It's Nobody's Fault_ New Hope And Help For Difficult Children And Their Parents Part 5

THE TREATMENT.

If a child diagnosed with SAD is in extraordinary distress, it may be advisable to medicate him right away, but behavioral therapy without medicine is usually the first line of attack against SAD. Sometimes behavioral therapy is all that's necessary; in a recent study 40 percent of the kids diagnosed with SAD were determined to be functioning quite well (although only about half were symptom-free) after four weeks of behavioral psychotherapy.

In behavioral therapy we concentrate on modifying the way a child acts under various circ.u.mstances, addressing both the child's separation anxiety and his antic.i.p.atory anxiety antic.i.p.atory anxiety-the worries he has about something that is going to happen. The goals are quite specific: for example, a child must sleep in his own bed, play with his friends, and, most important, go to school. He must not follow his mother from room to room or cry when he can't see her. He must allow a baby-sitter to care for him once in a while.

Therapists have tried many different ways of working with children to achieve these goals, but the one with which I have had the most success is the contract. This is a formal written agreement signed by the parents and the child and witnessed by me. To make it even more official, everyone gets a typed copy. (I've never gone so far as to get the doc.u.ments notarized, but I'd gladly do so if I thought I'd get better results.) To my way of thinking the contract offers a perfect way to let a child know what is expected of him, to rea.s.sure a child that there are things he can count on from his parents, and to reward him for positive behavior. What's more, if the child doesn't live up to his part of the bargain, we don't have to blame him. We can blame the contract.

Here are a few contracts I've drawn up.

"Jennifer agrees to go to bed by eight o'clock. She will stay in bed with the light on for 15 minutes. During this 15 minutes Mom will come three times to check on her. Jennifer will not leave the bed. At the end of 15 minutes Mom will turn off the light and Mom will continue to check on her every five minutes until Jennifer is asleep and twice after she's asleep. For every night that Jennifer does this, she gets a star. If she gets three stars, she gets a prize. If she gets five stars, she gets a prize and a half. With seven stars she gets two prizes." Jennifer traded in her stars for TV shows.

"Sara agrees to go to school every day. Sara will not cry during school or when Mom leaves. Sara will go to sleep without Mom or Dad in the room. Mom promises to take Sara to school and pick her up each day. Dad promises to tell Sara one five-minute story and will check on her every five minutes before she falls asleep and twice after she's asleep." Sara asked for tickets instead of stars. When she earned five tickets, she got a package of stickers.

"Roger agrees to go to bed quickly without complaining. Roger will stay in his own bed and not go to Mom and Dad's bed or his brother's bed during the night. Mom and Dad promise to let Roger keep his bedside light on. Roger can play or read quietly in bed." Roger used his stars to play video games.

"Cynthia agrees to stay in school from the beginning to the end of lunch. Two stars. She will not cry when she gets on the bus. One star. She agrees to stay with the baby-sitter on a weekend night, without Mom and Dad, for three hours. One star. Without crying, two stars. Going to bed before the parents come home, three stars." With 11 stars Cynthia may rent the video of her choice.

Obviously no one wants a child to fail-the last thing he needs is to feel worse about himself than he already does-so some contracts have to be especially easy and very specific, like the one I drew up for little eight-year-old Karen: "Karen agrees to brush her teeth, wash her face, and prepare for bed by eight o'clock. Karen will get into bed by 8:30 and turn off the lights by 8:45. Mom and Dad promise to let Karen watch TV until 8:30, tuck Karen in at 8:45, check on her every ten minutes till she's asleep. If Karen wakes up, she can call Mom. Mom promises to go to her room and sit in a chair for a few minutes." Once Karen has mastered these simple tasks, we'll draw up a more ambitious contract for her.

A few of my colleagues oppose the idea of attaching rewards to behavior with these contracts, but I'm in favor of them, provided they're not too lavish. Books, videos, baseball cards, doll clothes, or any other relatively small items that a child values make these kinds of contracts that much more effective. Rewards do a lot to increase a child's motivation, and children enjoy looking at their "trophies," tangible evidence of their accomplishments.

Behavioral therapy works relatively fast. If it doesn't work right away, it's probably not going to work, at least not without adding medication. To persist with this type of treatment without adding medicine becomes painful for the parents, the therapist, and, most of all, the child. If a child hasn't responded to behavioral therapy after about four weeks, it's probably time to add medication to the treatment. The drugs that have been used to best effect are Tofranil (a tricyclic antidepressant, or TCA), Luvox, Paxil, Prozac, and Zoloft (all selective serotonin reuptake inhibitors, or SSRIs), Xanax (an antianxiety agent), and Nardil and Parnate (monamine oxidase inhibitors, or MAOIs). All of these have been used to excellent effect, sometimes in a matter of days. One mother I know thinks that Prozac worked miracles, and she is not alone.

There can be negative side effects with some of these medications. Tofranil may cause dryness of mouth, constipation, and urinary retention, and there may be some behavioral disinhibition; children can become giddy or oppositional. Tofranil may also affect heart rhythm, so it's important for a child to have an electrocardiogram at the beginning and with each dose increase. Xanax, which treats antic.i.p.atory anxiety as well as separation anxiety, has no effect on the heart rhythm, but it may cause drowsiness and disinhibition in children. MAOIs carry dietary restrictions because the medicine may cause a reaction when taken with foods rich in a chemical called tyramine tyramine (aged cheese, red wine, beer, smoked fish, and aged meats). The SSRIs have the fewest side effects. When the dose of an SSRI is started low and increased slowly, there are few side effects. The most common ones are nausea, diarrhea, insomnia, and drowsiness. (aged cheese, red wine, beer, smoked fish, and aged meats). The SSRIs have the fewest side effects. When the dose of an SSRI is started low and increased slowly, there are few side effects. The most common ones are nausea, diarrhea, insomnia, and drowsiness.

Under normal circ.u.mstances the medication will take effect within six weeks. A child should continue to take the medicine for at least six months, at which time he should be taken off the medication-gradually, over a period of several weeks-and reevaluated. (I suggest that parents continue the contract policy during this time.) Some children taken off the medicine will redevelop their symptoms, in which case we gradually put them back on medication, enough to make the symptoms disappear; others will continue to be symptom-free without it. It is unlikely that a child will need medicine steadily for a very long period of time-more than a year-but many people diagnosed with SAD require medicine intermittently for many years.

