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MENTAL ILLNESS AND ITS CONSEQUENCES FOR A FAMILY

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NEW YORK TIMES COLUMN:  FAMILIES TODAY:
MENTAL ILLNESS AND ITS CONSEQUENCES FOR A FAMILY
By: T. Berry Brazelton, M.D., and Joshua Sparrow, M.D.

Q. Four years ago my son had a nervous breakdown. He has since been diagnosed with bipolar disorder. His wife divorced him because he became physically abusive during an argument. They have a 5-year-old son, who has not been allowed to see his dad for the last three years, due to a restraining order by the mother, which included my grandson (although he has never been abused). My former daughter-in-law is financially stable and has a good lawyer, while my son is still barely able to support himself and cannot afford a lawyer.

My grandson is restless, angry and is already having problems in kindergarten. He can’t sit still and pay attention. He yells at his mother and does exactly what he wants to do, like going to bed at 9:30 on a school night. She loves him very much and wants him to have everything he wants in life. I feel her behavior is causing him to be insecure, and his actions are a call for help.

I tried to continue to be involved in his life, but have not seen him as much as I did (my husband as well) because his mother always makes it difficult by making excuses not to schedule visits — not enough notice, he’s going to a friend’s party, etc. I have told her how important it is to keep our relationship. She always says she understands and wants him to have a relationship with us, but does nothing to help us.

We have told her that we feel it’s vital to our grandson’s mental health that he see his father, and have offered to supervise any and all visits so our grandson would feel safe and be in a familiar setting. Nothing we say or do is working. We are sick about this and honestly feel the stress and heartache is wearing us down to the point that maybe we would all be better off if we gave in to her and stopped seeing him and stopped trying to reunite him and his father.

She says she doesn’t feel her son is safe with us (although when they were married he was with us at least once a week) and she says our son is too unstable and hasn’t changed enough that she wants him to see their son. I have told her he can’t change — this is a mental health problem that’s not going away (although he is getting help). I have told her all we want is for their son to have the best life possible, to be included as part of our family and to have a relationship with his father. She can’t see that her son is suffering silently and now overtly. What more can we do?

A. You are all suffering, and you’d all like it to stop. So you try to understand what is causing the pain and the problems. Inevitably, you end up blaming yourselves, and each other. But finding fault just leads to bitterness, misunderstanding and more pain. Deep down you all know that if anything is to blame, it is your son’s serious mental illness. That, of course, is no one’s fault.

If you could all forgive yourselves and each other, you might have a better chance of developing the kind of communication and teamwork that you know you all need. (When there are tough decisions to make that threaten to pit you against each other, a neutral third party such as a court appointed guardian ad litem for the child who would independently represent the child’s best interest might also help settle down the understandable tensions.)

Of course it would be best for your grandson for family ties to be preserved and strengthened, even while squarely facing whatever limits there must be to your son’s interactions with his son when he is unstable. Repairing your relationship with your ex-daughter-in-law will have to come first, before any hope of influencing your grandson’s life more directly.

You have been so strong and brave to face the realities of your son’s illness. No wonder you may need your own time to heal before you can understand his ex-wife’s reactions. Until then, see if you can hold off on attributing the child’s “bad” behavior to her parenting. She’s unlikely to feel that he’ll be safe with you as long as she has to worry that you are judging her critically, which may subtly undermine the authority she needs as a parent.

Of course the boy needs limits, and he may need more limits than he is getting. But the sadness and fear that sets in when a marriage ends often drains parents’ ability to tune into their children’s needs until they’ve had a chance to heal. Can you help her to heal as a critical first step to helping your grandson? She might feel that you could understand her side better if you could consider the possibility that her boy might be hard to handle for a number of reasons beyond late bedtimes and lack of limits.

How could he not be thrown off by his father’s violent behavior (even if it was never directed at him), the divorce and all of the family’s stormy feelings that have resulted? Or he might be showing early signs of threats to his own mental health, especially since these are sometimes transmitted genetically.

You sound big-hearted and generous, as if you can acknowledge his mother’s challenges. Can you take it a step further to let her know you can see and appreciate what she is doing right by her boy? She’s been violated and traumatized. So have you — by your son’s terrible illness. She’s lost her love, marriage and dreams for her future with her life’s partner.

You may feel that you’ve lost your son — at least temporarily — to the delusions and distortions of acute manic episodes. Are your feelings about this something you can share with her? Only once she believes that you understand what she’s been through, that you know she has the child’s best interests at heart, that you will support her as a parent rather than blame her, will she begin to feel safe enough with you herself to entrust your grandson to you.

