It's Nobody's Fault_ New Hope And Help For Difficult Children And Their Parents Part 10

CHAPTER 17.

Eating Disorders Justine, 15, was warm, friendly, smart, and polite-one of the pleasantest young people I've ever met. The first time I saw her, Justine weighed 90 pounds. She was almost a skeleton, so thin that her collarbone and even the bone on her forehead stuck out. Her parents said they were almost afraid to touch her. A year earlier Justine's weight was 130, which was perfectly fine for her five-foot, five-inch frame. But then she started starving herself. She ate practically nothing, and the more her parents pleaded with her or scolded her or threatened her with punishment, the more determined she became to avoid even a sc.r.a.p of food. She eventually got so weak that her parents brought her to our emergency room. Her blood pressure and pulse were alarmingly low, and she had fine white hair, just like a newborn baby's, growing on her arms and back.

By the time she reached her seventeenth birthday, Trudy-another lovely, personable girl-was bingeing and purging for nearly six hours a day. That was three years ago. Today, at 20, she's down to only a half-hour a day and well on her way to recovery. Still, she's preoccupied with taking in and getting rid of large quant.i.ties of food. Trudy says that when she walks into her house, she feels as if she's walking into a giant refrigerator. When she opens the front door, all she can think about is food, food, food.

FEAR OF FATNESS.

The two most common eating disorders among adolescents, nearly all of them girls, are anorexia nervosa and bulimia nervosa. The peak age of onset for anorexia is 14, during the transition between childhood and adolescence. Bulimia's age of onset is 19, so it is a.s.sociated with the transition from adolescence to young adulthood. Because the two eating disorders are so different, I'll take them one at a time.

ANOREXIA NERVOSA.

Anorexia nervosa-commonly referred to as anorexia-is, quite simply, self-imposed starvation. The girl who is officially diagnosed with anorexia-more than 90 percent of these patients are female-will weigh at least 15 percent less than she should, according to the growth charts. However, the true hallmark of anorexia is body image distortion; body image distortion; no matter how much weight they lose, these girls still see themselves as fat, and being fat is what they fear most. Even 90-pound Justine, with the protruding forehead and clavicles, thought she looked fat. "Look how the fat just hangs off my arms," she'd say to her mother. About 1 percent of the school population will be diagnosed with anorexia, and some studies show that the number is growing. In the last 35 years the incidence of anorexia has increased some 30 percent every five years. no matter how much weight they lose, these girls still see themselves as fat, and being fat is what they fear most. Even 90-pound Justine, with the protruding forehead and clavicles, thought she looked fat. "Look how the fat just hangs off my arms," she'd say to her mother. About 1 percent of the school population will be diagnosed with anorexia, and some studies show that the number is growing. In the last 35 years the incidence of anorexia has increased some 30 percent every five years.

As I already said, the age of onset for anorexia is around 14, but it may take as long as a year after the symptoms begin for parents and their child to make their way to a child and adolescent psychiatrist's office. Often the parents will try to work with a child themselves for a while, a.s.suming that a refusal to eat is just part of their daughter's rebellious teens. A neighbor, a minister, or a family friend might get involved before the pediatrician is consulted. When parents do finally get to a pediatrician's office, most doctors are quick to diagnose anorexia and refer these children to a child and adolescent psychiatrist.

By the time we see these girls, there are nearly always some secondary physical symptoms to deal with, among them low blood pressure, low pulse, and dizziness when they stand up. Their estrogen, progesterone, and cortisol levels will probably be abnormal. They will have stopped having menstrual periods. They may have baby-fine white hair on their arms, back, and neck. In all likelihood they will be anxious about their s.e.xuality. Some girls with anorexia have boyfriends, but they are almost never s.e.xually active. These girls are often afraid of s.e.x and sometimes fearful of growing up. They are not ready for parties or the drugs, alcohol, and s.e.x that are often to be found there. Many of these girls want to stay prep.u.b.escent, childlike. The typical youngster with anorexia is the good little girl who studies hard and tries her best to please everyone.

Adolescents with anorexia will be obsessive in their thoughts, always thinking, "I can't believe how much I ate! Look how fat I am," and compulsive in their actions, incorporating food-related rituals that annoy and exasperate their friends and family. They cut their food into little slices and push them around the plate for a half-hour, never actually eating anything. They hide food in their rooms, not to eat it but just to make sure it's available. When they prepare their own meals, they make a huge, time-consuming production out of even the smallest concoction. They know everything there is to know about calories and weight reduction. Girls with anorexia have very poor self-esteem. Because their interests are so restricted-they're focused entirely on food-they usually don't have many close friends.

A diagnosis of anorexia requires a comprehensive history, including an examination of the course of the symptoms and observation of the family. In taking the history we get full details from these girls on their food intake, their eating behaviors, and their thoughts about and att.i.tudes toward food. A thorough physical examination by a pediatrician or family pract.i.tioner, including a complete blood workup and an electrocardiogram, are essential; kids with anorexia may have medical complications that have to be addressed immediately.