SAD is a serious disorder, but the prognosis for someone with SAD who gets treated is excellent. Left untreated, however, SAD may damage a child permanently over time. If a child can't separate from his parents, he can't play with his friends or concentrate at school. If he avoids school, he will fall behind in his studies and lose ground academically, and that in turn will create another group of problems. He may become socially isolated, demoralized, even depressed. (Close to 50 percent of all adolescents who are clinically depressed also have an anxiety disorder. In 85 percent of the cases the anxiety disorder came first.) Twenty-year follow-up studies of children with SAD show that these children are at a higher risk for panic disorder as adults (like Eve, described a few pages back). Parents who don't take their child's distress about separation seriously and seek professional help are making a mistake.

PARENTING AND SAD.

"Either she's she's going into an inst.i.tution, or going into an inst.i.tution, or I'm I'm going into an inst.i.tution." going into an inst.i.tution."

Those are strong words, especially coming from a mother talking about her intelligent, sweet-faced six-year-old daughter, Melissa. But this, as I soon discovered, was no ordinary six-year-old; this little girl was afraid of just about everything, including loud noises, Hulk Hogan, Big Bird, and the cas.h.i.+er at the local supermarket. She couldn't look at a newspaper or magazine because she might see a disturbing picture. She became anxious if anything, even a sc.r.a.p of garbage, was thrown into the trash. At the gas station she was terrified if someone tried to put gas into the car. When she started kindergarten, her mother spent the first two months in the cla.s.sroom with her. By the time I met Melissa, she refused to leave her mother's side, even for a moment. She almost never smiled. It's no wonder her mother was at the end of her rope.

Eight-year-old Matthew was terrorizing his family too. He had been fine in the first and second grades, but starting with third grade he was having difficulty getting up and out in the morning. At the same time he began trailing his mother as she took out the trash, prepared meals, and made the family's beds. He stood outside the bathroom door until his mother came out, and he crept into his parents' bed nearly every night. When things were at their worst, Matthew was getting up in the middle of the night with a mirror to make sure his mother was breathing. He couldn't fall asleep unless his mother was sitting in the room. He always went to school-that's a firm rule in the family-but he was constantly in the nurse's office, complaining of headaches and stomachaches. When he got home, he called his dad and stayed on the phone with him for an hour, until Mom got home. Dad has taken to putting Matthew on the speaker phone while he goes about his work.

Another boy with SAD has a mother who is never without her beeper, not because of her work as a real estate broker but because her 13-year-old son must be able to call her a dozen times a day to make sure she hasn't been in an accident. She and her husband are invited to a variety of business functions and parties at night, but they've long since stopped accepting invitations. Too often they were called away after 15 minutes by a baby-sitter unable to cope with their hysterical son.

"We had no life," yet another mother once told me. "I turned down every invitation. My son couldn't go to birthday parties. It was too frightening for him. All those people! And what if there was a clown?"

Parents who haven't experienced SAD may find the concessions that these parents make, the way they change their lives to accommodate a child, almost unbelievable. Even parents who see their children suffering can't always believe there's something really wrong. Many kids with SAD don't voluntarily share their fears, so parents find it hard, if not impossible, to understand their child's behavior. The word "manipulative" is often used-when a child has a stomachache before school but feels fine when his parents suggest a ballgame or when he seems to play one parent against another, shadowing and clinging to Mom but behaving normally around Dad. The latter situation is quite common, and the typical scenario shows an overindulgent mom giving in more easily than a tough dad. Again typically, fathers become furious and blame mothers for coddling their kids; mothers in turn get angry and accuse fathers of not being sufficiently involved.

Parents' emotions are often tempered by personal experience too, of course. If one of the parents has had SAD, the reaction can go one of two ways. It's either "Oh, I remember. It was so horrible, and my parents were so strict with me. I would never do that to my own kid. I won't make my child suffer the way I did" or "I'm not going to give in to this. I won't let this affect my child the way it did me." Complicating matters further is the guilt that many parents feel as they see a child asking for nothing more than to be with them. They see a child in pain and are led to think that by being available they can make that pain go away. It's not surprising that many parents find it difficult to turn away from a needy child.

Family members don't always help. In fact, I've talked to many parents who find it easier to avoid family gatherings altogether than to put up with the disapproving looks or critical comments they receive from friends and relatives when their child misbehaves. One mother said that family gatherings were the occasions she dreaded most: "We hated holidays, but we were expected to attend, even though they all knew that Jon had problems. We would go, but we were so anxious, so on edge about Jon that we never sat down to chat with the family or eat a meal. We had to be with him every minute, or else he'd make a scene and tear the place apart. I think they all thought, 'That's why Jon's crazy. They never leave that poor kid alone.' I know they blamed us." why Jon's crazy. They never leave that poor kid alone.' I know they blamed us."

I suspect that this mother is not imagining her relatives' reactions. The world is full of people eager to express baseless, ill-considered opinions. One faction says, "This kid's a brat. The mother should be firmer, harder with this kid. What do you mean, he has a stomachache? There's nothing wrong with his stomach." The other side's take is different: "Why are you being so hard on the poor kid? The kid has a stomachache. All he wants is to be with you. That should make you feel wanted. If he doesn't want to go, he shouldn't have to."

Parents sometimes receive less than useful advice from other sources as well. I once saw a four-year-old girl, Kim, who developed SAD when she started nursery school. A lot of mothers stay with their children in nursery school for a couple of weeks, but Kim's mom stayed for four months. At that point Kim's father stepped in and said to his wife, "You can't do this anymore. You've got got to stop." The next morning, a snowy February day, the mother told Kim that she would be going to school on her own, and Kim got hysterical. When the car pool pulled up in front of the house, Mom took Kim outside, at which point the little girl took off all her clothes and started screaming. It must have made quite a picture: snow falling, driver honking, and a stark-naked child shrieking loud enough to shatter gla.s.s. Not surprisingly, her parents decided to seek professional help. to stop." The next morning, a snowy February day, the mother told Kim that she would be going to school on her own, and Kim got hysterical. When the car pool pulled up in front of the house, Mom took Kim outside, at which point the little girl took off all her clothes and started screaming. It must have made quite a picture: snow falling, driver honking, and a stark-naked child shrieking loud enough to shatter gla.s.s. Not surprisingly, her parents decided to seek professional help.