We understand how close you feel to giving up, but we hope you won’t. We hope you have others in your family you can turn to so that you won’t have to turn away, and so that this little boy can have all the family he needs too. You sound like you have been such a critical support for your son — facing adversity together is the true test of family.

This article is not intended as a substitute for medical or psychiatric evaluation, diagnosis and treatment. Because of the rapid pace of research and new clinical findings, the information it contains is subject to change. If you are concerned about your child, consult your pediatrician, who can refer you to a mental health professional.

Dr. Brazelton, prior to his passing, was the founder and head of the Brazelton Touchpoints Center, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is currently the Director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

Reprinted with permission from the authors.

HOW CAN WE IMPROVE OUR KIDS’ NUTRITION

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NEW YORK TIMES COLUMN: FAMILIES TODAY:
HOW CAN WE IMPROVE OUR KIDS’ NUTRITION?
By: T. Berry Brazelton, M.D., and Joshua Sparrow, M.D.

Q. Please comment about how much vitamin D children need as they are growing up. Also, does the location of where a child lives make it necessary to supplement vitamin D? My husband and I, in our early 60s, take supplemental vitamin D per the advice of our rheumatologist.

A. Last month the American Academy of Pediatrics (www.aap.org) doubled its recommended amount of vitamin D – necessary for bone absorption of calcium – to 400 International Units, for infants, children and adolescents:

“Breastfed and partially breastfed infants should be supplemented with 400 IU a day of vitamin D beginning in the first few days of life.”

“All non-breastfed infants, as well as older children, who are consuming less than one quart per day of vitamin D-fortified formula or milk, should receive a vitamin D supplement of 400 IU a day.”

“Adolescents who do not obtain 400 IU of vitamin D per day through foods should receive a supplement containing that amount.”

“Children with increased risk of vitamin D deficiency, such as those taking certain medications, may need higher doses of vitamin D.”

“Given the growing evidence that adequate vitamin D status during pregnancy is important for fetal development, the AAP also recommends that providers who care for pregnant women consider measuring vitamin D levels in this population.” For babies, formula should be fortified with vitamin D, but breast milk may not contain enough, even though it contains all kinds of important ingredients for health that are not in formula: antibodies, digestive enzymes, and just the right kinds and amounts of fats. Parents should ask their pediatrician to advise them about vitamin D drops for their breast-fed infants.”

As your question suggests, vitamin D requirements vary with exposure to sunlight, since sunlight is required to convert vitamin D to its active form. Children living in northern regions, who are dark skinned, or who spend every daylight hour swaddled from head to toe are more likely to need supplements.

Good dietary sources of vitamin D include fortified milk, eggs and fish. Vitamin D is sometimes added to orange juice, but dairy products other than milk are usually not fortified with vitamin D.

Vitamin D supplementation has reduced the incidence of rickets – weak, bowed bones due to poor calcium absorption that can occur with a Vitamin D deficiency – a great example of the power of prevention.

Q. Is it really at all healthy to limit fats and other caloric nutrients in otherwise healthy and growing young children?

A. Children under the age of 2 years (or 3, according to some experts) actually need the fats contained in whole milk for the rapid brain development that occurs in the first years of life. Some pediatricians are adjusting this recommendation to switch to 2 percent milk after 1 year of age when a child is already overweight or if there are risk factors for obesity, for example, overweight parents.

Calories are not bad, but necessary, in the right amounts. Children have specific caloric needs that depend on their age, size and activity level. The word “calories” is just a measure of the energy a food contains. However, foods that offer only calories and have no other nutritional value are best avoided since they run the risk of filling a child up with “empty” calories before all of her nutritional needs have been met.

Q. Are young children (age 10 and below) at risk from a high cholesterol diet – for example, from eating lots of egg and cheese sandwiches and similar foods?

A. Cholesterol and triglycerides can be a problem for children, especially if their diet is high in saturated fats, if they are obese, or if there is a family history of coronary artery disease or high triglycerides.

Eating habits and preferences do not begin in adulthood. Why start and reinforce unhealthy eating in childhood and then struggle to undo it later?

Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

Dr. Brazelton, prior to his passing, was the founder and head of the Brazelton Touchpoints Center, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is currently the Director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

Reprinted with permission from the authors.

A 3-YEAR-OLD REACTS TO THE BIRTH OF A SIBLING

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NEW YORK TIMES COLUMN:  FAMILIES TODAY:
A 3-YEAR OLD REACTS TO THE BIRTH OF A SIBLING
By: T. Berry Brazelton, M.D., and Joshua Sparrow, M.D.

