It's Nobody's Fault_ New Hope And Help For Difficult Children And Their Parents Part 9

I later learned that there were very specific reasons for Ann-Marie's lack of eye contact and her hatred of the TV. Ann-Marie didn't want to look anyone in the eye because she was convinced she had special powers. She thought that if she looked directly at anyone, she would cause that person harm. In fact, she wouldn't even look in the mirror when she combed her hair, so frightened was she of what she might do. Her powers were so great they terrified her. She avoided the television because special messages were being broadcast to her through the TV. These facts combined with Ann-Marie's other symptoms led me to a diagnosis of bipolar disorder.

THE DIAGNOSIS.

"Are you sure sure this is manic-depressive illness?" a mother asked me. this is manic-depressive illness?" a mother asked me.

"Maybe I just have the world's most obnoxious teenager."

Bipolar disorder is a difficult diagnosis to accept. It's also not easy to make. There is no blood test or brain scan to aid the process. Furthermore, a lot of these troubled adolescents start medicating themselves-with alcohol, cocaine, marijuana, or Quaaludes. Drug and alcohol use clouds the diagnostic picture even more. In making a diagnosis we conduct a physical examination to rule out thyroid problems or drug abuse. Then we take a detailed history from the youngster, his parents, his teachers, and anyone else who knows him well. Along the way we look long and hard for a family history of depression, mania, schizophrenia, alcoholism, or drug addiction.

Bipolar disorder is especially difficult to diagnose in young children. Even very young children can have sleep disturbances, loud speech, and most of the other symptoms a.s.sociated with bipolar disorder, and they might also become suddenly oppositional. Of course, they're not likely to go on spending sprees or fly off to rock concerts. Their manic phase will probably look different from that of teenagers.

The most common symptoms of bipolar disorder in the very young are irritability, moodiness, talkativeness, hyperactivity, and distractibility -all symptoms for attention deficit hyperactivity disorder as well. A six-year-old child who is acting uncharacteristically silly or giddy may be doing so for any one of many reasons. The typical scenario is this: a first-grader who is sitting still in cla.s.s, concentrating on what the teacher is saying, suddenly jumps up out of her chair and starts giggling, pulling her dress up, and talking animatedly to everybody in the cla.s.s. Clearly she's out of control. Her behavior could be interpreted as ADHD, but she may also be showing signs of bipolar disorder. Children with bipolar disorder are more moody than kids with ADHD, and their activity is more focused. Furthermore, children with bipolar disorder may have hallucinations and delusions.

Nick, a 12-year-old boy who had been diagnosed (incorrectly) with ADHD, came to see me when his parents decided that his behavior was becoming more and more bizarre. The last straw was the hole he punched in his bedroom wall. Nick had been having problems at school for some time, refusing to study and often creating problems in cla.s.s. Lately he's been agitated, unmanageable, and out of control both at school and at home. His appet.i.te has decreased. He's been provocative and verbally abusive to his parents. When I met Nick, he told me that he hasn't been sleeping very well, and he's been having some crying spells. At night when he can't sleep he plays with a Ouija board, and he's convinced that he has powers that make the board talk to him. I diagnosed bipolar disorder and explained to the parents why their child didn't have ADHD. To begin with, Nick had not had any symptoms before the age of 12. The signs of ADHD must show up in early childhood.

Even when the child has reached adolescence, the diagnosis of bipolar disorder frequently comes via a long, circuitous route. Several related disorders must be ruled out along the way. One of the possible candidates is conduct disorder (described in Chapter 18 Chapter 18). Another is major depressive disorder, which is, of course, frequently one of the "poles" of bipolar disorder. Studies show that someone who experiences his first episode of depression in adolescence carries a 20 percent risk of developing a manic episode within three to four years. It is not uncommon to diagnose major depressive disorder and then, when the first manic episode finally occurs, to revise that diagnosis to bipolar disorder.

With teenagers the biggest diagnostic challenge is differentiating between bipolar disorder and schizophrenia (Chapter 16). The two illnesses have many characteristics in common. Like schizophrenia, bipolar disorder may be accompanied by psychosis. Kids with either of these diseases may lose touch with reality and have hallucinations and delusions. However, with bipolar disorder the delusion is usually a grandiose one, whereas with schizophrenia it is more likely to be simply bizarre. Debbie, a lovely, charming 17-year-old girl I treated for bipolar disorder, introduced herself at our first session as a famous supermodel and told me she had her own exercise show on television. When Debbie did her exercises in front of the mirror at home, she explained to me, her performance was transmitted through the mirror to a recording studio, which broadcast it on MTV. Schizophrenia was the first thing that came to mind when I heard Debbie's story, but once I focused on the grandiose nature of the delusion and the "coherence" of her story, I was inclined to go the other way.

Another difference between the two diseases is that bipolar disorder has mood swings-from mania to a normal mood or depression and back again-but schizophrenia doesn't. What's more, people with schizophrenia don't usually have a lot of energy or talk rapidly. Adolescents with bipolar disorder, unlike those with schizophrenia, have flight of ideas; flight of ideas; their thoughts and comments may be rapid and seemingly all over the place, but close examination will reveal that there is a connection between one thought and the next. (The lightning-fast comic routines of Robin Williams come to mind.) The thoughts a.s.sociated with schizophrenia are random and often disjointed-this is called their thoughts and comments may be rapid and seemingly all over the place, but close examination will reveal that there is a connection between one thought and the next. (The lightning-fast comic routines of Robin Williams come to mind.) The thoughts a.s.sociated with schizophrenia are random and often disjointed-this is called looseness of a.s.sociations. looseness of a.s.sociations. Despite all these differences, plus many more, distinguis.h.i.+ng the two disorders is a real challenge. Despite all these differences, plus many more, distinguis.h.i.+ng the two disorders is a real challenge.

THE BRAIN CHEMISTRY.

Bipolar disorder is genetic. Hardly a month goes by without a report in the scientific literature that the specific gene for this disorder is about to be identified. More than half of all people diagnosed with bipolar disorder have a relative who has either bipolar disorder or depression. If an identical twin has bipolar disease, the other will also have it 65 percent of the time; this occurs only 14 percent of the time with fraternal twins. Adoption studies add support to the genetic theory behind bipolar disorder; a child whose biological mother has bipolar disorder has a 31 percent chance of having the disorder even if he is adopted at birth; if his biological mother does not have bipolar disorder but his adoptive mother does, we're down to 2 percent.