THE BRAIN CHEMISTRY Parents have taken a lot of heat over anorexia-people blame mothers and fathers for their child's eating disorders-but it is undeserved. There is no scientific evidence that faulty parenting or dysfunctional families cause anorexia, or bulimia either. Those theories tossed around about how forcing children to clean their plates or not allowing them to have a piece of candy between meals when they were toddlers leads to eating disorders later have no basis in fact. The widely believed theory that a girl starves herself because she has a fear of physical and emotional maturity or that she's rebelling against her parents is still hotly debated.

Family and twin studies offer evidence to support a genetic component attached to anorexia. The families of girls with anorexia seem to have a higher than average incidence of weight problems, physical illness, depression, and alcoholism.

One biological theory that needs further study suggests that adolescents with anorexia have a physiological response to dieting that is different from that of the rest of the world. Most people feel discomfort when their calories are restricted; girls with anorexia are different. Weight loss makes them feel successful, disciplined; they aren't sensitive to the usual discomfort a.s.sociated with dieting. As the girls begin to starve, there is a release of opioids (brain chemicals that long-distance runners also produce), which give them a "high." Restricting calorie intake brings genuine pleasure, and a vicious circle has begun.

THE TREATMENT In some ways the biggest problem a.s.sociated with treating adolescents with anorexia is that adolescents with anorexia don't want treatment. adolescents with anorexia don't want treatment. They scream and cry and curse their parents for bringing them to psychiatrists' offices, accusing them of not trusting and not loving them. Then they deny having a problem at all. (Their parents see them as sick, but they feel wonderful, because they're thin!) Finally, they admit they have a problem but promise they'll eat if they can just leave the hospital and go home. The tears, denial, and recrimination are all perfectly understandable, of course. These girls know that getting "better" means putting on weight, and that's precisely what they don't want. They scream and cry and curse their parents for bringing them to psychiatrists' offices, accusing them of not trusting and not loving them. Then they deny having a problem at all. (Their parents see them as sick, but they feel wonderful, because they're thin!) Finally, they admit they have a problem but promise they'll eat if they can just leave the hospital and go home. The tears, denial, and recrimination are all perfectly understandable, of course. These girls know that getting "better" means putting on weight, and that's precisely what they don't want.

Even so, it is essential that these girls get the treatment they need. Anorexia is a very serious disorder. If these girls don't get better, they may die. Recent studies say that anywhere from 5 to 7 percent of all children with anorexia will die within 10 years. With treatment, about 70 percent will eventually have full medical, social, and psychiatric recovery. The sooner the disorder is treated, the more favorable the prognosis will be.

The best treatment for anorexia is cognitive behavioral therapy, often in combination with medication and family counseling. After an initial examination, including a thorough physical, children with anorexia will need at least weekly sessions with a psychiatrist; many will need to come in twice a week. They also need weekly weigh-ins and other medical follow-ups. In the past, when dysfunctional families were thought to be the cause of eating disorders, family therapy alone often was the treatment of choice. Today we rely largely on cognitive behavioral therapy, which concentrates on changing the girl's distorted perceptions about food and decreasing the significance of thinness in determining her self-worth. Family counseling can be very useful in helping parents and other close family members cope with a sick child.

Not all child and adolescent psychiatrists have experience with anorexia, and others aren't really comfortable treating these kids. Parents shouldn't be shy about getting answers to some important questions here, since finding the right physician is critical. "Do you treat kids with anorexia?" is the best place to start. "Do you believe in outpatient management?" "Do you use medication?" and "May I talk to you and be involved in the treatment?" are other questions to which a parent should receive an unqualified yes.

It's not necessary to find an eating disorders specialist for the child with anorexia or to check her into an eating disorders clinic, although there are many good ones out there. It is necessary to find a good psychiatrist who is interested in the disorder and can do the therapy, prescribe medication, and follow the child for at least a year and a half. That's about how long the outpatient therapy for anorexia will take, though severe cases will take longer, sometimes much longer. The worst case I've encountered took six years of treatment before the girl was completely well.

Many children being treated for anorexia will take some sort of medication, but the role of medicine is limited with this disorder. Antidepressants, specifically the SSRIs (selective serotonin reuptake inhibitors), such as Prozac, Zoloft, and Paxil, may help with the obsessive-compulsive symptoms and the depression that often accompany anorexia. Prozac has been effective in helping these girls maintain their weight gain and normalize their eating habits. The medicine needs to be taken for at least a year. Appet.i.te stimulants are sometimes recommended; the one most often prescribed is Periactin, an antihistamine that has been helpful in increasing weight and maintaining weight gain. The MAOIs (monamine oxidase inhibitors), especially Nardil, have also helped girls put on weight.

