

But most of us have no idea what we are doing. The frustration from being unable to solve a child’s emotional problems or mental lapses is greater the more out-of-the-ordinary those problems seem to be. School counselors can address some issues, pediatricians others, but true experts in our children’s mental health and development are hard to find. How do we nurture our children’s brains and how do we know when they in trouble and need professional help?

In an ordinary-looking Park Avenue office tower in New York City, an extraordinary cluster of professionals are working to understand, improve and advise the rest of us about the mental health of our children. The Child Mind Institute, founded just three years ago, is the only nonprofit organization in the U.S. dedicated solely to children’s mental health. Their mission includes diagnosing and finding better treatments for childhood psychiatric and learning disorders, gaining an improved understanding of healthy brain development, and helping families deal with issues ranging from school transitions to serious anxiety disorders and behavior problems.

Our kids need help. According to the Institute’s website, more than 15 million children in America have psychiatric disorders and at least half of them will never receive treatment. Lots of other children, no doubt, have psychological troubles that may fall short of a disorder but that parents do not know how to handle.

Allaying A Child’s Fears

One of the Institute’s areas of focus is childhood anxiety, which afflicts 13 percent of kids in its assorted forms, according to Ronald Steingard, a psychopharmacologist there. Some kids have severe separation anxiety, others panic or post-traumatic stress. In pediatric obsessive compulsive disorder, children have intrusive and repetitive thoughts—say, that something will happen to mom and dad—and attempt to stamp them out with an irrational ritual they perform compulsively. They might have to wash their hands six times before bedtime or perform a triple-tap on the front door before leaving the house. In some cases, the anxieties and behaviors become so numerous and pervasive that they essentially take over a child’s life.

cute boy looking nervousAnxiety is a problem for 13 percent of kids. Courtesy of shelbyasteward via Flickr.

The gold standard therapy is exposure with response prevention, in which the child repeatedly confronts the objects, thoughts and situations that prompt his or her anxieties without being allowed to perform his or her rituals. Most kids receive this remedy in short weekly doses in a therapist’s office, but the Child Mind Institute also offers an intensive program in which a child spends a better part of a week, four to five laborious hours a day, trying to beat back his illness. With this approach, therapists spend time with the children in the places that elicit the troublesome responses. If a child believes that stepping on a crack will really break her mother’s back, the child and the therapist might take a walk and step on cracks and together confront the associated angst. The program has seen considerable success, leading to a 40 to 90 percent reduction in symptoms for all participants, according to its director, Jerry Bubrick. Families from London, Hong Kong and across the U.S. have come to the center to get concentrated help for their kids.

Selective mutism is an extreme form of social anxiety in children. Kids with this problem will only speak to certain people—mom and dad, for example—and only in a certain environment, say inside their home. Everywhere else, they fail to utter a word. The cause of the condition is not defiance but extreme self-consciousness. Children want to chat with their pals at a party or answer a teacher’s question in class, but their fear muffles them.

As one answer to this silence, Institute offers a week-long day program called Brave Buddies for children ages four through nine. The program features a mock school setting in which children practice talking in front of a group, with a counselor at their side. It includes parts of a typical day that require lots of talking such as morning meeting and field trips to parks or museums. Children earn points and prizes for each instance of “brave talking.” By the end of the week, words and whispers fill a room that had once been soundless. The vast majority of children, who were mute at the start of the week, can, by the end, go to an ice cream shop and request their favorite flavor. Children speak on their own accord three times as often as they did before.

Parent Training

The Institute also offers behavioral intervention for attention-deficit hyperactivity disorder and disruptive behaviors such as oppositional defiance disorder. An approach called parent-child interaction therapy (PCIT) is directed less at difficult children themselves than at teaching their parents how to deal with problematic behavior. When Steven Kurtz, who directs the ADHD and Disruptive Behavior Disorders Center, first described it to me, it sounded useful as a general parenting strategy, even if your kid is just difficult in all the normal ways. Supposedly it works best on kids ages two to seven, but it seemed to me that some of the tips could be adapted to older children as well.

blurry small girl in doorwayCourtesy of frozenchipmunk via Flickr.