Q. I’ve read Dr. Brazelton’s book (“Understanding Sibling Rivalry,” Da Capo, 2005) but I need additional information about how to help an older child (3 years old) transition with the birth of a sibling. Our daughter is having major separation anxiety.

A. Often, when a child is experiencing separation anxiety, a parent is, too. I can make any mother cry when she announces a second pregnancy to me. All I have to say is what she is feeling but can’t quite face: “You will be deserting that older child.”

She’ll start weeping, but as we talk, she realizes that she must face these feelings if she is to be able to help the first child put this new family member into perspective.

On some level, the mother-to-be may identify with the older child’s feelings: “How could you do this to me?” translates into “How could I impose a second child on the first?”

But until she is able to answer this question for herself, she will find it difficult to answer if for the child. As long as she doubts this decision, and fears that she really is “harming” the first child, then this is the unnerving message that child is likely to receive. The child isn’t likely to forgive the mother for this “abandonment” until she can stop seeing it this way, until she can forgive herself.

Parents always worry in second or later pregnancies, “Will I have enough to go around for another child?” But of course they will. Children learn to adjust to new siblings as they come along. This adjustment can teach them important lessons that they will need to get along in the world later on, for example, that the world does not revolve around them.

Siblings get so much from each other – in the way of learning (learning how to compete, how to resent a sibling and yet to love the other anyway). They learn to share, and to care for each other.

Just watch the younger one imitate the older one in learning a new developmental step. The younger one will watch and watch, then put the whole step together – all from imitation and from modeling on the older one: “visual learning.”

Giving a child a sibling is like giving him a gift. But don’t expect the older child to thank you when you bring your new baby home. She won’t recognize the gift of this unique new relationship until much later on.

Preparation for the new baby while you are pregnant will help you and your first child face the “separation.” For you the “separation” from her will be an emotional one – so much of your energy will be called up to focus on the new baby. Already your 3-year-old can feel the family’s attention begin to shift away from her.

But you can involve her in this new family event too: “Feel mommy’s tummy. Can you feel the baby you and I will take care of? This will be your baby as well as mine.”

Play out the nurturing with a toy or a doll. Show the older child how to cuddle and feed a beloved baby doll beforehand. She may even want to diaper it. “Now you know how to love the baby like your doll or your truck. You can help me when we have a baby.”

For your 3-year-old, though, the separation she is most worried about is the time when you will go to the hospital. It’s all so mysterious, and so hard to explain.

What will happen? Will you be OK? Will you come back? To help prepare her, you must let your daughter know who will be with her while you are giving birth to the new baby. Encourage her to talk with that important person – her father, a grandparent – beforehand, to plan it all out. Then, when you come home, let your daughter help with the new baby as you’ve rehearsed.

You might also take a new special “lovey” – a stuffed animal or a doll – home with the new baby so that 3-year-old can nurture it, imitating you with the new baby.

But don’t expect your oldest child to share your enthusiasm for the new baby right away. Even if she does at first, the novelty will soon fade. Sulking, temper tantrums and the temporary re-emergence of other old behaviors are predictable.

Don’t pressure her to be a “big” sister, and don’t overdo the praise when she does try to nurture the new baby. Instead, let her know that she will always be your first baby, and that if she feels like being a baby sometimes now too, that’s OK with you. She’s far more likely to step into these big new shoes if you let her step into them herself, when she’s ready.

Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

Dr. Brazelton, prior to his passing, was the founder and head of the Brazelton Touchpoints Center, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is currently the Director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

Reprinted with permission from the authors.

SLEEPING SAFELY IN A CRIB

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NEW YORK TIMES COLUMN: FAMILIES TODAY:
SLEEPING SAFELY IN A CRIB
By: T. Berry Brazelton, M.D., and Joshua Sparrow, M.D.

Q. With the new precautions for SIDS in the crib, how do I help my infant learn to comfort himself? We follow the current thinking to keep a crib uncluttered with pillows and blankets.

In your books you suggest a “lovey” or a blanket for transition time. My son hasn’t yet found such an attachment.

We’ve gotten him to sleep in his crib at night, but he resists bedtime and is inconsolable at nap time. Instead, I continue to lie next to him on our bed, which isn’t safe if I leave the room.

A. The Back to Sleep campaign, sponsored by the National Institute of Child Health and Human Development, nichd.nih.gov/sids, has reduced the incidence of SIDS (Sudden Infant Death Syndrome), also known as “crib death.”

We should all stick with the campaign. Back to Sleep recommends placing babies on their backs to sleep. But we are still learning about the impact of altering infants’ spontaneous sleep positions and of giving up traditional ways to help them stay asleep.