Many of these girls hate taking pills, and not for the usual reason. They panic because they think the coating has too many calories. Others are terrified that the pills will make them eat, so I tell them-quite truthfully-that there is no pill that makes a person eat. "I wish there were a medicine that would make you eat, but there isn't," I say. "All this pill will do is help you not to worry so much about what you do do eat. eat.

When the medication and therapy described above don't work, when there is no increase in weight and no improvement in the child's overall health, hospitalization may be necessary. Hospital care offers a multidisciplinary approach to the disorder, involving diet.i.tians, nurses, and psychologists as well as psychiatrists. Inpatient treatment can be done in any adolescent psychiatric unit or in special eating disorder units that combine both pediatric care and child and adolescent psychiatry.

BULIMIA.

The young women who have bulimia (again, some 90 percent of the patients are female) don't starve themselves; they binge binge, they purge purge, they try to fast fast, and they have strange att.i.tudes about food. Like girls with anorexia, they're afraid of getting fat, but they don't have a distorted body image. They don't see themselves as fatter than they are. They're afraid of food, but they can't help taking in a huge amount of it-anywhere from 3,000 to 20,000 calories per binge. I've talked to girls who would eat several loaves of bread and boxes of cereal at home and then go from one fast food restaurant to another, consuming an enormous amount of food in a few hours. The frequency of the binges of someone with bulimia will vary greatly, from twice a week to several times a day. A binge may last from several minutes to several hours. Young women with bulimia describe having a lack of control during the binges; some describe it as an altered state of consciousness. Unlike girls with anorexia-who are preoccupied with their success at restricting their calorie intake-young people with bulimia are not very good at dieting. They often diet, but restricting calories makes them uncomfortable and usually leads to bingeing.

After bingeing usually comes purging (some people with bulimia binge but don't purge), by vomiting or using laxatives-as many as 20 a day -or both. Many use diuretics or diet pills. Some exercise for hours at a time. Not surprisingly, there are medical complications a.s.sociated with bingeing and purging, among them low blood pressure, dehydration, low pota.s.sium and other metabolic problems, cavities, constipation, swollen cheek glands, and hormonal changes. The physical signs of bulimia are frequently pointed out by other health care professionals, especially dentists, who notice the enamel wear on a young woman's teeth as a result of the acid in the vomitus.

It's not difficult to spot a girl who has anorexia, no matter how baggy her clothes are, but people with bulimia can look completely normal. In fact, most are of normal weight or even a little heavier. Young people with bulimia are generally older than girls with anorexia too; the peak age of onset of bulimia is 19 years. The incidence of bulimia is estimated at 2 percent of the population, but some studies show that 3 to 5 percent of all college-age girls have this disorder.

Many people with bulimia have a history of anorexia or obesity. There is also a high co-occurrence with major depressive disorder, generalized anxiety disorder, social phobia, and panic disorder. Alcohol and substance abuse are also common.

THE BRAIN CHEMISTRY There is almost certainly a genetic component attached to this disorder. Twin studies of bulimia show a higher rate in identical twins than in fraternal twins, and family studies tell us that the relatives of people with bulimia have a higher incidence of the disorder than the relatives of people who don't have it. Other evidence suggests that there is a neurochemical component to bulimia, specifically a decrease in the manufacture of serotonin and a hypersensitivity to changes in serotonin levels.

THE TREATMENT Unlike kids with anorexia, young women who have bulimia will ask for treatment. The distress and dysfunction a.s.sociated with this disorder are such that these girls with bulimia want want to get better. Untreated, people with bulimia will continue to get worse over time. Their binges begin to get more and more extreme, and their distress grows. A small but significant percentage of all young people whose bulimia is left untreated will die within five years; many of them will commit suicide. With treatment about 70 percent will have a full recovery. to get better. Untreated, people with bulimia will continue to get worse over time. Their binges begin to get more and more extreme, and their distress grows. A small but significant percentage of all young people whose bulimia is left untreated will die within five years; many of them will commit suicide. With treatment about 70 percent will have a full recovery.

Again, the treatment is cognitive behavioral therapy combined with medicine. We usually recommend individual therapy with a cognitive behavioral approach. This treatment, which requires a minimum of six months, has four phases. In the first phase, we examine the problem with the girl's active partic.i.p.ation, asking her to monitor her food intake and record her eating habits, especially binges and purging. Next we focus on changing her eating behavior, limiting food intake to three meals a day and two snacks. In the next phase we work on correcting her distorted thoughts and att.i.tudes about calories, weight, and body image. And finally we move to relapse-prevention, in which we simulate high-risk situations and encourage the girl to practice her new behavior. Interpersonal psychotherapy (IPT), discussed in Chapter 14 Chapter 14, has also been useful in the treatment of young women with bulimia. Group therapy can also be very helpful for these girls; discussing their eating behaviors openly tends to make them feel less isolated. College students often do well in group cognitive behavioral therapy.