In the formalized therapy, a parent leads her child or children in a series of tasks while a therapist watches through a one-way mirror. Though not part of the action, the therapist guides the parent by speaking instructions into a microphone that the parent receives by way of an earbud. Kurtz told me about a case in which two siblings were playing a game that involved slamming a door. Concerned that the game would result in a broken finger, the mother did what most of us would do: She told the kids that if they kept slamming the door, the game would have to stop. But the therapist had different advice. Instruct the children to practice closing the door carefully, the specialist said, advancing a positive behavior rather than trying to block a negative one.

In this “school,” parents graduate after 14 to 17 weekly sessions. Studies show that the program leads to more compliant and less disruptive children, shifting their behavior into the typical range. Parents’ stress levels also drop dramatically. According to a 2003 study, these improvements last up to six years.

In its effort to reach more children, the Institute is increasingly sending its tentacles into the community. According to Steingard, emerging pathology shows up primarily in two places: at school and in the pediatrician’s office. As a result, the Institute is trying to connect with both. For instance, it maintains an access line for pediatricians to call with questions about children’s mental health. “I want to see kids early on, before they even have a diagnosis,” Steingard says. In its efforts to reach into schools, Institute therapists have adapted PCIT to a classroom setting to help teachers control disruptive students. They tested the approach last year in 11 kindergarten and first grade classrooms in three New York City public schools. Preliminary results indicate that the therapy greatly improves class management. The teachers who used the techniques they learned referred fewer children to special services than did untrained educators in comparison classrooms.

Aside from its efforts on behalf of troubled kids and the adults in their lives, the Institute offers a plethora of advice for all parents. It provides support for families in the throws of separation or divorce. Its website also suggests solutions to conundrums from school transitions to teen sex and substance abuse.

father hand and tiny daughter handCourtesy of apdk via Flickr.

Perusing the website, I immediately encountered three articles I found helpful. The Secret to Calm Parentinghighlighted the dangers of being overprotective of children, perhaps making them overanxious and afraid to explore or tackle challenges. InFamily Dinner: How Much Does It Matter? I learned that I won’t harm my kids irrevocably by not regularly wrapping us all around a table every mealtime as long as I practice mindful attention when i am with them (most of the time) . And in Back-to-School Dos and Don’ts, I got some good advice for transitioning my kids for the new school year. I’m lucky that my own children do not seem to have significant psychological troubles, but I still need a lot of help.

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Something dark this way comes…

Something dark this way comes…

 

All couples argue…

However deeper, sometimes dangerous difficulties arise when  particular  psychological constellations align in the spaces between and within couples. When the right combination unfolds, our unconscious primal wounds may be hooked and begin to stir dark, half-formed leviathans beneath our conscious awareness.

I am currently in the fierce grip of one of these half-known beasts that trawl the darker recesses of the mind. What I do know is that the wound is deeper than my current relationship, but it is being hooked by the present set of circumstances.

The challenge at this volatile time is to differentiate and deconstruct the bewildering display put on by my defenses. This is an extremely difficult task with a hyper-aroused amygdala primed for what it feels is imminent threat. The problem is that the real threat happened a long time ago and the psychic defensive reflex is now more harmful than protective. It is like a castle that was built during a time of great strife, an impenetrable fortress that was extremely effective in protecting that which it felt was valuable, sacred tracts of the Self. Now, many years later the war has passed, my life has grown roots- and yet, if my partner stumbles across this old terrain, those on the walls are galvanized once again into action and I watch helplessly as they pour boiling pitch from above.

Intimate partners often know aspects of the interior landscape of the Other, but some of the roads are winding and lead into deep, dark  thicket. There should be warning signs up-

“BEWARE- Primal monster afoot, ignore at your peril”

 

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Through the glass half darkly…

The Gloom-and-Doom Disease: Should Woody Allens Have a Home in the Manual of Mental Illness?

Depression and anxiety are like a pair of warring siblings. Both are disruptive and trying. They don’t want each other’s company, but are stuck together by virtue of the same parentage. Depression, after all, is often a product of rumination, the grating mental do-overs of ugly past events, usually with no solution in sight. Anxiety is the brainchild of too much forecasting of doom. Both seem to emerge from the sort of person who is stuck so securely in his mental time machine that he has no idea the roses are even there. Forget about stopping to smell them.