Many parents find that their infants have trouble settling into a restful state when placed on their backs to sleep. In this position, babies can’t easily curl up into the more familiar fetal position or get their hands to their mouths to suck and soothe. Swaddling can help babies settle down to sleep. Swaddling’s pressure may feel like the womb’s support.

We agree with you that infants must learn to console and comfort themselves. The ability to experience distress, and to overcome it, is developed early and lasts a lifetime. The ability starts with a parent or other caregiver’s soothing a baby, who gradually learns to imitate and then internalize it.

Infants discover how to comfort themselves – sucking a thumb or finger, or stroking their cheeks or a blanket’s soft satin border. You can introduce your baby to his thumb, or to a small stuffed animal or a piece of soft cloth – be sure that there’s no possibility it could obstruct his nose or mouth.

Hold the object close while you lie with your baby so he connects the comforting feeling of your skin, warmth, breath and heartbeat with something small and safe that may even take on your familiar smell. Try a soft piece of one of your own old shirts. Other ways to make a crib more welcoming: Record yourself singing your baby’s favorite lullaby and play it softly as he goes to sleep. Or try a CD of lullabies by others.

Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

Dr. Brazelton, prior to his passing, was the founder and head of the Brazelton Touchpoints Center, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is currently the Director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

Reprinted with permission from the authors.

WHEN PARENTS DIVORCE

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NEW YORK TIMES COLUMN:  FAMILIES TODAY:
WHEN PARENTS DIVORCE
By: T. Berry Brazelton, M.D., and Joshua Sparrow, M.D.

From TOUCHPOINTS: BIRTH TO THREE: YOUR CHILD’S EMOTIONAL AND BEHAVIORAL DEVELOPMENT, by T. Berry Brazelton, M.D., and Joshua D. Sparrow, M.D., published by Da Capo Press, a member of The Perseus Books Group.

Parents whose marriages seem to be failing have a major obligation to protect their children as much as they can, whether this means trying to work things out or deciding to divorce. This is a lot to ask of parents who are already overwhelmed with their own feelings.

In the aftermath of divorce, it is very hard for parents who may not only be angry, but also frightened, anxious and grieving the loss of their relationship, to focus on the needs of their children.

But there is no other choice. In the first years after a divorce, a child blames himself for his parents’ breakup and dreams of having his two parents to himself again, even though the original family may have been stressed and stressful. While everyone in the family suffers during a divorce, and during the first year or so that follows, the long-term effects of divorce vary depending on a wide range of protective and risk factors, including how parents handle the divorce and how well they recover from its immediate effects to become effective parents again. Over time, it turns out, many other individual characteristics of the child and parents, as well as life events, play a bigger role than a past divorce in a child’s well-being and healthy development.

As a result, there is no need to label the children of divorce with a self-fulfilling prophecy or to burden their parents with more guilt and anxiety than they may already feel.

The most serious harm to children is done by placing them in the middle of parents’ animosity – using them as a football. Angry parents all too readily take out their feelings on each other by using the child. That is sure to hurt the child. Her capacity to make solid relationships with other adults in the future is likely to be impaired by this insensitivity on the part of divorcing parents.

At first, children may continue to wish for the “old family.” They will feel deserted by the nonresident parent and will fear desertion by the resident parent, reasoning, “If one can leave me, why won’t the other?” Short-term separations become magnified in the child’s mind. Every time a parent leaves, the child must wonder, “Will she be gone for good? Will she remember to come back? Who will take care of me?” Or she may wonder, “Why does he leave me? Am I bad, and no one will want me?”

Before every separation, parents must prepare a child as carefully as possible. After they return, they must say, “I missed you. Did you miss me? Remember I told you I’d be back at (such and such a time), and here I am. You worry, don’t you?” Then, the parent needs to be ready for the child’s feelings about being deserted. Every time the child has a chance to air them, the adult has a chance to demonstrate that desertion is not in the nature of all relationships.

The nonresident parent has a parallel responsibility. Visitation should be clear, dependable and on time. Even a 15-minute wait is an eternity for a small child. Visits from the absent parent offer reassurance about what he fears most – desertion.

A child takes everything personally. No matter how often she is told that a separation or a divorce is not her fault, she will continue to blame herself.

A child will fear that the reason the absent parent has gone is because he or she doesn’t love her, because she’s been “bad.” Later, children dare to put their fears into words: “I knew if I’d been a better kid, they’d never have split up.”

Small children are less able to express it, but they also feel responsible for the split. Both parents must be ready to reiterate over and over and over: “We love you and we never wanted to leave you. We grown-ups couldn’t live together, but we both want to be with you. Nothing you do could ever change that for us.”