Unfortunately their problems didn't end there. The therapist told Kim's parents that Kim was acting out because of the recent birth of her baby sister and that all Kim really needed to get her through this difficult period was to be babied. "Give her a bottle and some dolls, hug her a lot more," the therapist said. By the time I saw Kim she could barely let her mother out of her sight without hysterics. After six weeks of behavioral therapy and a low daily dose of Zoloft she was attending school-fully clothed-without a problem.

Some aspects of the treatment of SAD are subject to debate, but everyone agrees on one thing: kids have have to go to school. Missing school is one of the few true psychological emergencies for a child, a major danger sign. The longer a child is out of school, the harder it is to get him back. Home tutoring is sometimes recommended, even by some school officials (who should know better), but I'm completely opposed to it. Having a tutor may relieve anxiety over the short term, but in the long term it makes things worse. The sooner a child returns to school the better, and parents who enlist the aid of the school in the process will get the best results. to go to school. Missing school is one of the few true psychological emergencies for a child, a major danger sign. The longer a child is out of school, the harder it is to get him back. Home tutoring is sometimes recommended, even by some school officials (who should know better), but I'm completely opposed to it. Having a tutor may relieve anxiety over the short term, but in the long term it makes things worse. The sooner a child returns to school the better, and parents who enlist the aid of the school in the process will get the best results.

If a child has been out of school for a long time, it's unfair to make him go for a whole day right away, so the teacher and princ.i.p.al should be notified that a child is going to need a more flexible schedule for a while. One mother I advised went to the princ.i.p.al and said, "Here's the deal. I want my kid back in school, but it's going to take time. The doctor says it's important to get him back slowly. The first week he's only going to stay an hour a day. For that hour I'd like him to stay in the library. The next week he'll stay for two hours a day, maybe with the guidance counselor or the school psychologist. After that I'd like him to go back to his cla.s.s." The princ.i.p.al agreed to help.

A child can be reintroduced to school even more gradually than that. Another little boy I treated took two weeks to get back to his regular cla.s.sroom. The first day all he did was walk in the front door of the building without his mother. Then he turned around and left. Each day he got a little closer. Again, the princ.i.p.al was more than eager to cooperate and made sure that the boy had the work he was missing to take home with him every day. It is the rare school official who takes a hard line about attendance when SAD has been diagnosed, although once in a great while a princ.i.p.al may insist that a child be "in or out." If that happens and simple reason doesn't prevail, the child's doctor should be able to help parents clear any hurdles erected by the school authorities.

In any successful treatment of SAD parents must be co-therapists, and that takes commitment, patience, and a structured plan. It's rarely easy. Checking on a child every 10 minutes in the evening after a full day's work is no parent's idea of fun, but the knowledge that next week it will be every 15 minutes and the week after that once every half-hour should provide some comfort. So should the prospect of going out to a movie or not not sharing a bed with a five-year-old every night. Efforts made today will pay dividends later, in the form of a healthy, well-rounded, happy child. sharing a bed with a five-year-old every night. Efforts made today will pay dividends later, in the form of a healthy, well-rounded, happy child.

CHAPTER 10.

Social Phobia/Shyness The day I first met Rebecca, 16 years old and just coming to the end of her junior year of high school, she had made herself so small that it looked as if she were trying to disappear into the woodwork of my office. I greeted her and asked her how she was feeling. There was no response. I tried again, but she said nothing. Finally, after I asked a third time, I got an answer. "I don't have any friends," she said in the softest voice I've ever heard, barely a whisper. "I can't talk to people." For Rebecca, that statement was practically the Gettysburg Address. As I discovered, she almost never talked to anyone. She didn't answer her teachers' questions in cla.s.s or chat with her cla.s.smates. When she used the school bathroom, she had to be alone; her one friend stood guard in the hallway outside the door to a.s.sure her complete privacy. She ate by herself in the school cafeteria. If someone joined her, she moved to another table and scattered papers and books around to discourage others. Then she hid behind a notebook while she ate. Rebecca had a number of other anxieties as well, each of which has an element of social concern. She worried that teachers would call on her in cla.s.s. Any kind of social interaction forced her anxiety level through the roof.

Ten-year-old Eric is in fifth grade. He's been in therapy since he was five, with three different therapists. The first diagnosis was separation anxiety disorder, because Eric was afraid to leave his house in the morning. Every day since kindergarten his parents had had a battle royal on their hands when they tried to get him ready for school. Extremely bright, Eric did well academically once he got to school, but socially he was having problems. He didn't have a single friend. If another kid tried to start up a conversation with him, Eric responded in monosyllables and retreated to a corner somewhere. The teachers tried to involve him in activities, but he was having none of it. He would talk to his teacher but only one-on-one, never in a cla.s.sroom setting. Eric was terrified that he was going to say or do something so stupid that it would make everybody hate him. If he stayed home, he reasoned, that wouldn't happen. By the time I met Eric, I had to make a house call. When I got there, he was hiding under his bed.

BEYOND SHYNESS.

"I was really shy as a kid. I was one of those youngsters who'd hide behind my mother's leg when my aunts came to visit."

"I'm okay in most social situations, but I don't really like them. I really have to push myself to talk to people."

"I hate hate parties. I never know what to say. I couldn't do it at all without a gla.s.s of wine." parties. I never know what to say. I couldn't do it at all without a gla.s.s of wine."

Everybody is shy some of the time. Meeting strangers, making a speech, being the guest of honor at a surprise party-those are not situations that most people consider relaxing. Some years ago it was reported that the three greatest fears of the American people are death, heights, and speaking in public. (In fact, speaking in public ranked higher than death!) Of course, some are more shy than others; they're usually the ones standing behind the potted plant hoping no one will spot them or over by the bar having a third c.o.c.ktail to loosen their tongue. Many people outgrow their shyness-by the time they're too big to hide behind Mom's leg when the aunts come to call, they don't feel the need to do it anymore-but others continue to be uneasy in specific situations. Shyness is a perfectly natural response to events, especially in children and adolescents. As long as it isn't excessive, as long as it doesn't seriously interfere with a child's ability to function, shyness is nothing to be particularly concerned about.

Obviously, Rebecca and Eric are not not functioning very well. Both children are suffering from social phobia, an anxiety disorder characterized by the persistent fear of being scrutinized and judged by others and of doing or saying something that will be humiliating or embarra.s.sing.Some children become so concerned that people will be critical of them that they become unable to speak, drink, or eat in front of other people. Others are afraid to use public toilets, not because they worry about hygiene but because they worry about doing something that will make them look bad. functioning very well. Both children are suffering from social phobia, an anxiety disorder characterized by the persistent fear of being scrutinized and judged by others and of doing or saying something that will be humiliating or embarra.s.sing.Some children become so concerned that people will be critical of them that they become unable to speak, drink, or eat in front of other people. Others are afraid to use public toilets, not because they worry about hygiene but because they worry about doing something that will make them look bad.