Woody Allen portraitCourtesy of Luiz Fernando/Sonia Maria via Flickr.

Psychologists tend to link the depressed and the anxious by personality. Both groups share the trait of “negative emotionality,” the propensity to harbor bad feelings such as anger and anxiety. (In contrast to those with depression, though, those with textbook anxiety spike their dourness with a dollop of wellbeing, energy, closeness to others, and the like.) And of course, the two temperaments feed each other. If your future is so terrible, what’s not to be depressed about? Conversely, if you rake over the past enough, you’ll undoubtedly unearth a goof that is sure to destroy your prospects. For all these reasons, not to mention shared genetic risk factors, lots of people who are depressed are also anxious—and vice versa.

Yet these practically conjoined twins of psychological distress have long been separated in psychiatrists’ diagnostic bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), currently in its fourth incarnation. A depressed person is someone who feels overwhelmingly sad and worthless, the DSM says, and who can no longer enjoy activities they used to like. They may also have thoughts of death or suicide. Generalized anxiety disorder (GAD)—to pick one of the many certified forms of fretting—involves excessive, and at least somewhat debilitating, anxiety and worry about more than one part of your life that you experience on most days for six months or more.

But what about all those ruminators who can’t help forecasting future doom—and yet don’t qualify as officially depressed or pathologically anxious? Currently, as of the DSM-IV, these folks remain in a kind of diagnostic limbo. Their pending label, “mixed anxiety-depressive disorder” is in the book’s appendix, a place for proposed ailments in need of further study. Accumulating data suggest that these people are numerous. In the United Kingdom, national surveys suggest that 8.8 percent of the population would qualify for mixed anxiety and depression as defined by the World Health Organization’s compendium of diseases—the International Statistical Classification of Diseases and Related Health Problems (ICD-10). By comparison, fewer people—only 7.7 percent—satisfied diagnostic criteria for major depression, GAD or a combination.

Many of the 8.8 percent are more than moderately miserable. Studies show that the impact of this cocktail of sadness and worry on quality of life is similar to that for anxiety disorders: 12 percent of sufferers, for example, have reported suicide attempts and the disorder accounted for 20 percent of all disability days in the United Kingdom. So these folks do seem to need help.

Man in gorilla suit chases after Woody Allen.Woody Allen escapes a “gorilla,” in the 1969 movie “Take the Money and Run.” Courtesy of John McNab via Flickr.

As a result of such findings, the framers of the DSM-5 originally proposed to move “mixed anxiety/depression” (with its slightly altered name) up to an official diagnosis, meaning insurance would reimburse you for treatment (which, drug-wise, is likely to be Prozac and its ilk). The proposed criteria for the new disorder included having three or four of the symptoms of major depression along with anxious distress. The latter required having two or more of the following issues: feeling nervous & anxiousinability to control worrying, having difficulty relaxing, being so restless it is hard to keep still, and fearing that something awful might happen. These problems must have plagued you for at least two weeks and must have caused “marked distress or significant impairment.” “Mood and anxiety disorders blur together,” says Scott Lilienfeld, a psychologist at Emory University. “This was an admission that they can’t be separated in any clean, neat way.”

And in this respect, the mixed disorder makes a great deal of sense. And yet as of last Thursday, the DSM-5’s framers seemed to take it all back. They reversed their initial push to promote this ailment to the body of the diagnostic bible. The criteria for mixed anxiety/depression were a bit vague and elastic, critics contended. The naysayers fretted that scads of mild chronic worriers—the Woody Allens of the world—would fall into it, their hypochondria ironically legitimized. The proliferation of false positives is a problem with the new DSM in general, some argue. “They are going to be diagnosing almost everybody,” Lilienfeld quips. Taking back the proposed mixed anxiety/depression diagnosis was one attempt to cut back on the number of newly mentally ill.

Of course, these critics could have been among the masses eligible for the proposed-now-nixed label, worriers that they are. But let’s give them some credit. Maybe they think they’re fine. And maybe they are.

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