Meanwhile, antidepressant medication, such as Tofranil, Desyrel, and Prozac, will help to cut down the frequency of the bingeing and vomiting cycles and alleviate the underlying depression. Tofranil may cause dry mouth and sedation, and it has effects on the heart that make cardiac monitoring necessary. The most common side effect of Desyrel is sedation, and because it may also cause nausea and vomiting, the medicine should be taken with meals. Prozac and the other SSRIs have minimal side effects. For best results, medication for bulimia should be taken for six months to a year.

PARENTING AND EATING DISORDERS.

Family dinners are often the setting for conflict and disagreement in any household. It is a rare family indeed that doesn't feature a tantrum, a blowup, or some other scene at the dinner table once in a while. When there is a child in the house who has an eating disorder, every meal is a potential nightmare.

"We just sit there, day after day, watching her starve herself to death, and it's killing all of us," one desperate mother told me. "I know that the minute we go upstairs she's going to run into the downstairs bathroom and start vomiting, and there's nothing we can do about it," said another. "My husband and I are desperate."

Parents faced with their child's eating disorders do do become desperate. They also become depressed, angry, and worried. Having a child with anorexia or bulimia has a tremendous impact on the entire family. Parents feel frustrated and helpless because they can't control their children and make them well. After all, giving a child nourishment is one of a parent's fundamental responsibilities. Normal siblings may become jealous and angry because, the way they see it, their parents are being tricked and manipulated. "I think you should just become desperate. They also become depressed, angry, and worried. Having a child with anorexia or bulimia has a tremendous impact on the entire family. Parents feel frustrated and helpless because they can't control their children and make them well. After all, giving a child nourishment is one of a parent's fundamental responsibilities. Normal siblings may become jealous and angry because, the way they see it, their parents are being tricked and manipulated. "I think you should just make make her eat," they might say. "She always gets her way. She's just doing this so you'll pay attention to her." her eat," they might say. "She always gets her way. She's just doing this so you'll pay attention to her."

The parents of Susannah, a 17-year-old girl who was successfully treated for an eating disorder, say now that in some ways the hardest thing about the disorder was admitting that they couldn't fix what was wrong with their daughter. For nearly a year they did everything they could to persuade Susannah to eat, but she was obviously getting worse. They finally took her to a child and adolescent psychiatrist who specializes in treating anorexia and bulimia.

"The hardest thing for us was accepting the fact that we couldn't do it alone, that we needed someone to help us. We really thought we could handle Susannah's problem ourselves. Once we did put her and ourselves into the hands of a professional, things really did get better, not just for her but for the rest of the family too. It was such a relief to talk to someone who didn't blame us for what our child was going through and who didn't hold it against us when we lost our tempers with her. And because he kind of 'took charge' of Susannah, he freed us up to spend more time thinking about our other kids. In that year before we took Susannah to see the psychiatrist, there were times we almost forgot we had had other children. But the best thing about it is that Susannah got better. He gave us our daughter back." other children. But the best thing about it is that Susannah got better. He gave us our daughter back."

CHAPTER 18.

Conduct Disorder Douglas, 12 years old, was brought into the hospital by his parents after he tried to choke his five-year-old brother. It wasn't the first time Douglas had done something terrible at home. Over the three or four years before we saw him for the first time, Douglas had set several fires. Quite recently he had soaked a whole package of firecrackers in gasoline and had lit them, basically destroying half of his family's backyard. Douglas was odd and socially awkward, and his cla.s.smates never let him forget it. They teased him mercilessly and refused to include him in their activities. In the last year Douglas had been going through some tremendous mood swings, including lengthy periods of depression. I don't think I've ever met anyone of Douglas's age who was so socially inept.

Jared was 10 years old and in fifth grade when he first came to see me, but he had been having behavior problems ever since nursery school. At three years old he was already a "handful," his parents said, and as the years went by, Jared's behavior got worse. At school he routinely stole from his cla.s.smates. In third grade he beat up a child because the boy had "squealed" on Jared, telling the teacher that Jared cheated on his math test. He took the pet turtle from science cla.s.s, threw it into boiling water, and watched as the turtle died. Jared was an unusually attractive boy, with blonde hair, blue eyes, and a dimple. He was even a little charming, despite his grisly exploits. As he told me about the things he had done, he showed no remorse whatsoever.

THE "BAD SEED"

It's the stuff of fiction: children who set fire to the living room curtains, boil their turtles, throw their baby brothers down the stairs. But it can also be fact, if a child has conduct disorder. Children with conduct disorder-CD-are physically and verbally aggressive. They routinely lie, steal, set fires, and torture animals. When they reach adolescence, they may rape and otherwise physically abuse people and terrorize the community. It's no wonder that kids with CD are featured so prominently and so often in fiction. They seem too bad to be true.

THE SYMPTOMS.