Neuroimaging techniques have been performed on only a small number of youngsters with bipolar disorder, but preliminary findings suggest that the left and right sides of their brains are different in very specific ways. Neurotransmitter regulation is also believed to be abnormal in people with bipolar disorder. Excess dopamine and the disregulation of norepinephrine may cause manic episodes. Lithium, the medication most commonly prescribed for bipolar disorder, affects both dopamine and norepinephrine.

THE TREATMENT.

There is no known cure for bipolar disorder, but there is a fairly effective treatment: medication combined with supportive psychotherapy. The medicine of choice is Lithium, a natural salt that acts as a mood stabilizer. Lithium, which is occasionally used in children to treat aggressive outbursts, works in two ways: it treats a current episode of mania or depression, and, in 70 to 80 percent of all patients, it decreases the frequency and seventy of future episodes.

For many people Lithium is an honest-to-goodness miracle drug; it gives them back their lives. Of course, not everyone responds so dramatically to Lithium. I've had patients with bipolar disorder who take their Lithium faithfully, never missing a dose, and still have problems once in a while. Still others do just fine for a time and then have a "breakthrough" episode-the illness basically breaks through the Lithium. When that happens, we either adjust the dose of Lithium or recommend an additional medication.

Lithium treatment requires monitoring, especially in the first few months after the medication is prescribed. It is especially important to check people on Lithium when the temperature is high; hot weather and strenuous activity lead to dehydration, which increases the concentration of Lithium in the blood and may produce unpleasant side effects. Lithium may also suppress thyroid functioning, so we check the thyroid on a regular basis with a simple blood test. If thyroid functioning is being affected, it's easily treatable by adding a synthetic hormone. Lithium is so beneficial that most people prefer to take the additional synthetic thyroid hormone rather than discontinue the Lithium.

There are many potential side effects a.s.sociated with Lithium. The most common are acne, weight gain, increased thirst, frequent urination, nausea, and hand tremor. Having witnessed the side effects of many different drugs, my colleagues and I regard these as relatively benign-we call them "nuisance" side effects-but most adolescents would disagree. I've been put in my place more than once by an irate teenager who told me in no uncertain terms that having bad skin or being overweight is is a big deal. The hand tremor can be upsetting to these kids too, since it makes them look odd, something no child or teenager relishes. A 16-year-old patient of mine quit her job as a cas.h.i.+er after one day because the customers noticed that her hand was shaking as she gave them their change. All of these side effects can be minimized by adjusting the dose of Lithium, adding another medication that addresses the specific side effects, or both. a big deal. The hand tremor can be upsetting to these kids too, since it makes them look odd, something no child or teenager relishes. A 16-year-old patient of mine quit her job as a cas.h.i.+er after one day because the customers noticed that her hand was shaking as she gave them their change. All of these side effects can be minimized by adjusting the dose of Lithium, adding another medication that addresses the specific side effects, or both.

Another medication-related difficulty for teenagers is the inadvisability of drinking alcohol or taking drugs when being treated for a mood disorder. To my patients with bipolar disorder I strongly recommend moderation when it comes to alcohol and abstention from illicit drugs.

Because of the nature of Lithium-it is a mood stabilizer-kids and especially their parents often express concern about the effect the medication will have on the child's personality. "We want our son to be well, but we don't want to lose lose him," one mother said to me. "Will he still have that spark?" They worry that a child's emotions will be chemically regulated and that he'll end up bland and boring. That's not what happens. Lithium doesn't change the personality; it just prevents those undesirable extremes-mania and depression-from happening. A child on Lithium will still be upset if something bad happens and extremely joyful when there's something to be happy about. One of my colleagues likens the role of Lithium to regulating a thermostat. Most of the time the thermostat that controls our mood works just fine, but every now and then there's a little glitch and we go up too high or down too low. This salt, Lithium, helps our thermostat to function better. him," one mother said to me. "Will he still have that spark?" They worry that a child's emotions will be chemically regulated and that he'll end up bland and boring. That's not what happens. Lithium doesn't change the personality; it just prevents those undesirable extremes-mania and depression-from happening. A child on Lithium will still be upset if something bad happens and extremely joyful when there's something to be happy about. One of my colleagues likens the role of Lithium to regulating a thermostat. Most of the time the thermostat that controls our mood works just fine, but every now and then there's a little glitch and we go up too high or down too low. This salt, Lithium, helps our thermostat to function better.

Lithium is not the only medication recommended for the treatment of bipolar disorder. An anticonvulsant called Tegretol, another mood stabilizer, has also been used to good effect. A patient taking Tegretol has to be monitored too; we particularly look for a drop in the white blood cells, which fight infection, and an effect on the liver. (These side effects are uncommon but serious.) Depakote, another anticonvulsant, is also often prescribed for bipolar disorder. There are fewer side effects with this medicine than with either Lithium or Tegretol. The "nuisance" side effects are stomachache and nausea, but the major problem-which seems to occur only in very young children-is liver toxicity. Liver function should be checked regularly, particularly in the first six months a child or teenager takes the medication.

Not surprisingly, treating the two poles of this disorder-mania and depression-can be quite complicated, especially since antidepressants have been known to bring on a manic episode. That happened with a teenage girl I recently treated for major depressive disorder. The Zoloft she had been taking for her depression for nearly two years eventually brought on a manic episode. It's very important to remember that the antidepressant didn't cause cause her mania; that was there to begin with, and the episode was bound to happen some time. The medication just pushed her into the manic phase. (What's more, the mania didn't go away when the medication was stopped.) Some people with bipolar disorder require not just one medication but several working at once. For instance, antipsychotic agents such as Haldol may be given in conjunction with the mood stabilizer during the onset of the manic episode. her mania; that was there to begin with, and the episode was bound to happen some time. The medication just pushed her into the manic phase. (What's more, the mania didn't go away when the medication was stopped.) Some people with bipolar disorder require not just one medication but several working at once. For instance, antipsychotic agents such as Haldol may be given in conjunction with the mood stabilizer during the onset of the manic episode.