The key to this brain disorder is intense self-consciousness. Children with social phobia are basically afraid that they're going to do something the wrong way and consequently look foolish to others. They don't speak in cla.s.s because they're afraid they'll get the answer wrong or say it in a voice that will sound strange. They don't eat in public because they might spill their food or choke. They have trouble urinating in a public toilet if anyone is around. Children with social phobia believe that all these things (and many more) will make them seem stupid. They're afraid that people will mock them for their inadequacies.

Children and adolescents with social phobia have not lost touch with reality. When confronted with the force of logic, these kids will readily acknowledge that their fears and anxieties don't make a whole lot of sense. They know that they're being "silly," but they just can't help themselves.

The numbers on garden-variety shyness are astronomically high, but true social phobia is thought to be uncommon among young people, affecting about 1 percent of the child and adolescent population. (Recent studies have found that social phobia affects as many as 12 percent of all adults.) The symptoms of social phobia are usually noticed in adolescence, especially the mid-teens, but we have good reason to think that adolescence is not when the symptoms actually begin. Teenagers with social phobia often report a long history of painful shyness or social inhibition, but until their teens, they were able to cope. With the increased demands and expectations of adolescence-part-time jobs, interviews for college, dating, and other social pressures-come the distress and dysfunction that bring these kids to psychiatrists' offices. Even perfectly normal teenagers usually go through a patch of greater-than-average self-consciousness. Teenagers with social phobia go off the charts during these years.

Social phobia in very young children often is seen as a closely related disorder: selective mutism.

SELECTIVE MUTISM.

Lydia was an enchanting child-pretty, beautifully dressed, exceptionally bright. At the age of five she was already reading quite well. Her parents brought her to see me because most of the time Lydia did not speak. She could could speak. She talked to her parents and to her brother a little, and once in a while she spoke to her grandparents. She read aloud. But otherwise she didn't talk-even to respond to direct questions-and she never partic.i.p.ated in sharing or "show and tell" at school. Neighbors, relatives, schoolmates, and teachers had been expressing their concern and their irritation. Her teacher was worried about pa.s.sing her on from kindergarten to first grade. speak. She talked to her parents and to her brother a little, and once in a while she spoke to her grandparents. She read aloud. But otherwise she didn't talk-even to respond to direct questions-and she never partic.i.p.ated in sharing or "show and tell" at school. Neighbors, relatives, schoolmates, and teachers had been expressing their concern and their irritation. Her teacher was worried about pa.s.sing her on from kindergarten to first grade.

At nine years old Alice had been going to school for several years, but she hardly ever talked. She had one friend to whom she'd occasionally whisper. When she had no other choice but to speak to her teacher, she would get up close and speak softly into her ear. Alice's parents had been taking her for therapy for a couple of years. Every week for two years she'd go in and whisper to her therapist. The week before I saw Alice, the school had sent a letter home to the parents: "There's a real problem with Alice," it read. "We can't really evaluate what she knows and what she doesn't know. What's even more important is that Alice is incredibly uncomfortable all of the time."

A child's failure to speak-called selective mutism-has many possible explanations. It could be perfectly normal shyness; many five-year-old kids aren't crazy about chatting with strangers. It could be the result of a traumatic experience, such as physical or s.e.xual abuse, but that connection is very rare. It might be caused by a problem with language; there is a higher than average incidence of selective mutism among children of non-English-speaking parents and among kids who have a developmental speech delay or a learning disability. Children who stutter sometimes decide not even to try to speak.

The most common cause of a child's failure to speak is anxiety. Children who are selectively mute are, quite simply, too anxious and nervous to talk in front of others. For that and other reasons selective mutism (sometimes called elective mutism) elective mutism) may be regarded as a symptom, or at least a first cousin, of social phobia. may be regarded as a symptom, or at least a first cousin, of social phobia.

THE SYMPTOMS.

Social phobia is divided into two general types. Type one is generalized generalized, an anxiety marked by the avoidance of most daily social interactions. Eric, the child hiding under his bed, described at the beginning of this chapter, has the symptoms of generalized social phobia. Just about anything that involves other people makes Eric anxious.

Type two social phobia is characterized by discomfort in and the avoidance of specific specific situations, such as speaking in public, using public lavatories, and eating, writing, or speaking in front of others. (This is a form of pathological performance anxiety.) With type two, the phobia isn't generalized; in fact, there may be just one situation that brings on anxiety. A college student I treated a few years ago was normal except for his terrible fear of using a public bathroom. He eventually had to move out of the dorm and into his own apartment because of it. When we talked about it, all he could say by way of explanation was: "I'm afraid someone will walk in on me." A junior high school girl was fine too except for her fear of being called on in cla.s.s. "I have the feeling that I won't know the answer and I'll say something stupid," she told me. She would rather take a zero in cla.s.s partic.i.p.ation than respond to her teacher. situations, such as speaking in public, using public lavatories, and eating, writing, or speaking in front of others. (This is a form of pathological performance anxiety.) With type two, the phobia isn't generalized; in fact, there may be just one situation that brings on anxiety. A college student I treated a few years ago was normal except for his terrible fear of using a public bathroom. He eventually had to move out of the dorm and into his own apartment because of it. When we talked about it, all he could say by way of explanation was: "I'm afraid someone will walk in on me." A junior high school girl was fine too except for her fear of being called on in cla.s.s. "I have the feeling that I won't know the answer and I'll say something stupid," she told me. She would rather take a zero in cla.s.s partic.i.p.ation than respond to her teacher.

Communicating with some of these troubled children, especially the young ones, can be quite a problem. The difficulties with the kids who are selectively mute are obvious; we're lucky to get them to speak at all. I've interviewed a five-year-old who did nothing but grunt and moan in response to my questions. One of my colleagues is treating a little girl through her father; the father does all her talking for her. It's not at all unusual for these youngsters to have appointments and not show up. When the time comes to interact with a new person, they just can't do it. What's more, the very young children who do do show up and show up and do do speak are not skilled at articulating the distress and dysfunction a.s.sociated with social phobia. We're not likely to hear, for instance, any version of, "Doctor, I'm afraid to answer questions in cla.s.s because I'll be embarra.s.sed and humiliated by my peers" from a child with social phobia until he's well into adolescence, if then. speak are not skilled at articulating the distress and dysfunction a.s.sociated with social phobia. We're not likely to hear, for instance, any version of, "Doctor, I'm afraid to answer questions in cla.s.s because I'll be embarra.s.sed and humiliated by my peers" from a child with social phobia until he's well into adolescence, if then.