All children misbehave some of the time. Children and adolescents with CD misbehave a lot of the time, in fairly serious ways. They have temper tantrums and use bad language. They do things that violate the rights of others, such as stealing or defacing property or creating a nuisance. They're physically aggressive and may even be s.e.x offenders. They have symptoms that fall into four categories: aggression toward people and animals; destruction of property; deceitfulness and theft; and serious violation of society's rules. It is estimated that 6 percent of all children have CD, with a male-female ratio of about 4 to 1.

There are two types of CD: early-onset CD, which occurs before the age of 10 and is the most common type; and late-onset CD, which comes after age 10. The age of onset for CD is significant; there's a tremendous difference between someone who first shows the symptoms of CD at age six and someone who does so at age 15. The earlier the onset of CD is, the worse the prognosis is.

CD may show up in the very young. Children as young as three may behave aggressively, fighting with their siblings and their peers. I've seen five-year-olds who become s.e.xually aggressive. They're too young for rape, of course. Small children are more inclined to take off all their clothes and play with their genitals or to try to touch their peers. The more violent behavior a.s.sociated with CD, such as animal torture and attacks on people, occurs during the elementary school years. Rape and the other serious a.s.saults come later, in the teenage years.

Another significant factor a.s.sociated with CD is the IQ of the child. A child with CD whose IQ is 70 presents a very different picture from one with an IQ of 125. On the one hand, the child with the higher IQ will be easier to work with when it comes to treatment; on the other, he's probably more imaginative and creative in acting out his antisocial behavior to begin with. He may also be more wily in evading detection.

Many children with CD have learning disabilities and lower-than-average verbal skills. Although children with CD often seem tough and fearless, the very embodiment of the word bravado bravado, they usually have very poor self-esteem. The younger children are impatient and easily frustrated, given to frequent outbursts of temper. Teenagers with CD tend to be more reckless and accident-p.r.o.ne.

A few years ago there was a story in the New York newspapers about a gang of girls in their early teens who were roaming the streets of Manhattan's Upper West Side, sticking unsuspecting pa.s.sersby in their backsides with pins. It didn't take long for the girls to be apprehended, and when police questioned them, their ringleader explained their behavior in a way that has stayed with me ever since: "We thought it would be fun, and it was."

The leader of that girls' gang vividly ill.u.s.trates one of CD's most dramatic symptoms. Children with conduct disorder do not seem to experience remorse. Quite the contrary: they enjoy their antisocial behavior and often welcome the opportunity to tell people what they've been up to. Listening to some of their stories can be positively bloodcurdling. I'll never forget the time a cherubic six-year-old told me in gruesome detail what he did to the gerbil the teacher brought to his cla.s.sroom. Just about the only time these children are in any real distress is when they've been caught and are about to be punished; they show remorse to lessen the punishment. Then they become angry and upset at the system for not letting them do exactly what they want.

THE DIAGNOSIS.

In making the diagnosis of CD we talk to the child, of course, but we also interview parents and teachers and look closely at school records. We take a comprehensive history, paying special attention to the youngster's development and his aggressive behavior, and examine the family history for conduct problems and criminal infractions. Before an official diagnosis of CD can be made, the symptoms of CD must be persistent-children have to have several symptoms for a period of at least one year and at least one symptom for the past six months-and the symptoms must exist in more than one setting. (We have to satisfy ourselves that the symptoms are not just reactions to a bad situation.) Finally, we look for other disorders, especially attention deficit hyperactivity disorder, separation anxiety disorder, and major depressive disorder, all of which are likely to co-exist with CD. At least 50 percent of all kids with CD also have ADHD.

THE BRAIN CHEMISTRY.

Conduct disorder has not been widely studied, but the information that has been gathered indicates that certain children have a genetic vulnerability to this disorder. When that vulnerability is combined with certain high-risk environmental factors, such as poverty, parental neglect, marital discord, parental illness, parental alcoholism, and having a parent with antisocial personality disorder-the adult version of CD-the child's chances of having the disorder are even greater.

The role of genetics in CD is less than crystal-clear. We do know that a vulnerability to the disorder is inherited. The chances that a child will have CD increase if one parent has it and go up even more if both parents have it. (If either of the parents abuses drugs or alcohol as well, the chances of CD in a child are greater still.) Twin studies have shown that if one twin has CD, the other is more likely also to have it if he or she is an identical twin rather than a fraternal twin. Adoption studies show that there is an increased risk for a child to have CD if both both his adoptive and his biological parents have this disorder, further supporting the nature-plus-nurture "double whammy" theory. his adoptive and his biological parents have this disorder, further supporting the nature-plus-nurture "double whammy" theory.

Neuropsychological testing has shown that children and adolescents with CD seem to have an impairment in the frontal lobe of the brain, the area that affects their ability to plan, to avoid harm, and to learn from negative consequences. Another study demonstrates that the serotonin levels in the brains of children and adolescents with CD were even lower than the serotonin levels in the brains of children and adolescents with obsessive compulsive disorder.

THE TREATMENT.