The biggest problem a.s.sociated with the treatment of bipolar disorder is getting kids to take their medication. Studies show that one-third of all adolescents stopped taking their Lithium within a year of its being prescribed. Patients never run out of reasons to stop taking their medicine. They start to feel normal, and they forget that it's the Lithium that's making the difference. Or they'll start to pine for that great feeling they used to have in the manic phase and decide to go for it again. Many kids deny that they are sick, so they stop taking the medicine to prove their point. Unfortunately, relapse rates are very high, and sometimes kids do not respond as fast or as well the second time medication is tried as they did the first time.

When it comes to the problem of noncompliance with medication, parents don't always help either. They mean well when they say things like, "There's nothing wrong with her. Maybe she shouldn't be taking medication" or "Let's experiment. Take him off the Lithium," but their refusal to accept the fact that it's the medicine that's making their kids better only makes the problem worse. It's hard to think of a youngster taking a mood stabilizer for a lifetime after only a single episode, I know, but parents need to understand that a serious disease-which bipolar disorder most a.s.suredly is-calls for serious treatment. Bipolar disorder is a treatable illness, but the only way the medicine can work is if the child takes it. Moms and dads who have doubts should know that more than 90 percent of adolescent manic patients who discontinue treatment for bipolar disorder will have a recurrence of the disease within 18 months.

In addition to medication we recommend psychotherapy for youngsters with bipolar disorder, and we encourage their families to join them. Therapy can help everyone concerned to understand the nature of this complicated illness and deal with the strong emotions that it brings to the surface. One patient with bipolar disorder I have been treating is a 16-year-old girl who blames her father, who also has bipolar disorder, for her disease. "He's never been any good, and now he's pa.s.sed on his lousy genes to me so I have to suffer," she said. The therapist can help her and her father understand the truth about the disease.

A therapist will help families deal with practical as well as emotional issues. They'll learn how to cope with the medication, how to detect the early signs of a relapse, and how to identify the stressors that might trigger an episode. For instance, a college student with bipolar disorder should know that pulling all-nighters to study can be dangerous, since a lack of sleep can precipitate a manic episode. Drinking and taking drugs may also act as triggers.

Bipolar disorder calls for prompt, active treatment. Severe mood changes and high-risk behaviors during a child's formative years may have lasting effects on his development. Left untreated, this dangerous disorder may lead to alcohol and drug abuse and even suicide. The suicide statistics for this disorder are staggering; some 15 percent of all patients with bipolar disorder commit suicide.

PARENTING AND BIPOLAR DISORDER.

Parents of children with bipolar disorder have their work cut out for them, and some are better at it than others. One set of parents I know nearly drove themselves to distraction looking for early signs that their son was having a relapse. They were constantly hovering, on the lookout for signs of mania. "One of us is always watching Lee. I'm afraid to go out at night any more. What if he goes haywire while I'm at the movies?" the mother said to me. The parents were obviously pa.s.sing along their anxiety to their son. Lee called me one afternoon without telling his mother and father. "I can't take it. I'd rather go back to the hospital," he told me. "If I laugh two seconds longer than anybody else, they think I'm manic. If I'm upset because I got a bad grade, they're worried I'm going to fall into a depression." It is important for parents to be knowledgeable about the disease and watchful for signs of a relapse, but it's equally important to keep surveillance efforts under control.

With bipolar disorder there are times when hospitalization is necessary. Kids who are very very distressed and distressed and very very dysfunctional may need the around-the-clock medical care and attention that only a hospital can provide. When a kid is not taking care of himself-not bathing or eating or sleeping-and he's in a severe state of mania, he needs medication and intensive supervision until he gets back on track. dysfunctional may need the around-the-clock medical care and attention that only a hospital can provide. When a kid is not taking care of himself-not bathing or eating or sleeping-and he's in a severe state of mania, he needs medication and intensive supervision until he gets back on track.

Many parents have difficulty accepting the behavior a.s.sociated with bipolar disorder as a real illness. Sharon's parents had always been very proud of their teenage daughter. Smart, outgoing, and funny, she had many friends, and all the parents in the neighborhood used to enjoy her company. Sharon was constantly being invited to her friends' homes for dinner or a sleepover date. All of a sudden things began to change. Sharon became obstreperous, disruptive, noisy, and very disrespectful to her elders. "She's turned into a real troublemaker," one of the neighbors told Sharon's mother. "I'm sorry, but we just don't want her over here anymore."

Unfortunately, Sharon's parents were not able to recognize how severely ill their daughter was. As a matter of fact, the father thought he could solve the problem himself. Convinced that Sharon was just being willful, he decided to punish her for her behavior. Needless to say, the punishment did not improve Sharon's demeanor or her behavior; if anything, her disease grew steadily worse. Her parents, finally realizing that they couldn't fix things for their child, brought her in to see me.

Most children being treated for bipolar disorder will need help regaining their confidence and self-esteem, especially after a manic episode. There's a good chance that children who go through a manic episode are severely embarra.s.sed by their behavior afterward, and even though they had no control over what they said or did, they may need to be forgiven by their families, their friends, their teachers, and even their doctors.

I'll never forget a girl I treated for bipolar disorder in the hospital several years ago. In the throes of a manic episode she was completely out of control, screaming curses and ethnic slurs at me and being s.e.xually provocative. We soon got her Lithium to the right level, and she was fine. In fact, she was a lovely girl, charming and good-humored. As she was leaving the hospital, I could see that she was in tremendous pain when she said good-bye to me. With tears in her eyes she said, "I can't stop thinking about the terrible things I said to you. I called you such awful names."

I told her not to give it another thought. "That was your illness talking, not you," I explained. What I told the girl was true, of course, but that didn't make the burden that she was carrying any less heavy. Understanding, sympathetic parents can do a lot to lessen a child's load of guilt and shame.

CHAPTER 16.