Even when the kids are in their teens and very smart, talking to them is often like pulling teeth. I was treating a 16-year-old boy who was on the cusp of being a genius. He had a very high IQ, and he was a whiz at math and computers. Socially, however, he was completely lost; the only people he could converse with were his sister and his mother.

When kids are capable of communicating, they may not be willing to communicate; they're reluctant to acknowledge, let alone describe the nature of, their symptoms. Many of them will dismiss symptoms as being nothing to worry about. An 18-year-old boy named Eugene was virtually dragged in to see me by his mother. He was finis.h.i.+ng the first semester of his freshman year away at college, and his mother thought-correctly in my estimation-that he was having some serious problems. He'd been quiet and withdrawn his whole life, she told me in front of her son, but this year he'd gotten worse. All alone in his new school, Eugene hadn't spoken to a soul in over a month.

For the first half-hour I couldn't get any response out of Eugene at all. Eventually he told me, haltingly and with no eye contact: "I don't know why my mother's making such a big deal out of this. So I don't speak in cla.s.s. So I don't talk to people. I just don't have anything to say."

Children later diagnosed with social phobia come to see me for three main reasons: they don't speak, they don't go to school, and they have no friends. In many cases these problems have existed for quite some time, but something has happened to make the situation intolerable. For example, one young woman's social phobia caused her to drop out of college. First she dropped an American history cla.s.s because she was asked to make an oral report. The moment she stood in front of the cla.s.s, she started sweating and felt light-headed. After reading only three lines of her report she had to sit down; she was sure she was going to faint. Then she dropped biology because of the lab work; it meant interacting with other people, and she just couldn't deal with it. She finally got so anxious that she dropped out of school completely. Other adolescents who have been suffering for some time may be brought in by their parents because they've started using drugs and alcohol to ease their anxiety. By the time they reach me, many young people with social phobia show symptoms of other related disorders. Studies show that some 50 percent of people with social phobia will have other anxiety disorders, and many others will eventually require treatment for depression.

THE DIAGNOSIS.

Making a diagnosis of generalized social phobia is not always easy. Sifting through the underbrush of family troubles, extraneous symptoms, and other facts that occasionally clutter up the diagnostic landscape can be quite challenging, particularly if the child has been sick for some time. Penny, a 16-year-old high school senior, came to me because her homeroom teacher told the parents that there was a problem. Penny was acting strange in cla.s.s-a little "nutty," her parents called it. According to the teacher, she almost never spoke in cla.s.s, but she would often giggle uncontrollably, sometimes so much that she disrupted the cla.s.s. (It's not unusual to hear complaints about the behavior or the att.i.tude of children with social phobia. Many of them, especially the young ones, come off as rude and defiant.) As I learned during our first visit, Penny had other symptoms as well: frequent urination, depressive complaints, and some anxieties. There were some conflicts at home too. Penny's parents were in the process of getting a divorce, and her sister was quite ill. It took me some time to explore the issues of anxiety with Penny, distracted as I was by the family crises. But when I did get her to talk about what she was worried about, I discovered that she was a ma.s.s of fears and anxieties. Even getting on the school bus every morning scared her. "I'm nervous about saying h.e.l.lo to the bus driver," she told me. "I might say it wrong and sound really stupid."

Symptoms related to social phobia must be carefully a.s.sessed before a diagnosis is made. Taking a history from the child himself is only the beginning. Besides, we can't always count on what the youngsters report, because they're usually nervous about making a bad impression-one of the key factors in social phobia. We make it a point to get a detailed history from the child's parents and teachers. Teachers are not always ideal sources of information either. Some children with social phobia are completely ignored by teachers. After all, they sit quietly-very quietly-in the back of the cla.s.sroom, not bothering anybody. They appear shy or withdrawn, as if they're watching the scene rather than partic.i.p.ating in it. Sometimes they're perceived as being stuck up or judgmental, but it's fear that keeps them from taking part in the action. They don't want to say or do anything that will get them into trouble. The disruptive disorders are the ones that usually get a teacher's attention. quietly-in the back of the cla.s.sroom, not bothering anybody. They appear shy or withdrawn, as if they're watching the scene rather than partic.i.p.ating in it. Sometimes they're perceived as being stuck up or judgmental, but it's fear that keeps them from taking part in the action. They don't want to say or do anything that will get them into trouble. The disruptive disorders are the ones that usually get a teacher's attention.

In making a diagnosis for social phobia we have to rule out other diseases with similar symptoms, especially separation anxiety disorder (described in Chapter 9 Chapter 9), obsessive compulsive disorder (Chapter 8), and generalized anxiety disorder (Chapter 11). Schizoid disorder must be ruled out as well. A teenager sits at the table at a large family holiday dinner. She doesn't socialize with her cousins or the other guests and leaves the table as quickly as possible. The behavior could be that of an adolescent with schizoid disorder, a chronic condition that may start in late adolescence and is characterized by detachment and limited interest in others, or these could be the actions of someone with schizophrenia (Chapter 16). If the girl is silent and withdrawn because she's convinced that she will say something stupid, she has social phobia. It's important to note that people with schizoid disorder are not uncomfortable or anxious in social situations; they just have peculiar interactions. In the case of schizophrenia the youngster will be anxious and nonresponsive with everyone, while the girl with social phobia may be a chatterbox with her parents once the dinner guests go home.

Another important distinction is in the patient's desire to get well. People with social phobia aren't comfortable with their disorder; they want to go to school, speak out in cla.s.s, and play with their friends. They'd like to go to a birthday party without being terrified of looking silly. They know they're in pain, and they want to feel better.

Psychiatrists look for-and frequently find-signs of depression (see Chapter 14 Chapter 14) a.s.sociated with social phobia. In the course of a recent study of adolescent depression it was discovered that 47 percent of the children with depression also had an anxiety disorder, most often either separation anxiety disorder or social phobia. Of those adolescents 84 percent had the anxiety disorder before before the depression. What the study did not say was whether the connection between anxiety disorders and depression is biological-that is, dictated by brain chemistry-or causal. Perhaps social phobia, and the social isolation it usually brings, contribute to depression. the depression. What the study did not say was whether the connection between anxiety disorders and depression is biological-that is, dictated by brain chemistry-or causal. Perhaps social phobia, and the social isolation it usually brings, contribute to depression.