Conduct disorder is by far the most difficult disorder to treat in all of child and adolescent psychiatry. There is no one drug of choice for all the symptoms of CD and no one therapy that has an appreciable effect except in rare cases. When treating children with conduct disorder I, like every other child and adolescent psychiatrist, hope that in addition to the CD there is another disorder that we can can treat. If CD is co-morbid with another disorder, we treat the other disorder first; if there is evidence of ADHD, for instance (and about half the time there is), we'll prescribe Ritalin or sometimes Cylert. Dexedrine works well too, but we've found that kids with CD are more likely to treat. If CD is co-morbid with another disorder, we treat the other disorder first; if there is evidence of ADHD, for instance (and about half the time there is), we'll prescribe Ritalin or sometimes Cylert. Dexedrine works well too, but we've found that kids with CD are more likely to sell sell their Dexedrine than to take it as prescribed. Once the symptoms of the other disorder have subsided, we're often faced with a very different child. With luck the "new" child will be more responsive to medication or behavioral therapy or both. their Dexedrine than to take it as prescribed. Once the symptoms of the other disorder have subsided, we're often faced with a very different child. With luck the "new" child will be more responsive to medication or behavioral therapy or both.

If the child with CD does not have ADHD, we'll probably give him Ritalin anyway, since Ritalin is effective in decreasing negative behavior (specifically aggression toward teachers and other kids) in children with CD. If Ritalin is not effective and the child is very aggressive, we may give him a trial of Lithium, which is used to reduce aggressive behavior in adult males. Also prescribed in the treatment of bipolar disorder in children and adolescents, Lithium alleviates the aggressive explosiveness that kids with CD sometimes demonstrate. (Because of the possible effect that Lithium may have on the thyroid, a youngster taking the medication will require blood monitoring.) If Lithium doesn't work, we usually try Depakote, another medication used for bipolar disorder.

In addition to medication we recommend therapy for the child, specifically a cognitive behavioral approach that helps the child learn new ways to resolve conflict. This is a very active process, employing a lot of role playing and rehearsal. A child is taken through simulated or real events that involve conflict and encouraged to forget his usual responses-aggression and other forms of antisocial behavior-and learn new, nonviolent, socially appropriate ways to react to these events. This form of behavior modification basically gives the child a whole new way to behave and to respond to conflict of any kind. Because of its strong cognitive component (that is, it requires thinking), the program usually works better with adolescents than with young children.

When the diagnosis of a child with CD is in question or when it becomes necessary to get immediate control of a very aggressive child or adolescent, hospitalization will probably be called for. An out-of-home setting provides more intensive supervision and structure than anything that can be done while the child is living at home. Once the child has made significant progress, and provided his parents are cooperative, treatment can be continued on an outpatient basis.

Early detection and treatment are vital here. Every day care center in America should be on the lookout for obviously aggressive and out-of-control three-year-olds. Nothing is to be gained by watching and waiting to see if these kids will outgrow this behavior by the time they're four or five or 10. By then their behavior will be even more sociopathic; also, they'll do badly in school and won't have any friends. Even more important, they'll probably have parents who can hardly bear to be around them. If there is any chance of turning these kids around, it must be done in the early stages of the disease, before they've "progressed" from lying and shoplifting to a.s.sault and rape. Left untreated, these kids are at high risk for substance abuse, imprisonment, and death by unnatural causes.

PARENTING AND CD.

In my practice I meet a lot of unhappy, angry, embarra.s.sed, frustrated, helpless, hopeless, and overwhelmed parents. The ones who would take first prize in all categories were the mother and father of Edward, an 13-year-old boy being treated for conduct disorder. The parents adopted Edward at birth, and they had a few good years with their son, they said. By the age of three, however, Edward was already a terror. The parents, who are conscientious to a fault, looked for help right away, and over the years they had tried everything, including trials of medication, private schools, and family therapy. Still, a week doesn't go by without an alarmed phone call from Edward's teacher, saying that he beat up one of the other kids. The neighbors call too, to report that Edward stole the barbecue grill or urinated on the front lawn. Edward's parents are at their wits' end. They don't know what to do next.

I'd like to say that I was able to give them an easy solution to their problem, but that wouldn't be true. Treating conduct disorder, which Edward clearly had, is never easy. We treated Edward with Ritalin, and we started him in therapy; at 13 the child was a good candidate for the cognitive behavioral approach. We also added yet another element of this "team" approach to the treatment of CD: parent training, in which a therapist works with parents to help them understand the disorder and gives them strategies for making the other parts of the treatment more effective. Normally this means asking parents to learn how to discourage their child's negative behavior-temper outbursts, destructiveness, refusal to follow the rules, and so on-and to reward desirable, socially acceptable behavior. Punishments are nonviolent, of course, and usually involve the loss of privileges, such as watching television or playing outside. Rewards are stars and check marks that can be traded in for something a youngster particularly values. Parents must monitor their child's behavior regularly and stand ready to intervene promptly with either positive or negative reinforcement.