Schizophrenia The first time I met Thomas, he was 15 years old, and his parents had just about given up on him. According to Mom and Dad, Thomas had been a problem child for a long time; he was always acting "kind of weird," they said. A few days before I saw him, Thomas's school bus driver said the boy had "flipped out" and refused to get off the bus when they reached the school. A couple of teachers finally had to pull him off the bus and into the building. Thomas's parents had been trying to cope with their son's behavior by themselves for several long months, but the night before our meeting, he had crossed over the line. When Thomas's father came home after work, Thomas walked up to him and, without saying a word, punched him in the face, hard. The event could have been interpreted as typical adolescent conflict gone haywire, but after spending only a few moments with Thomas I realized that there was something a lot more serious going on. Thomas was hearing voices, and those voices told him that his father was out to get him. That's why he struck his dad. He couldn't get off the school bus because he was too frightened. The lights in his homeroom emitted rays that were controlling his mind.

Sixteen-year-old Miranda was transferred to my care from the emergency room of a nearby hospital. Miranda had gone to the ER by herself after school that afternoon because she wanted to have X rays taken. Miranda was convinced that there were rats living in her stomach, and she wanted proof. When Miranda's mother and father were called, they were horrified but not really surprised. They hadn't heard about the rats before, but they knew very well that Miranda sometimes saw and heard things that weren't there. She thought that the television was talking to her, and she had been communicating regularly with Marilyn Monroe and Elvis Presley; in fact, Marilyn had recently been telling Miranda not to bathe, change her clothes, or go to school. Recently Miranda had started to use drugs and hang out with a bad crowd.

THE REALITY TEST.

All children enjoy make-believe. One of the best pans of childhood is being able to pretend, to create fantasies and make up stories. Even imaginary playmates are acceptable under the right circ.u.mstances; they're part of the package of being a normal, well-adjusted kid. However, being controlled by rays from lights in the cla.s.sroom and taking orders from Marilyn Monroe-these are a far cry from the enchanting world of make-believe. They are the symptoms of a extremely serious brain disorder called schizophrenia.

Schizophrenia affects about 1 percent of the country's population. According to the National Inst.i.tutes of Mental Health, about a million people in this country are being treated for schizophrenia on an outpatient basis. In childhood the gender distributions of schizophrenia is marginally weighted toward boys, but by adolescence the female-male ratio is just about even. Among adults there are as many women diagnosed with schizophrenia as there are men.

Childhood onset schizophrenia-before the age of 12-is extremely uncommon. (The youngest patient I ever saw with diagnosed schizophrenia was a five-year-old girl named Deborah, who thought she had a baby caught in her throat.) The earlier the disorder shows itself, the more severe it will be. It is during adolescence, most commonly at about age 18, that schizophrenia is most often diagnosed. That's when a child is most likely to have his first break from reality. break from reality. The break is usually dramatic, and it can sometimes be quite sudden. I've spoken to parents who describe their child as perfectly normal one day and totally off the wall and out of control the next. (These are the parents who usually show up in the emergency room.) It's more common, however, to see a gradual decline in a child's behavior before the first big break, some early signs that trouble is on the way. The break is usually dramatic, and it can sometimes be quite sudden. I've spoken to parents who describe their child as perfectly normal one day and totally off the wall and out of control the next. (These are the parents who usually show up in the emergency room.) It's more common, however, to see a gradual decline in a child's behavior before the first big break, some early signs that trouble is on the way.

Children later diagnosed with schizophrenia fall into two broad categories. The first group is the childhood asocials; these are the withdrawn kids, the ones whose behavior has always been strange. "He never seemed quite right" and "She was always a little off are descriptions we commonly hear from the families of these children. There is a great deal of evidence to suggest that those families are correct in their not-very-scientific a.s.sessment. Some years ago an experiment was conducted with the home movies of the families of children who were eventually diagnosed with schizophrenia. In each case the families had more than one child, but only one of the kids had schizophrenia. With 100 percent accuracy the mental health professionals who viewed those old home movies could pick out the child with schizophrenia when he was only five or six years old. There was nothing specific about their findings. There was simply the sense that there was something "not quite normal" about the child in question, in the way he interacted with the other kids or with the camera. These youngsters are often aloof, not interested in socializing.

Not all children demonstrate those early signs of more serious disorders to come. The other basic group of people with schizophrenia is made up of kids who seem perfectly "normal" right up until the break. I myself had a childhood friend who belongs in this category. Mike had everything going for him; he was valedictorian of our cla.s.s, all-city tennis champion, and Mr. Popularity. His life seemed absolutely perfect until the September he went off to an Ivy League college, at age 18. Three weeks later he had his first break with reality; he was convinced that his room was under surveillance and that he was being monitored 24 hours a day by Martians. He was eventually diagnosed with schizophrenia.

THE SYMPTOMS.

Schizophrenia in children may be hard to recognize in its early stages. The child suffering from schizophrenia may have delusions delusions, fixed beliefs that other people don't have. He may have hallucinations hallucinations, hearing things that others don't hear and seeing things that others don't see. He may have difficulty distinguis.h.i.+ng dreams from reality. He'll have vivid and bizarre thoughts and ideas. He'll be moody, exhibit strange behavior, and withdraw from social interactions. Often he'll think that people are out to "get" him. He'll confuse television with real life, and he'll have problems making and keeping friends. To meet the official definition of schizophrenia the symptoms must persist for a period of six months. (If the symptoms have not been present for six months, we make an initial diagnosis of schizophreniform disorder. schizophreniform disorder. The treatment for this disorder is the same as that followed for schizophrenia.) The treatment for this disorder is the same as that followed for schizophrenia.) The delusions a.s.sociated with schizophrenia may take many forms. I've talked to a 15-year-old boy who thought that David Letterman was talking directly to him every night; another teenage boy who was so convinced that his parents were trying to poison him that he stopped eating; an 11-year-old girl who thought that her parents had been taken over by aliens; a 16-year-old girl who sat in the TV room of the hospital and watched her favorite soap opera, Another World Another World, completely convinced that the show was being performed just for her; and a 17-year-old who thinks that it's his his face on the dollar bill. I treated an 18-year-old teenage boy who believed the government was beaming poisonous rays down on his head that were making him bald and deaf. One day during a session with him I scratched my head, and he shouted, "I knew it! You're in on it!" It turns out that head-scratching was a sign that I was part of the government's plot against him. face on the dollar bill. I treated an 18-year-old teenage boy who believed the government was beaming poisonous rays down on his head that were making him bald and deaf. One day during a session with him I scratched my head, and he shouted, "I knew it! You're in on it!" It turns out that head-scratching was a sign that I was part of the government's plot against him.