Social phobia is underdiagnosed and undertreated. Parents often wait a long time-too long-before seeking professional help for their kids with social phobia. "He's just shy. He'll outgrow it," is their perfectly reasonable response. They resist going to a child psychologist or psychiatrist because they're afraid, quite naturally, to find out that their child's behavior is not quite normal. "We've waited six months. Let's wait a year." "We've waited a year. Let's wait another six months." So goes the typical reaction of parents who are faced with a child who is not getting better.

I encountered some parents who said exactly that for nearly three years while their daughter got progressively sicker. Rita was seven when I first saw her. For two years and nine months the only people Rita had spoken to were her mother, her grandmother, and two of her four siblings. She had barely said a word to her teacher or to any of her cla.s.smates since the first day of nursery school, but she'd recently started mouthing words to her teacher. In fact, this concerned teacher was the reason Rita finally made it to my office. At a recent parent-teacher conference she sat the mother and father down and told them to take Rita to see a professional or else. "We're very worried. You have to deal with this. You are neglecting your daughter," she said sternly. Mom brought Rita to see me, of course, but she didn't accept the teacher's a.s.sessment of the situation. "Rita's really much much better," said the mother. "She's mouthing words to her teacher now. And last week I think she whispered something to her cousin." Parents, feeling protective of their child, become defensive and may have a hard time accepting negative reports from the school. better," said the mother. "She's mouthing words to her teacher now. And last week I think she whispered something to her cousin." Parents, feeling protective of their child, become defensive and may have a hard time accepting negative reports from the school.

THE BRAIN CHEMISTRY.

Certain children are born with a genetic predisposition for social phobia. In plain English: excessive shyness runs in families. Supporting this theory is the fact that if one twin has social phobia, the other is more likely also to have it if he or she is an identical twin (with the same genetic makeup) rather than fraternal (with similar but not identical genes)-even if the twins are raised apart. Children adopted at an early age show a great similarity to their biological mothers on ratings of shyness. Parents of behaviorally inhibited children, kids who are fearful or withdrawn in new or unfamiliar situations are much more likely to have social phobia or to have had the disorder as children than are parents of normal or uninhibited youngsters.

What specific brain chemistry do children with social phobia have? As always, we can't be sure, but we can make an educated guess. Most probably the brain has too much norepinephrine and not enough serotonin. Certainly the effective medication for this disorder supports that theory. The medications that are most useful in the treatment of social phobia are the MAOIs (monamine oxidase inhibitors) and the SSRIs (selective serotonin reuptake inhibitors), both of which have an impact on norepinephrine and serotonin. TCAs (tricyclic antidepressants) have no effect on this disorder.

The animal model adds support to the argument. Studies done with rhesus monkeys have been able to identify two different behavioral styles-laid-back or uptight-and to determine that the uptight monkeys have a different brain chemistry from those who are laid-back. When given an SSRI, the uptight monkeys become more sociable and more comfortable, more like their laid-back fellow monkeys.

There's some evidence that with social phobia "nurture" plays a part as well as "nature." The basic a.s.sumption is that infants come into the world with a predisposition for anxiety. After that, any of several scenarios are possible. For example, a temperamentally inhibited infant is very reactive and hard to comfort, and a parent may find this distressing and be less attentive. The lack of attention affects the parent-child relations.h.i.+p, of course, and it may make the child insecure and less inclined later on to partic.i.p.ate in other social contacts. To take another example, a shy mother or father with a shy infant is less likely to expose that child to social situations, so the child never learns to be comfortable socially. His parent, not wanting to cause the child discomfort, continues to "protect" him from the outside world. In both of these examples the children, with limited social experience, become even more anxious.

THE TREATMENT.

A five-year-old boy being treated for selective mutism is making progress, but it's slow, very slow. So far the treatment has consisted only of behavioral therapy, mostly directed toward modifying the boy's behavior in school. His teacher is working with us on a program by which the child is rewarded with stars and stickers for communicating. The first step was a yes or no answer to a direct question. Step two required more than one word as an answer. Now, three months after the treatment began, there are lots of stars and plenty of stickers but no qualitative gains. The child is still uncomfortable and largely dysfunctional; his teacher said he looks pained all the time.

We give the boy a small dose of Prozac, much smaller than the customary dose-about a quarter of a teaspoon, or 5 milligrams, in liquid form from a dropper each day-and continue the therapy. Within a month the boy is communicating easily with everyone. "He became a different person almost immediately," his mother said. "He's talkative, he's friendly, and he feels at ease." Six months later we discontinued the Prozac, and the boy continued to be fine.

There's no such thing as a "good" brain disorder, but if there were, social phobia would be it. With active treatment social phobia can be cured. Behavioral therapy is an effective and necessary part of the treatment of social phobia, but because of the nature of the disorder-the patient is afraid to interact with and be judged by other people, including psychiatrists and psychologists-it is almost always a good idea for the child to be medicated as well. (Sometimes medication is all that a child with this disorder needs. I've seen it happen many times.) Medicine alleviates a child's anxiety so that he can benefit from the behavioral therapy. Most of the children we treat for selective mutism and social phobia simply couldn't do the work without the medication.

The first line of medication treatment used for children with social phobia and selective mutism is the SSRIs, specifically Prozac, Luvox, and Zoloft. With their minimal and infrequent side effects (occasional nausea, weight loss, restlessness, drowsiness, moodiness, and insomnia), these medicines are the drugs of choice. Also effective are the antianxiety agents, such as Klonopin, Xanax, and BuSpar. Klonopin and Xanax work fast and are quite effective in reducing the anxiety children experience before certain events. The most common side effect is drowsiness.

The MAOIs, especially Nardil, have been proven effective in treating adults with social phobia, but there are serious dietary restrictions attached to the MAOIs. When people taking MAOIs eat foods containing tyramine, a chemical found in aged cheese, red wine, beer, smoked fish, and aged meats, they may develop high blood pressure. Because of the difficulty in monitoring the diets of children and adolescents, this category of medication is rarely prescribed for them.