A divorced parent must remember that demonstrating any animosity to the ex-spouse in the child’s presence will frighten her. She will take it personally. “If Dad and Mom can fight with each other, they can hate me, too. I must be a perfect child, or I’ll be in for it.”

Parents can help reassure a child that she needn’t try to be perfect. She may need constant reassurance about this, for she is likely to regress with the trauma of the divorce.

Most children regress in the area of the last achievement. If she has just become dry at night, she may begin to wet all over again. If she has been talking well before, she may begin to stutter. Her behavior may be either too good or too provocative. A sensitive parent will accept this and discuss it with the child so that she, too, understands it as normal and expectable. The usual limits should apply, however, and are more important than ever. Limits reassure the child that someone is still in control.

The presence of a sibling can lessen the fear of separation. Sibling relationships can become closer than they were before. Although rivalry will still surface, taking it too seriously can make relationships in the split-up family seem more fragile than they really are.

Grandparents, aunts, uncles and cousins can become important supports for children during and after a divorce. Not only can they give the child help in understanding the split-up, but they also fill her need for reliable, caring people who remain constant in her life.

Resident parents need to reconcile their own feelings about their in-laws in order to respect the child’s need for family. During a divorce, grandparents are likely to “spoil” the children in the family. They may let down all discipline. The resident parent may feel threatened by the lack of rules at Grandma’s. The child will use this: “Grandma gives me what I want. You’re mean and you don’t realize what I’m going through.”

Since you are feeling pretty raw and deprived yourself, this criticism hits below the belt. You bristle. If these are your in-laws, you will feel even angrier at this undermining of your household rules.

If you can, discuss this with your in-laws. Ask them to back you up in your effort to support the child with firm rules and discipline. If relations are too tense for such discussions, simply tell the child, “Grandma does things her way at her house, we do them our way here.” Respectful discipline becomes a source of security.

Try not to overprotect the child. Let her make her own adjustment, and from time to time, point out how well she is doing. When a child can master the stress and change, she can take pride in this demonstration of her competence. Your continued love, respect and discipline can be shown without hovering.

AFTER THE DIVORCE, IF YOU BEGIN DATING

  • If you begin dating, be careful about introducing new people of the opposite sex to your children. Wait until you are pretty sure the child can rely on the relationship. A child of divorce will make new relationships with adults of the same gender as the missing parent all too easily, and she will be deeply disappointed if it doesn’t work.
  • When you do form a lasting relationship, point out that “friends” and stepparents are different from parents, but having two of each can be great.
  • Talk about the child’s fears of your desertion of her. Tell her that you aren’t going to leave her under any circumstance.
  • Find BOOKS about divorced families, or introduce your child to other children whose parents have gone through a divorce. These days, children of divorce are not a small minority, but it still helps a child going through one to know other children who are adjusting to divorce.

Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

Dr. Brazelton, prior to his passing, was the founder and head of the Brazelton Touchpoints Center, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is currently the Director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

Reprinted with permission from the authors.

MEDICATED KIDS: A PARENT’S GUIDE, PART 2

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More than 6 million children in the United States are taking psychiatric drugs — the result of a dramatic recent increase in the number of children being diagnosed with serious psychiatric disorders. The drugs, which are often not fully assessed in children, can cause serious side effects, and little is known about their long-term impact. Reporting on the phenomenon, the PBS program FRONTLINE aired “The Medicated Child” to help families sort through a range of medication-related issues and to team up with their children, doctors, and teachers to face these issues, Frontline asked Joshua Sparrow, M.D., a child psychiatrist at Children’s Hospital, Boston, and an assistant professor at Harvard Medical School, to contribute to a Viewer’s Guide to accompany the program. The Viewer’s Guide is posted at www.pbs.org/frontline/medicatedchild. This article, adapted from that guide, was the first of two parts in successive weeks in the FAMILIES TODAY column.

This article, adapted from that guide, was the second of two parts in successive weeks in the FAMILIES TODAY column. (This article, the second of a two-part series, accompanies “The Medicated Child,” that aired on Frontline on PBS. A more extensive version of the article appears in the Viewer’s Guide posted at www.pbs.org/frontline/medicatedchild, where the program itself may also be seen online.)

When a child is troubled and needs help, it is crucial that parents, the child, doctors and teachers work together as a team. An unfortunate but avoidable consequence of diagnostic labels and medication treatment is that these may lead children to believe that their future is no longer in their hands. But they can be helped to understand that even though their struggles are not their fault, their actions remain their responsibility.

This can be presented to the child not as more pressure, but as a form of respect that will help them fight for their own role in their recovery. Parents too may feel that as they entrust their child’s psychiatric care to a professional they themselves can do little to help.