All of these unfortunate children and adolescents have one important characteristic in common: they are living in a world of their own creation, and they believe in it totally, regardless of the efforts of others to bring them back to reality. The voices they hear become as real to them, and as important to them, as anything in the real world. For example, nothing anyone could do or say would persuade Miranda that rats are not not living in her stomach. We seriously considered giving her the X rays she asked for in the emergency room but decided against it. It would be pointless to show her an X ray of her stomach-without rats, of course. She would simply say that the rats had moved to her knee or that we had given her someone else's X rays by mistake. Reasoning or arguing with kids suffering from these kinds of delusions-saying, for example, "Don't you see? This just doesn't make sense"-is fruitless at best. living in her stomach. We seriously considered giving her the X rays she asked for in the emergency room but decided against it. It would be pointless to show her an X ray of her stomach-without rats, of course. She would simply say that the rats had moved to her knee or that we had given her someone else's X rays by mistake. Reasoning or arguing with kids suffering from these kinds of delusions-saying, for example, "Don't you see? This just doesn't make sense"-is fruitless at best.

Adolescents with schizophrenia at times exhibit bizarre and inappropriate behavior. One 16-year-old I talked to about his delusions (he thought that the FBI was following him) couldn't stop smiling and giggling as we talked. He seemed to be having a wonderful time.

People with schizophrenia have an explanation for everything, no matter how strange. One little girl, just starting the second grade, came to us because she heard voices that wouldn't stop. She used to walk around with her hands covering her ears, crying, "Make them stop! Make the voices stop! I can't stand it anymore." After a few weeks of Haldol the voices finally did stop, and she told us so. "Where did the voices go?" we asked her. "They went shopping," she replied.

There are two kinds of symptoms a.s.sociated with schizophrenia: positive and negative. The positive symptoms positive symptoms (called positive not because they're good but because they involve excessive distortion of normal function) include the delusions and hallucinations, which are relatively easy to identify. A 16-year-old girl who thinks she's a rock star whose video runs on MTV every night at midnight exhibits a positive symptom. The most common of the (called positive not because they're good but because they involve excessive distortion of normal function) include the delusions and hallucinations, which are relatively easy to identify. A 16-year-old girl who thinks she's a rock star whose video runs on MTV every night at midnight exhibits a positive symptom. The most common of the negative symptoms negative symptoms (negative because they involve loss of normal function) is withdrawal, demonstrated in kids who pull back from the world. These kids seem flat and distant; they don't initiate or respond to conversations; they're detached but not really depressed. Positive symptoms are easier to treat than negative symptoms. We can give medication to an adolescent and make his hallucinations and delusions go away. What we can't do quite so easily, even with medication, is motivate kids who sit in their rooms all day and watch television while the world pa.s.ses them by. (negative because they involve loss of normal function) is withdrawal, demonstrated in kids who pull back from the world. These kids seem flat and distant; they don't initiate or respond to conversations; they're detached but not really depressed. Positive symptoms are easier to treat than negative symptoms. We can give medication to an adolescent and make his hallucinations and delusions go away. What we can't do quite so easily, even with medication, is motivate kids who sit in their rooms all day and watch television while the world pa.s.ses them by.

Some of the symptoms we see in examining schizophrenia may seriously endanger a child. One of the saddest cases I've come across was that of a seven-year-old boy who was admitted to our unit with severe burns on his abdomen. The little boy had been burning himself with his father's cigarette lighter. When we asked him why he did it, he said, without blinking an eye, that the voices told him he had to.

THE DIAGNOSIS.

It is not particularly difficult to identify a symptom of psychosis, but identifying the symptom is not enough. To make a proper diagnosis-to find out precisely what is wrong with a child or an adolescent-we have to know more about the company that symptom keeps. Symptoms of psychosis may have many causes, including drug abuse and extreme stress. A psychotic symptom is like a headache. It can be caused by an allergy or a simple infection. Or it can be the result of something considerably worse. Kids, especially teenagers, may be guarded or even deceptive about their symptoms, and this complicates the process of making a diagnosis even further.

In the early stages of this disorder, just after the first or perhaps the second episode, it can still be quite difficult to pinpoint the problem. As the disease progresses, the symptom picture usually becomes a lot clearer, and we can be more precise. Bipolar disorder (Chapter 15), major depressive disorder (Chapter 14), pervasive developmental disorder (Chapter 19), and obsessive compulsive disorder (Chapter 8) are just some of the diseases that must be ruled out. Because of the serious and complicated nature of schizophrenia, it is crucial that a correct diagnosis be made, ideally by a child and adolescent psychiatrist with experience in dealing with severely ill youngsters.

In examining a child or an adolescent who shows symptoms a.s.sociated with schizophrenia (especially delusions and hallucinations) we have to rule out some of the other disorders that have similar symptoms. Psychotic symptoms can be categorized as mood congruent mood congruent or or mood incongruent. mood incongruent. Quite simply, the mood congruent symptoms make a little more sense than the mood incongruent ones, because they correspond to the mood of the patient. For instance, if the youngster has depression with psychotic symptoms, his delusions or hallucinations will have a tone that is consistent with being depressed. For example, he'll think he has a terminal illness and is going to die. If he hears voices, they'll say something along the lines of, "You're no good. You've never been good. You never will be good. You must be punished." If an adolescent is manic, his mood congruent symptoms will echo that mood, telling him that he's a world-famous sports hero or a millionaire with superpowers. On the other hand, adolescents with schizophrenia will have symptoms that are mood incongruent; they have no relations.h.i.+p to their mood or to reality. Quite simply, the mood congruent symptoms make a little more sense than the mood incongruent ones, because they correspond to the mood of the patient. For instance, if the youngster has depression with psychotic symptoms, his delusions or hallucinations will have a tone that is consistent with being depressed. For example, he'll think he has a terminal illness and is going to die. If he hears voices, they'll say something along the lines of, "You're no good. You've never been good. You never will be good. You must be punished." If an adolescent is manic, his mood congruent symptoms will echo that mood, telling him that he's a world-famous sports hero or a millionaire with superpowers. On the other hand, adolescents with schizophrenia will have symptoms that are mood incongruent; they have no relations.h.i.+p to their mood or to reality.