The category of medication most commonly prescribed for type two social phobia (pathological performance anxiety and anxiety in specific situations) is the beta blockers, especially Inderal and Tenormin. Beta blockers, which were originally developed for the treatment of high blood pressure, block the peripheral physical symptoms of anxiety, such as palpitations, tremors, and sweating. Teenagers with severe test anxiety have been treated very successfully with Inderal. One child I treated, David, age 12, hated tests. He had headaches for a few days before an exam and would awake with a terrible stomachache on the morning of the test. During the test his hands would sweat and his heart would race, but his thoughts were sluggish. He said his mind would just go blank sometimes. David's IQ was above average, and he knew the material, but he was nonetheless convinced that his teacher thought he was stupid. He just couldn't control his thoughts when he sat down in front of a test. On a low dose of Inderal he was able to take tests comfortably.

Beta blockers are usually taken an hour before any "performance," including tests, and only on an as-needed basis. Few side effects are experienced by youngsters taking these medicines, but a child's heart rate and blood pressure should be measured and an electrocardiogram done before he takes any beta blocker for the first time.

Certain medicines work well for particular kinds of anxiety but not for others. For instance, Xanax tends to relieve antic.i.p.atory anxiety-it keeps a patient from worrying in advance-but it's not recommended for performance anxiety, because it does tend to take away the edge that many performers say they need to do their best work. ("I want want that sharpness," a musician told me. "I want to be very clear-headed. I don't want any cloudiness when I'm onstage.") On the other hand, a small dose of Inderal can work wonders for performance anxiety. I treated a nine-year-old boy, a talented musician who could not perform. He'd get backstage and just freeze with panic. He'd sweat and feel light-headed. Eventually he developed a tremor. On a very low dose of Inderal taken an hour before a performance he became anxiety-free and was able to get up on stage and play, completely clear-headed. Not only does he feel less anxious, his teacher says he's also playing better than ever. that sharpness," a musician told me. "I want to be very clear-headed. I don't want any cloudiness when I'm onstage.") On the other hand, a small dose of Inderal can work wonders for performance anxiety. I treated a nine-year-old boy, a talented musician who could not perform. He'd get backstage and just freeze with panic. He'd sweat and feel light-headed. Eventually he developed a tremor. On a very low dose of Inderal taken an hour before a performance he became anxiety-free and was able to get up on stage and play, completely clear-headed. Not only does he feel less anxious, his teacher says he's also playing better than ever.

If a child begins a careful program of behavioral therapy at the same time he takes medication, there is a good chance that he won't have to take the medicine for very long. A 12-year-old boy I treated took 20 milligrams of Prozac a day for only six weeks, during which time he worked hard with a psychologist on improving his social skills. We started the treatment in late May. By July 1 he was ready to go away to camp, without his medication. He needed a lot of encouragement arid a fair amount of coaching, but he did it. What's more, his mother told me proudly, he made two friends the first day of camp.

While we're on the subject of medication, I should say that one of the major pitfalls a.s.sociated with social phobia in adolescents is self-medication; self-medication; these adolescents drink and take drugs to make themselves feel better. Many of them say that the only time they don't feel horrible is when they drink or smoke marijuana. However, when they sober up, they feel even worse than before. What's more, this self-medication inevitably escalates; as time pa.s.ses, it takes more alcohol and more marijuana to get that loose, relaxed feeling. these adolescents drink and take drugs to make themselves feel better. Many of them say that the only time they don't feel horrible is when they drink or smoke marijuana. However, when they sober up, they feel even worse than before. What's more, this self-medication inevitably escalates; as time pa.s.ses, it takes more alcohol and more marijuana to get that loose, relaxed feeling.

Behavior modification-learning how to act even after the medicine has been taken away-is the ultimate goal here. The social and coping skills that come naturally to most people must be consciously learned by children with social phobia, a process that requires time and a lot of effort. Most therapists begin by teaching the child some basic relaxation techniques to combat anxiety, especially deep breathing and progressive muscle relaxation. Visual imagery, the process by which a child pictures himself in a situation that scares him and then creates an image of himself working through it, is another basic treatment technique.

Children being treated for social phobia are given a.s.signments for behavioral changes, starting very small and working up to the big challenges. Parents are indispensable co-therapists in these efforts. "Okay. Talk to one person today. Just say h.e.l.lo," a mother might say to her daughter on Monday morning. On Tuesday it would be, "That was great. Now today I want you to talk to two people. And smile when you say h.e.l.lo." The a.s.signments escalate, and the child is gradually exposed to more social situations and made to feel more confident. Small rewards for completed a.s.signments will increase motivation. Stars, stickers, check marks on a calendar-all of these signs of success can be traded in for comic books, video rentals, half hours of television, or any other token or activity the child holds dear.

a.s.signments are great, but it's not enough to pat a child with social phobia on the head and send him out to have random conversations with the kids at school or the relatives at a family get-together. After all, children don't have a lot of experience with idle chit-chat. Kids need to be coached, and they need to rehea.r.s.e. "But what will I say? What should I talk about?" a "But what will I say? What should I talk about?" a child will want to know. Those are good questions. All of us, not just kids with social phobia, feel more relaxed if we know what's coming next and what we're supposed to do. child will want to know. Those are good questions. All of us, not just kids with social phobia, feel more relaxed if we know what's coming next and what we're supposed to do.

I remember helping Henry, a six-year-old who had been in treatment for social phobia for a couple of months, get ready for a day he was truly dreading: Thanksgiving dinner with his large extended family. He had no idea what he was going to say to these people, and he was scared to death. I asked the parents to find out who would be sitting on either side of Henry. Then we came up with three questions he could ask each of his dinner partners. His a.s.signment for the day was to ask those six questions and to answer any questions that were put to him. We even worked on answers to some of the more obvious questions: How is school? How old are you now? What do you want to be when you grow up? And finally, we rehea.r.s.ed Henry's good-bye and thanks to his grandmother. The little boy came through it beautifully. In fact, to hear his parents tell it, Henry's social skills were a lot better than those of his aunts and uncles.