Yet of course parents remain children’s most important caregivers and advocates. To play this role effectively, parents can take several steps:

  1. Pay attention to your questions and doubts about your child, and to the fears, feelings and memories that these may stir up in you. Parents may be haunted by their own pasts and the family’s history, or their worst fears for the future, and not dare to speak them.
  2. Talk about your concerns with the professional caring for your child, or, if it is more comfortable, with friends and family members. Many parents find relief and renewed strength when they meet other parents experiencing similar ordeals. Often they set up their own support groups to face challenges and share resources together.
  3. Stay connected with friends and family who care. Find allies who can help, even if just with daily routines. The symptoms of a psychiatric disorder in a child can overwhelm a family and derail its usual ways.
  4. Become an expert on your child’s condition. Expect that doctors and counselors will answer your questions, and that they acknowledge when and what they don’t know. Talk with other parents, teachers and school counselors, read, and use — with caution – the Internet.
  5. Trust your instincts. You know your child better than anyone.
  6. Involve your child in the process. Far too often children are not respected as partners in working to understand their challenges, and learning to manage them.
    Listen to your child. Try to understand and value his perspective. Ask your child how he understands his struggles and what he thinks will help. Help him find ways to describe the problem that preserve his self-image and give him hope for the future: “Sometimes your feelings just get too strong for you to handle, but we can work on this together so that you’re back in control.”

You may be referred to a child psychiatrist by your child’s pediatrician, or a school guidance counselor, or, if he’s already receiving treatment from a non-medical mental health professional (a social worker or psychologist) who isn’t trained and licensed to prescribe medications.

If you decide to pursue this recommendation, prepare for your visit by gathering together medical information, reports you have about your child’s behavior and notes from your own observations.

You can expect that the psychiatrist will do the following

  1. Take a thorough history, including allergies and medications, along with the child’s other medical and/and or psychiatric conditions and the family history of medical and/or psychiatric conditions.
  2. Carefully consider and rule out possible medical and neurological causes of the child’s symptoms before settling on a psychiatric diagnosis.
  3. Ensure that you and your child understand his or her views on the problem and what to do about it, and that he or she understands yours.
  4. Plan for regular monitoring and follow-up. Children should be seen at regular intervals by the prescribing physician to monitor medication response, side effects, and to assess whether the drug is still needed.
  5. Take a conservative approach. The psychiatrist should help you weigh the risks and benefits of medication, and of not using medication. The lowest effective dose possible should be used, and, whenever possible, the use of more
    than one drug at a time should be avoided to decrease the risk of side effects.
  6. Inform you about side effects. Before your child starts on medication, the doctor should explain what to look for to know that it is working. He or she should also point out possible side effects and what to do about them, and when
    to call the doctor or to go to the emergency room.
  7. Provide holistic and carefully coordinated treatment. All appropriate non-drug treatments should also be considered. The psychiatrist should collaborate with your child’s pediatrician and other professionals (teachers, and when other treatments are needed, with psychologists or social workers providing counseling or psychotherapy, speech and language therapists, physical and occupational therapists).
  8. Be compassionate. The physician should be ready to respond to the most pressing question that many parents ask: “What would you do if this was your child?”
  9. Treat your child with respect. The physician should include the child in the process of understanding his struggles. He or she also should take great care to show you all that the child’s strengths and potential are appreciated, and that his psychiatric disorder does not define him.

Partnering with your child’s school can also make a big difference. The school ought to offer plenty of opportunities for him to learn about himself, to discover his strengths, to compensate for his vulnerabilities, and to experience success
as the reward for his efforts.

School can also be a useful resource to help you assess, observe and monitor your child’s behavior. Often, a teacher might be the first person to alert you to potential trouble. That news may be painful to hear — but this is the time to preserve and strengthen your relationship with teachers and other school personnel:

  1. When you disagree with teachers about their judgments or recommendations, or when you are first informed of an upsetting behavioral problem, try to keep your initial reactions to yourself until you’ve had a chance to gather your thoughts, and to strategize about how to best respond so that everyone will be on your child’s side. Start with positive, appreciative comments about some aspect of teachers’ efforts, even if you disagree with others.
  2. Show you understand the need for classroom rules and expectations so that the child’s teacher will be more inclined to balance these with your child’s individual needs.
  3. Invite teachers to describe your child’s behavior, and show them that you are listening carefully, even when you disagree. Then start with your observations rather than your conclusions so that consensus on a more complete picture of the child’s behavior can emerge.
  4. Instead of criticizing teachers for how they’ve handled your child’s struggles in the past – which is bound to make them defensive, focus on working together to avoid such problems in the future. Ask them to share with you their ideas about what is causing the behavior, and then concentrate your efforts on the causes that you all can do something about.