Someone with bipolar disorder will have flight of ideas flight of ideas in his speech; he moves quickly from idea to idea, but there will be a connection between those ideas, however tenuous. The ideas of someone with schizophrenia are completely disjointed, characterized by "looseness of a.s.sociations." The conversation of someone with schizophrenia in its most extreme form is incomprehensible; we call it "word salad." Words just come spilling out, and no one can understand them. More often than not, the patient isn't even aware that he's not making sense. in his speech; he moves quickly from idea to idea, but there will be a connection between those ideas, however tenuous. The ideas of someone with schizophrenia are completely disjointed, characterized by "looseness of a.s.sociations." The conversation of someone with schizophrenia in its most extreme form is incomprehensible; we call it "word salad." Words just come spilling out, and no one can understand them. More often than not, the patient isn't even aware that he's not making sense.

People who have schizophrenia are usually frightened and confused. I've examined kids who heard voices and had imaginary companions but weren't afraid of them or impaired by them. One boy I remember in particular, five years old, was able to exercise full control over his invisible friends. They did exactly what he told them to do. Another kid, this one age seven, had voices who helped him with his homework. He said to me: "Oh, I like this voice. He gives me the answers on my test." It's developmentally normal for kids to hear voices and have imaginary playmates. Neither of these children was diagnosed with schizophrenia.

Adolescents with schizophrenia do not not have that control over the voices, and they don't like them. They're the kids who say, "The voice is telling me to do something I don't want to do. If I don't do it, it's going to make me do something even worse." They are deluded, but their fear is very real. Often they're afraid to eat, to sleep, or to walk down the street. They have belief systems that are personal and often painful. They're tortured by their symptoms. Children and adolescents with schizophrenia are often in great pain. have that control over the voices, and they don't like them. They're the kids who say, "The voice is telling me to do something I don't want to do. If I don't do it, it's going to make me do something even worse." They are deluded, but their fear is very real. Often they're afraid to eat, to sleep, or to walk down the street. They have belief systems that are personal and often painful. They're tortured by their symptoms. Children and adolescents with schizophrenia are often in great pain.

A diagnosis of schizophrenia is not easy for a physician to give or for a parent to hear, and no one is inclined to use the term lightly. A correct diagnosis is essential. One of the most significant criteria for a diagnosis of schizophrenia is "deterioration with no return to baseline," which means that even with treatment, the patient's condition is unlikely to get better over time. In fact, as time goes on and the number of episodes increases, a youngster's level of function may become lower. In the case of childhood onset schizophrenia a child will probably fail to reach the expected developmental milestones. Adolescence is a critical period for the acquisition of vocational skills. New learning is difficult for young people with schizophrenia. An adolescent who used to be able to drive a car before the "break" will most likely be able to drive again; however, an adolescent who didn't learn to drive before the illness will find the new task very difficult indeed.

One set of parents I know refused even to say the word schizophrenia. schizophrenia. They insisted on calling what was wrong with their son "an anxiety disorder" or "a psychotic problem." At 16 their son Rick had his first psychotic episode when he was away at summer camp. He thought that people were out to get him, that his food was being poisoned, that his camp counselor was interested in having s.e.x with him. Rick became increasingly agitated at camp, and his parents were finally summoned to take him home. Rick's diagnosis was schizophrenia, and he started taking Haldol right away. It took his parents nearly a year to use the correct word. They insisted on calling what was wrong with their son "an anxiety disorder" or "a psychotic problem." At 16 their son Rick had his first psychotic episode when he was away at summer camp. He thought that people were out to get him, that his food was being poisoned, that his camp counselor was interested in having s.e.x with him. Rick became increasingly agitated at camp, and his parents were finally summoned to take him home. Rick's diagnosis was schizophrenia, and he started taking Haldol right away. It took his parents nearly a year to use the correct word.

I can't really blame those parents for their reluctance to acknowledge that their boy had schizophrenia. There's no way around the fact that schizophrenia is an extremely distressing diagnosis. Still, for all the pain and disappointment the news may bring, the sooner the diagnosis is made, the sooner the treatment can begin.

THE BRAIN CHEMISTRY.

There's no doubt about it: schizophrenia is the result of a malfunction in the brain. However, what causes the brain to malfunction is still a largely unanswered question. According to the most recent studies, there are many underlying influences of schizophrenia, some of them genetic and some environmental.

We know quite a bit about the genetic influences a.s.sociated with schizophrenia. For example, we know that the first-degree relatives-offspring and siblings-of people with schizophrenia have 10 times greater likelihood of developing the disorder themselves. We also know that the concordance rate of schizophrenia in identical twins is 50 percent, as opposed to 10 percent in fraternal twins. (Among identical twins reared apart from each other in separate families, the concordance rate is still extremely strong.) Other research shows that when a mother with schizophrenia adopted a child who was not genetically predisposed to the disorder, the child did not develop schizophrenia, no matter how crazy or disturbed the adoptive mother was.

Obviously, this disorder has a strong biological component, but just as obviously, schizophrenia is not always pa.s.sed on from generation to generation. Plenty of cases are sporadic, and many theories have been advanced to explain them. Some say it's caused by a virus. Others say it must be the result of a genetic mutation or a neurodevelopmental delay. Evidence for the genetic mutation theory is supported by the fact that adults with schizophrenia do not reproduce as often as the general population, yet the prevalence of the disorder remains constant.

We have benefited a good deal from knowing something about what the brain of an adult adult with schizophrenia looks like. Brain scans-both CAT scans and MRIs-of adult patients show that the brain of someone with schizophrenia looks different from that of a "normal" adult. There are several differences, but the most telling are the enlarged cerebral ventricles and the diminished activity of the prefrontal cortex in the brains of people who have schizophrenia and the fact that the overall brain volume of adults with schizophrenia is 8 percent smaller than that of normal adults. There are studies in progress now that will tell us more about the brains of children and adolescents with schizophrenia, but early findings suggest that the same kinds of brain discrepancies will be found. with schizophrenia looks like. Brain scans-both CAT scans and MRIs-of adult patients show that the brain of someone with schizophrenia looks different from that of a "normal" adult. There are several differences, but the most telling are the enlarged cerebral ventricles and the diminished activity of the prefrontal cortex in the brains of people who have schizophrenia and the fact that the overall brain volume of adults with schizophrenia is 8 percent smaller than that of normal adults. There are studies in progress now that will tell us more about the brains of children and adolescents with schizophrenia, but early findings suggest that the same kinds of brain discrepancies will be found.