It doesn't always go that smoothly, of course. Henry wasn't a terribly tough case. Children with especially severe social phobia will have to work long and hard before they dazzle the family over the turkey at Thanksgiving. Some never quite get there. It's not unusual for kids to freeze when the moment of truth arrives. "I knew I was supposed to say something, but I couldn't remember what," one little girl said sadly. "It all just went out of my head." But practice does does make perfect, and with the right medication combined with good coaching and rehearsal, reasonable a.s.signments, and a lot of parental support, a child will make progress. A change of scenery can make a big difference too. Kids with social phobia may be labeled at school or at camp or even at family gatherings-singled out as that "shy kid" or the one who "never says anything"-and labels are hard for anyone, especially children, to shake. make perfect, and with the right medication combined with good coaching and rehearsal, reasonable a.s.signments, and a lot of parental support, a child will make progress. A change of scenery can make a big difference too. Kids with social phobia may be labeled at school or at camp or even at family gatherings-singled out as that "shy kid" or the one who "never says anything"-and labels are hard for anyone, especially children, to shake.

Not surprisingly, group therapy sessions can be very useful for teaching social skills, since they replicate the social experience more closely than individual sessions do. One of the most interesting groups I know of was a.s.sembled by one of my colleagues, a psychologist. She invited three 11-year-old girls with social phobia to her office with the intention of doing some tests. What happened instead is that the girls somehow clicked. One of the girls was carrying a Baby-Sitters Club Baby-Sitters Club book, and the other two said they liked the series too. The next thing my colleague knew, they were talking among themselves, three preteens with social phobia. After discussion of the book, and the other two said they liked the series too. The next thing my colleague knew, they were talking among themselves, three preteens with social phobia. After discussion of the Baby-Sitters Club Baby-Sitters Club had been exhausted (none of them thought that the TV show was as good as the books), they needed coaching from the therapist. "Why don't you tell us about what happened when you went horseback riding?" she said to one. "Tell us about the new dress you got for your birthday," she told another. "What kind of costume will you be wearing for Halloween?" she asked the third. The responses were quite lively, and the session went surprisingly smoothly. The girls really seemed to understand one another. had been exhausted (none of them thought that the TV show was as good as the books), they needed coaching from the therapist. "Why don't you tell us about what happened when you went horseback riding?" she said to one. "Tell us about the new dress you got for your birthday," she told another. "What kind of costume will you be wearing for Halloween?" she asked the third. The responses were quite lively, and the session went surprisingly smoothly. The girls really seemed to understand one another.

When social phobia is treated promptly and aggressively, the prognosis is excellent. Left untreated, it may get worse, and it may have a negative impact on all important aspects of a child's life: school, work, and play. In all likelihood later on it will affect his job choice and performance and will hinder his ability to have a romantic relations.h.i.+p. It will have a lasting effect on self-esteem and may well result in alcohol and drug abuse.

PARENTING AND SOCIAL PHOBIA.

A few years ago I saw Michael, a very bright, handsome 18-year-old boy whose mother had died six months earlier after a long illness. It was a close family, and everyone took the mother's death very hard. Michael was clearly in terrible pain. Every time his mother's name up, he would start to cry, sometimes uncontrollably. The reason he finally came to me was that a few nights earlier, at a party with his friends, he got so upset that he went to the bathroom and started smas.h.i.+ng his fist against the wall. "I was. .h.i.tting the wall and crying about how much I miss my mother," he told me.

Michael had even more reason to miss his mother than his brothers and sisters did. Although it had never been diagnosed, Michael had social phobia-his symptoms were quite obvious even in our first session-and he had always been dependent on her for help in coping with the outside world. Probably without even being aware of it, the mother had coached Michael and rehea.r.s.ed with him. "I used to talk to my mother about how I was nervous about going to parties, and she would give me ideas about how to act. I could tell her anything," Michael said tearfully. She made his appointments, chose his cla.s.ses, and helped him schedule every detail of his life, including what he would wear to any important social occasion. The idea of life without her was devastating.

Behavior modification, with a strong emphasis on social skills training, calls for the informed a.s.sistance of the child's mother and father-or trainers trainers, as I like to think of them. Ideally Mom and Dad will help their child learn social skills by making a.s.signments, coaching, and rehearsing. Parental intervention is not always possible, however. Some parents just aren't temperamentally suited for the task of trainer. One type of parent who's likely to have a problem is the kind who's always asking kids for a progress report. "How did everything go? What did the teacher think of your paper? Did everyone like your new s.h.i.+rt? Did you make a lot of friends?" Those are not the sorts of questions that put a child with social phobia-who's overly concerned about being scrutinized and evaluated to begin with-at his ease. There's already far too much anxiety a.s.sociated with his social performance.

Other parents become too emotionally involved with a child's social success and consequently apply more pressure than the kid can manage. The unspoken message here is that a child's inability to handle himself in a social situation is a reflection on the parents. Such mothers and fathers inevitably communicate their disappointment or disapproval, and sometimes even their anger, to their child, and that only increases the poor kid's anxiety. To be truly helpful, parents must take the matter of social skills training seriously but not so seriously that it makes the child more nervous than he already is. A parent's goal should be to make a child feel more confident and secure. That may mean putting some emotional distance between parent and child.

"You don't understand. You have no idea what it's like to be shy," one of my patients with social phobia, a 10-year-old girl named Mary Ann, said to her father in my office one day. Mary Ann had a point. Her father, an extremely outgoing family lawyer, didn't show the remotest signs of social phobia. Not even a c.o.c.ktail party filled with strangers would scare this man. Of course, he wanted to understand and help his daughter, but trying to relate to a girl for whom the briefest conversation was a trial cannot have been easy for this natural extrovert. It's not necessarily easy if the parent does does understand what it's like to be shy. I treated a little girl with selective mutism whose mother found the child's disorder completely intolerable. She had no patience with it, and the child knew it. It turned out that Mom was painfully shy herself. understand what it's like to be shy. I treated a little girl with selective mutism whose mother found the child's disorder completely intolerable. She had no patience with it, and the child knew it. It turned out that Mom was painfully shy herself.

No matter how empathetic parents are-and no matter how skilled at advising and coaching their kids-there are plenty of children who simply won't let let their parents be their trainers. They'll take advice from a therapist or a teacher or a family friend, but not from their folks. There's not a great deal parents can do when they meet this kind of resistance, except to insist that the child work with their parents be their trainers. They'll take advice from a therapist or a teacher or a family friend, but not from their folks. There's not a great deal parents can do when they meet this kind of resistance, except to insist that the child work with someone someone who knows what he's doing. "Okay, if you don't want to rehea.r.s.e with Daddy and me, you have to talk to Aunt Laurie about it," a mother might say. The child needs training, regardless of who the trainer is. who knows what he's doing. "Okay, if you don't want to rehea.r.s.e with Daddy and me, you have to talk to Aunt Laurie a