Work with teachers to recognize that you all need a plan of action for your child that you can agree on. It is easier for children to relax and understand what is expected of them when parents and teachers can show that they know how to work together as a team, share the same expectations, and give the same messages.

  1. With the school as your partner, you can ask teachers and other personnel to:
  2. Describe their understanding of the child’s problems, and of the behaviors that lead to their concerns.
  3. Agree to put aside terminology that labels a child and instead provide carefully
    articulated, nonjudgmental descriptions of what they observe.
  4. Acknowledge what they don’t know, and when they need help from you, your child, or from other professionals to understand your child and how to work with him. For example, a psychologist may be needed to test for a learning disability (that often underlies a child’s frustration and explosive behavior) and recommend strategies to overcome it.
  5. Respect your decisions, even if they may disagree with them.
  6. Try to see the situation from your perspective.
  7. Show compassion to you, and care about your child.

ONLINE RESOURCES

As you would in gathering any information on the Internet, stick to trustworthy sources. The American Academy of Child and Adolescent Psychiatry (www.aacap.org) offers parents extensive, widely respected information on psychiatric conditions and treatment in childhood.

Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

Dr. Brazelton, prior to his passing, was the founder and head of the Brazelton Touchpoints Center, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is currently the Director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

Reprinted with permission from the authors.

MEDICATED KIDS: A PARENT’S GUIDE, PART 1

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By: T. Berry Brazelton, M.D., and Joshua Sparrow, M.D.

More than 6 million children in the United States are taking psychiatric drugs — the result of a dramatic recent increase in the number of children being diagnosed with serious psychiatric disorders. The drugs, which are often not fully assessed in children, can cause serious side effects, and little is known about their long-term impact. Reporting on the phenomenon, the PBS program FRONTLINE aired “The Medicated Child” to help families sort through a range of medication-related issues and to team up with their children, doctors, and teachers to face these issues, Frontline asked Joshua Sparrow, M.D., a child psychiatrist at Children’s Hospital, Boston, and an assistant professor at Harvard Medical School, to contribute to a Viewer’s Guide to accompany the program. The Viewer’s Guide is posted at www.pbs.org/frontline/medicatedchild. This article, adapted from that guide, was the first of two parts in successive weeks in the FAMILIES TODAY column.

(This article, the first of a two-part series, accompanies “The Medicated Child,” that aired on Frontline on PBS. A more extensive version of the article appears in the Viewer’s Guide posted at www.pbs.org/frontline/medicatedchild, where the program itself may also be seen online.)

Psychiatric medication can rescue a child from a desperate future, and sometimes even save a child’s life. But such medication’s effects on children’s developing minds and bodies are largely unknown. Most psychiatric drugs aren’t approved by the Federal Drug Administration for use in children. Even the diagnosis that may occasion the drugs is challenging since “normal” behavior in
children varies widely. Symptoms like impulsivity or hyperactivity may suggest a host of diagnoses.

Parents are bound to wonder whether psychiatric drugs will really help. Many parents also wonder whether such drugs are used to control developmentally “normal” but “unacceptable” behavior. For example, hyperactivity in a child can interfere with learning and maturing — but sometimes it simply means that too much sitting-still is being demanded of the child. Even when a psychiatric diagnosis is appropriate, parents worry about the price the child
will pay. Identity and self-esteem take form in the vulnerable childhood years but last a lifetime. Taking psychiatric drugs is a tangible symbol of a diagnosis that children often misunderstand to mean they are defective. However, when treatment helps children manage more effectively at home and school, it can
bolster fragile self-esteem. In some instances, cognitive behavioral therapy or other nondrug treatments may replace medication or reduce the amount needed.

Adjustments of the school and home environment to the child’s needs may also help. Parents often can sense when psychiatric attention is warranted. The following are a few of the warning signs that parents are usually right to worry about when the signs persist and pervade — though none indicates a specific condition, nor that medication will necessarily help.

  • You spend more time being angry or upset with your child, or trying to control her behavior, than having fun together.
  • You realize that you are not enjoying your child, and worry that you have fallen “out of love.”
  • You feel worn out or worried by your child’s behavior.
  • People in the family are arguing about the child.
  • You feel like you don’t know or understand your child anymore.
  • Your child’s behavior changes suddenly — for example, activity level or choice of friends.
  • Your child spends prolonged periods withdrawn or in isolation,
  • She rarely smiles or seems happy. Her emotions seem limited mostly to anger or irritability.
  • Your child’s reactions are out of proportion to the situation.
  • Other children don’t like your child, keep their distance, think she’s odd or are afraid of her.