These days the most widely held theory about what causes the psychotic symptoms of schizophrenia is too much dopamine too much dopamine in the brain. One of the facts supporting this case is that drugs that increase the brain's level of dopamine, such as cocaine and amphetamines, may bring on psychosis; certainly they can mimic some of the psychotic symptoms. Another reason to take this theory seriously is the fact that all the medications that reduce the symptoms of schizophrenia have some effect on the dopamine system. As usual, nothing is simple about this area of research, however. The drugs that seem to work best-especially Risperdal-affect other neurotransmitters as well, especially serotonin. in the brain. One of the facts supporting this case is that drugs that increase the brain's level of dopamine, such as cocaine and amphetamines, may bring on psychosis; certainly they can mimic some of the psychotic symptoms. Another reason to take this theory seriously is the fact that all the medications that reduce the symptoms of schizophrenia have some effect on the dopamine system. As usual, nothing is simple about this area of research, however. The drugs that seem to work best-especially Risperdal-affect other neurotransmitters as well, especially serotonin.

THE TREATMENT.

Treatment for schizophrenia should ideally include family support and education, social skills training and other behavioral therapy, vocational rehabilitation, and, eventually, supervised housing, all of which will make the adolescent with schizophrenia and his family more comfortable and better able to cope with this serious illness. But before any of these efforts can be put into motion, the first and most effective line of treatment is medication. medication. The only treatment that has any marked effect on the symptoms a.s.sociated with this disorder is medicine. The only treatment that has any marked effect on the symptoms a.s.sociated with this disorder is medicine.

The drugs traditionally prescribed for the treatment of schizophrenia are the neuroleptics neuroleptics, which are divided into two categories: high-potency neuroleptics, such as Haldol and Prolixin; and low-potency neuroleptics, of which the most commonly prescribed are Thorazine and Mellaril. The medicines are equally effective in the treatment of the symptoms of schizophrenia, but they have different side effects. The low-potency neuroleptics may cause low blood pressure, dry mouth, blurred vision, lethargy, constipation, and weight gain. The side effects of the high-potency neuroleptics sometimes cause "pseudo-Parkinsonism," restlessness, weight gain, and acute dystonic reactions (muscle spasms). Dystonic reactions may be frightening to patients and family members, but they are easily reversed with an injection of the antihistamine Benadryl.

The most disturbing side effect a.s.sociated with long-term use of neuroleptics is tardive dyskinesia, in which various parts of the body-especially the tongue, the facial muscles, and the arms and legs-wriggle and writhe involuntarily. Tardive dyskinesia ranges from very mild to quite severe. The most serious concern about tardive dyskinesia is that it can be permanent. The other side effects a.s.sociated with the neuroleptics will disappear quite quickly if the medication is stopped. Tardive dyskinesia doesn't always go away even if the drug is discontinued. The more neuroleptic medication the adolescent takes over time, the greater is his risk of developing tardive dyskinesia. However, if the medication is stopped too soon-because of the patient's noncompliance, for example-the likelihood of a return of the psychotic symptoms increases. This often means that the adolescent will need larger doses for each new episode, which in turn increases his chances of developing tardive dyskinesia.

In the late 1980s a new antipsychotic medicine, clozapine (brand name Clozaril), was introduced for the treatment of schizophrenia. The good news: Clozaril has proven to be very effective, even on particularly resistant, hard-to-treat cases of schizophrenia. There are fewer side effects with Clozaril than with Haldol; and Clozaril is less likely than Haldol to bring on tardive dyskinesia. The bad news is that Clozaril may cause the white blood cell count to drop, sometimes dangerously. Anyone who is taking Clozaril must have his blood monitored closely.

Another promising newcomer in the treatment of schizophrenia is the antipsychotic risperidone (brand name Risperdal). Like Clozaril, Risperdal has fewer side effects than the neuroleptics and seems less likely to cause tardive dyskinesia. Over the next few years there will undoubtedly be many other new entrants in this area of pharmacology.

Children and adolescents diagnosed with schizophrenia respond quite well to low doses of antipsychotic medication, especially if they're treated promptly. One study showed an 80 percent response rate in children between the ages of five and 12. The longer someone diagnosed with schizophrenia goes without treatment, the less likely he is to get rid of all his symptoms when help does finally come. A child who has been sick for six months is probably less likely to respond to treatment than one who has been sick for a month.

One of the most serious problems a.s.sociated with schizophrenia has to do with the fact that people being treated for the disorder have a tendency to discontinue their medication. For example, a patient who hears voices will take his medicine, the voices will go away, and he'll decide that he feels fine. If he feels fine, then why, he wonders, should he bother to take his medicine anymore? So he goes off the medicine, and the voices come back.

Going on and off the medication makes the problem even worse than it already is. Studies show that this disease progresses with each psychotic episode. The more often the medication is discontinued, the less effective it is the next time it's taken. There's an 80 percent response rate in people with schizophrenia who are given medication after their first break. By the time patients have reached the fourth or fifth episode, the response rate drops to about 70 percent. With ensuing episodes, the response continues to drop. The higher the number of episodes, the worse a patient feels and the less effective the treatment becomes.

For best results someone diagnosed with schizophrenia should take his medicine without interruption. (The best way for parents to encourage their youngsters to keep taking their medication is to believe wholeheartedly, and without ambivalence, that it is the right thing to do.) Sticking with medication has become a lot easier recently, since some neuroleptics, including Haldol, now come in injectable form. One injection is good for 30 days. Unfortunately, that means that side effects last for 30 days too, so great care has to be taken with dosages. There is a good chance that people diagnosed with schizophrenia will have to take medication for the rest of their lives. Since the average age of onset of schizophrenia is about 18, that could mean 60 or more years of medication-a daunting prospect to even the most stalwart of parents. There's all the more reason, then, for families to be aware and informed about what the medication can and cannot do and what the side effects are likely to be and to make sure that their child's progress is closely monitored. An essential component of the treatment of schizophrenia is management. In recent years there have been great advances in the long-term management of this disorder, which usually includes rehabilitation and occupational therapy.