This is not as easy as it might sound. Kids with conduct disorder are tough tough, and parents should be prepared for a labor-intensive, time-consuming treatment. For these mothers and fathers there's no such thing as being "off duty." Frequently these children, when faced with new rules and regulations, become even more defiant, and that makes the training program even more challenging for even the most motivated, devoted parents. And the changes usually come a lot more slowly than anyone would like. In my experience the program takes at least a year.

CHAPTER 19.

Pervasive Developmental Disorder, Autism, and Asperger's Disorder Terry, 11 years old now and getting along quite well, has had developmental problems ever since he was two. He grunted and pointed, but he didn't speak, and his mother wasn't sure he understood what was being said to him. For a while his parents thought he was deaf, but they had him tested and discovered that his hearing was fine. He slept badly from the beginning too, and his behavior was always a little off. There were a lot of temper tantrums. When Terry wanted something, he couldn't express himself, so he'd throw things. He wasn't any good at throwing, either, even when he got older. His coordination was terrible. He couldn't run or throw a ball like the other kids. When he did eventually speak, he could barely be understood. At 11, Terry has been seeing various specialists for nearly nine years.

Clara, age three and a half, is a spectacularly beautiful little girl-big blue eyes, blonde hair, pink cheeks. The day I met her, her mother had dressed her up like a little doll. Clara didn't speak or make eye contact. According to her parents, she never did. She screamed, though. If she didn't get what she wanted right away, she would let loose the most bone-chilling shrieks, sometimes for hours at a time. Clara didn't interact with me the way a typical three-or four-year-old usually does. There was no connection between us. She wouldn't play. She didn't respond to, "Can you say h.e.l.lo?" or "Please pick up the doll." When I asked her to wave bye-bye, she stared right through me. I offered her a piece of candy, but she wasn't interested. Her parents say that all Clara will eat, literally, is food from McDonald's-a hamburger for breakfast, french fries for lunch, and another burger for dinner. Every morning they drive to the golden arches for Clara's daily rations.

Bobby is twenty years old and has been my patient since he was ten. His parents claim he was always an "odd duck" and he didn't seem to need people. Bobby had been in a special school program for many years, and he was doing quite well. Every day Bobby took a city bus to his school, and he never missed his stop. In fact, he had committed the entire bus system to memory. Bobby's IQ was 128-well above average-and his grades were quite good all the way through high school. After graduation, he found the perfect job: managing the flow of checks in a local bank. He had to take three buses to get to the bank-no problem whatsoever for Bobby, of course. He was absolutely terrific at his job. He never missed a day, and he never, ever made a mistake.

DEVELOPMENTAL DELAYS.

Most parents know a little something about the milestones of child development-when a child should walk, talk, use the toilet, and so forth. Many parents take these things for granted, not even realizing how fortunate they are to have children who are right where they should be, just like clockwork. Terry's, Clara's, and Bobby's parents don't have the luxury of such thoughts. Their children have pervasive developmental disorder, PDD. Terry's case is relatively mild; today he is quite high-functioning, and with continued work he will probably go to college and maybe even get married. Clara's prospects are not so bright. Clara has autism, the most severe form of PDD. With treatment and a lot of hard work she may well be able to hold a job of some sort, but it's unlikely that she'll ever be independent or have a family of her own. Bobby has Asperger's Disorder. He had no significant delay in his language or his cognitive development but always had social difficulties and repet.i.tive behaviors.

THE SYMPTOMS.

Regardless of the severity of the disorder, all kids with PDD have serious impairments in several areas of development, especially language and communications skills and social interactions. Sometimes physical coordination will be impaired and the child will exhibit strange behavior. The development may be uneven-a child will be strong in one area and very weak in another-but overall these kids are weak in many spheres of development. That's what makes this disorder pervasive. pervasive. Reports indicate that approximately 1 percent of the population has PDD; most people with PDD are diagnosed after the age of three. Reports indicate that approximately 1 percent of the population has PDD; most people with PDD are diagnosed after the age of three.

Autism is a very rare disorder (it occurs about five times in every 10,000 live births, with a boy-girl ratio of 4 to 1) but widely studied. Some say that there are more people doing research on autism than there are people who have have the disorder. People, not just psychiatrists and medical researchers, seem to be fascinated by this bizarre, inexplicable disease. Television shows and movies are filled with characters who have autism: a doctor's son on the disorder. People, not just psychiatrists and medical researchers, seem to be fascinated by this bizarre, inexplicable disease. Television shows and movies are filled with characters who have autism: a doctor's son on St. Elsewhere St. Elsewhere, a victim on Law and Order Law and Order, and, of course, the movie Rain Man. Rain Man. Most of them don't exactly conform to the facts of the disease, but the true symptoms of autism don't always make for good theater. Most of them don't exactly conform to the facts of the disease, but the true symptoms of autism don't always make for good theater.