The prognosis for childhood onset schizophrenia has not been well studied, but we know something about the outlook for adults and adolescents. We know, for instance, that the earlier the onset of the disorder is, the poorer the prognosis will be. In some rare cases there is full remission, but "deterioration with no return to baseline" is the more likely prospect. What's more, most people with schizophrenia are not going to be high achievers after the disorder has struck, not even the ones who started out as valedictorians of their cla.s.s. The typical person with schizophrenia is unlikely to hold a significant job or to maintain a marriage or any other successful long-term relations.h.i.+p. Women with schizophrenia have been more likely than men to get married and have children, but there is no question that a severe relapsing disorder impairs a person's ability to interact with others. Not surprisingly perhaps, some 25 to 50 percent of all people with schizophrenia will abuse drugs or alcohol, and there is a very high suicide rate attached to the disease, the highest of all the psychiatric disorders. According to recent studies, 35 percent of all people diagnosed with schizophrenia will attempt or will seriously consider suicide at some time. About 15 percent of all people with schizophrenia will commit suicide.

PARENTING AND SCHIZOPHRENIA.

The parents of Deborah, the five-year-old girl who thought she had a baby living in her throat, thought at first that their daughter's illness was their fault. They had just had a second child, and they were sure that the new baby was upsetting their older daughter and making her feel unloved. "She wasn't ready to share the limelight. I'm sure she'll be okay if we just pay more attention to her," Deborah's mother said.

Geoffrey's parents also blamed themselves for what happened to their son. Geoffrey, a seemingly healthy, happy, overachieving young man, went off to Harvard in September. His goal: a bachelor of arts degree and then law school. By November of his freshman year he was back home with his parents, being treated for schizophrenia. "I'm sure it's because we pushed him too hard," his father told me. "He was doing fine."

"And he would have stayed fine if he'd gone to City College," his mother added. "Why did we make him go to a high-pressure university like Harvard?"

So many parents reproach themselves for things they could have done and should have done. "I should have seen this coming," they'll say. "Remember how quiet he was, even back in third grade? I should have known something was wrong. If I'd done something about it then, this never would have happened."

It's not hard to understand why Deborah's and Geoffrey's parents and just about all other parents of children with schizophrenia feel the way they do. Schizophrenia has no satisfactory explanation and a terrible prognosis, so taking the blame can be a comfort to many parents. "If it's our fault, then maybe we can fix it," the thinking goes. It's often easier to accept the blame than it is to accept the truth.

The truth, whether parents like it or not, is that it's not not their fault their child has schizophrenia. It's n.o.body's fault. Having a new baby brother or matriculating at Harvard can create stress in a child or an adolescent, true, but it does not bring about a psychotic episode. Little kids have baby brothers every day and teenagers go away to college every September, and most of them get through it just fine. They don't always love or even welcome the changes in their lives. Some are even made uncomfortable by them. But discomfort is a long long way from psychosis. their fault their child has schizophrenia. It's n.o.body's fault. Having a new baby brother or matriculating at Harvard can create stress in a child or an adolescent, true, but it does not bring about a psychotic episode. Little kids have baby brothers every day and teenagers go away to college every September, and most of them get through it just fine. They don't always love or even welcome the changes in their lives. Some are even made uncomfortable by them. But discomfort is a long long way from psychosis.

It's not usually necessary to urge parents to get prompt treatment for children who have the symptoms of schizophrenia. Mothers and fathers can and often do ignore the symptoms of other brain disorders, or at least they take their time having the child looked at, but there's a certain urgency a.s.sociated with schizophrenia that simply will not be ignored. When a child has a break from reality, most parents will head straight for an emergency room, and from there they're sent to a child and adolescent psychiatrist. Most of the children with schizophrenia I see are sent not by a pediatrician but from a hospital emergency room.

Of course, there are exceptions. One girl I treated had her first break at age 16, almost exactly a year before her parents brought her to see me. They had been in family therapy for most of that year, but it didn't seem to help. She continued to have paranoid delusions, mostly about people following her and thinking bad thoughts about her. When she was driving her car one day, she thought that a young man who pulled up next to her at a traffic light was planning to kill her.

I've come across parents who refused to be involved with their children with schizophrenia or even to see them after they got sick. One woman wouldn't allow her son in the house after a few particularly bizarre outbursts, and eventually she refused to see him at all. His father visits him every Sunday without his wife.

Having a sick child is never easy. When that child is diagnosed with schizophrenia, it is incredibly difficult for parents. From the moment a child is born, parents have hopes and dreams and plans for that child. In some ways they think they'd like to keep their kids small and helpless forever, but not really, of course. All parents look forward to the day that their kids become independent. They want their kids to go to college, get a job, get married, have kids, move away but not too far. They look forward to having an adult relations.h.i.+p with their child.

When a child has schizophrenia, those hopes and dreams will probably not be realized. A child with schizophrenia will in all likelihood not become an independent adult, capable of having an adult relations.h.i.+p with his parents. Even when he reaches maturity, he'll depend on his parents for many of his needs. He probably won't get a good job, marry, or have his own home. Coming to grips with these cold, hard facts is a truly heart-wrenching experience for parents. Some look for and find solace in therapy or in support groups. One of the most widely respected is the National a.s.sociation for the Mentally Ill. NAMI offers a wide range of resources that have proved invaluable to parents of children and adolescents with schizophrenia.

It's natural and healthy for parents to grieve over their loss, because that's what this is. One of my colleagues describes it as "mourning the loss of what you expected from your child." After that mourning period is over, parents can get on with the new relations.h.i.+p they must forge with their child. The new relations.h.i.+p is not what Mom and Dad had in mind when the new baby was born, to be sure, but any parent-child relations.h.i.+p has enormous satisfactions.

Here's how one mother described her feelings about her son, now in his late twenties, who had been diagnosed with schizophrenia nearly ten years earlier. "For a long time I walked around in pain. It was as if my old son had died, and I was grieving for him. His personality and his sense of humor just weren't there anymore. His 'essence' was missing. But then I realized I had a new, different son in his place, and I started to feel better. I miss my old son-I'll probably always miss him-but I love the new one too, very much."