Autism is a congenital disorder-that is, a child is born with it-characterized by severe impairment in the areas related to communication, social interaction, and the ability to use play and abstract thinking. The essence of autism is a lack of interest in people and a failure to appreciate and make use of the nuances of social interplay. Kids with autism don't respond to the subtle social cues that are obvious to most youngsters. A child with autism will know when his parents are very very angry or angry or very very happy, for example, but he's not able to detect anything in between. The difference between a grimace and a friendly smile of greeting will be lost on him, and voice inflections will mean little or nothing. Children with autism understand black and white, but they don't usually understand gray. Subtleties are wasted on them. happy, for example, but he's not able to detect anything in between. The difference between a grimace and a friendly smile of greeting will be lost on him, and voice inflections will mean little or nothing. Children with autism understand black and white, but they don't usually understand gray. Subtleties are wasted on them.

Language deficits are a major component of this disorder. Only half of all children with autism will develop functional speech. Children with autism commonly have echolalia, which is the repeating of the words or phrases they have heard. They misuse p.r.o.nouns and invent new words. The tone, pitch, accent, and cadence of their speech are abnormal. They have trouble sequencing sequencing (putting a story in order so that it makes sense) and (putting a story in order so that it makes sense) and encoding encoding (storing information that has an emotional component). About 75 percent of all children with autism are also mentally r.e.t.a.r.ded to some degree. The key difference between Asperger's disorder and other types of pervasive developmental disorder is language acquisition. Kids with Asperger's disorder have no significant delay in language: they have less echolalia and fewer p.r.o.noun reversals, and therefore initially may often not be identified as having a problem. (storing information that has an emotional component). About 75 percent of all children with autism are also mentally r.e.t.a.r.ded to some degree. The key difference between Asperger's disorder and other types of pervasive developmental disorder is language acquisition. Kids with Asperger's disorder have no significant delay in language: they have less echolalia and fewer p.r.o.noun reversals, and therefore initially may often not be identified as having a problem.

Children with autism may have strengths, though, especially in such skills as putting together puzzles or constructing objects. A very small number of people with autism-the Dustin Hoffman character in the movie Rain Man Rain Man, for instance, who was fantastic with numbers and had memorized all the statistics about airline accidents-have phenomenal abilities in particular areas, such as memory, calendar calculations, and art.

Many kids with PDD and especially autism have attentional problems and exhibit repet.i.tive behaviors. They may also be impulsive and hyperactive, often to the point of being self-destructive. I once treated a 14-year-old boy who would pick at his own skin until it bled. He'd also bang his head and his legs against brick walls until he'd break a bone or knock himself unconscious.

THE DIAGNOSIS.

When PDD is suspected, we concentrate on getting as much information as possible about a child's history, his behavior, and his abilities, looking to parents, teachers, and anyone else who has spent time with the child. Long-term baby-sitters, grandparents, and other relatives can sometimes be very valuable historians. In taking a history we pay special attention to delays and deviations from normal development, especially in the child's acquisition and use of language and his social interactions. We check the family medical history, looking for language or social communication difficulties, a neurological disease or psychiatric disorders, particularly PDD or autism. The child's pediatrician does a complete physical, including a neurological examination. Psychological testing can help in the diagnosis by giving us an a.s.sessment of the child's social skills, language skills, and intelligence. Children with PDD will have higher performance scores than verbal scores. Because of their relatively normal language development, kids with Asperger's disorder are diagnosed later than children with autism or PDD.

An official diagnosis of autism is rarely made until a child is 18 months old, but often the disorder can be detected much earlier. Autism can appear from birth all the way up to 30 months. Babies with autism don't make eye contact and don't even want to be held. Even in the crib they may show a tendency toward repet.i.tive actions. Other children will be fine in infancy but will start to show signs of autism later. Typically, they don't pick up language when they should. At age three or four children with autism will have significant delays in all developmental areas, especially language. They'll be unable to make distinctions between people and objects in their environment, and they won't get or give pleasure during social interactions.

What may at first seem like autism in a child may be developmental language delay; language problems often lead to problems in communication and in some social interaction. However, children with language delay, unlike those with autism, engage in imaginative play and usually have normal social interactions with their family and friends. They don't exhibit the same abnormal patterns of language as those typical among children with autism.

THE BRAIN CHEMISTRY.

PDD is a complex disorder that probably involves variations in the structure of the brain; that is, the brain was not put together correctly, so there are some chemical abnormalities, ones that will probably never be repaired. As I mentioned earlier, there have been many studies of autism, so most of the information we have about the causes of PDD have to do with its most severe form.

Twin studies support the belief that autism is genetic; the concordance rate of the disorder is 91 percent in identical twins and 0 percent in fraternal twins. Family studies reveal that if one child in a family has autism, the likelihood that his brother or sister will have the disorder is increased. Studies of the brains of children with autism indicate that there is something wrong with how the brain processes certain information, especially sounds and language. Neuroimaging techniques and autopsies show that there are abnormalities in the cerebellum.