If you have concerns about your child, you deserve honest answers to your questions. Start with your pediatrician, who can refer you to a mental health professional if your child needs this kind of help.

UNDERSTANDING YOUR CHILD’S BEHAVIOR WHEN IT SEEMS ‘OUT OF CONTROL’

When parents are concerned about a child, catchall terms like “angry outburst,” “temper tantrum,” “meltdown” or “out-of-control” are bound to come to mind. But careful observation and detailed descriptions of the behavior will be more useful to parents, children, and mental health professionals as they work together to understand the behavior and then determine how they can help.

Try keeping a journal of your descriptions, and note the following:

Warning signs
Can you tell that your child is on the verge of an “episode”? Can he tell? Can he ask for help before it’s “too late”? Is he especially vulnerable when tired, hungry or anxious, or stressed?

Triggers
What seems to set the behavior off? Sometimes there is no apparent trigger — yet there still may be one that isn’t easily recognized. Was the child’s reaction out of proportion with the trigger’s severity? Ask your child if he thought something happened that made him upset, and get a sense from him of his perception of its seriousness relative to his reaction. But try not to make him feel that you are criticizing him for reacting the way he did, since that will only make it harder for him to team up with you to work on regaining control.

Contexts, settings
Is there a pattern to when and where the troublesome behavior occurs? Always before leaving for school? When there is a transition? Separations? Only with certain friends? Only in private?

Symptoms
What does your child do and say during an “episode? How would you describe his mood? If he’s angry, is there some basis in reality to his concerns? Can he continue to converse? Can he be reasoned with? Does he settle down quickly if something happens that he cares about, like a friend’s visit or call? How long does the episode usually last? How often does it occur? How have you tried to help him settle down? How does he calm himself? What makes the episode worse?

Aftermath
Does he go right back to “normal” after an episode? Or does he seem tired or moody for a prolonged period? Can he remember what happened? Can he talk about it? How does he feel about it? Ashamed? Remorseful? Indifferent?
Does he want help? Or has he given up? Can you plan together to watch out for the warning signs and work together to prevent other episodes or to settle them sooner?

The price you and the child pay
How do your child’s symptoms affect him and the family? Have you had to change the way you and other family members live your lives? Do you all feel that you are “‘held hostage”‘ by the child’s behavior? Has the child’s performance at school or relationships with friends been affected? Does he feel that he can no longer understand or like himself?

Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

Dr. Brazelton, prior to his passing, was the founder and head of the Brazelton Touchpoints Center, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is currently the Director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

Reprinted with permission from the authors.

WHERE DO PRESCHOOLERS LEARN MOST?

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NEW YORK TIMES COLUMN:  FAMILIES TODAY:
WHERE DO PRESCHOOLERS LEARN MOST?
By: T. Berry Brazelton, M.D., and Joshua Sparrow, M.D.

Q. What are your thoughts on preschool? Are very young children better off constantly interacting with a dedicated adult parent to stimulate their brain growth, or is there a benefit to socializing them with their peers at an early age? What’s the optimum balance of this for raising an intelligent yet independent and socially adept child?

A. How fortunate you are if you have a choice! And yet what a sense of responsibility!
Most parents in the United States today have no choice, and must work in order to be able to provide for their families. Because of the decline in real wages over the past decade, most single and two-parent families need all adults to bring in paychecks. While quality child care is hard to find and harder to pay for, it may be harder still to do without a parent’s salary. Some families find, though, that with two or more children under age 4, there’s no choice but for a parent to stay home. For others, friends and relatives are the only solution.

Early Head Start (for infants and children to age 3) and Head Start have been the salvation of many families, although for decades there have been no openings for the vast majority of eligible families. Finally new funding is on its way to make room for more children in these high-quality and proven programs.

To our knowledge, there are no actual studies that compare the brain development of children in preschool to children who spend their days at home with a dedicated adult parent. Such a study would be difficult to conduct both because the specific experiences in individual homes and preschools can vary so much and because there are so many other variables that influence brain development, including pregnancy, health, nutrition, air and water quality, and genetics.

What we do know is that high-quality early childhood education has been proven to save up to $17 for every dollar it costs because it leads to better academic success, fewer special education expenditures, greater chances for employment and productivity, and less risk of ending up in jail.

Quality criteria include a low child-teacher ratio, a high level of formal training in child development and education for teachers, positive relationships between teachers and parents, and meaningful parent involvement.

There is no evidence that such high-quality experiences can’t also be provided by dedicated and caring parents for children at home. Positive learning and growing may occur in either setting.

Since most parents don’t have a choice, and are either at home or at work because they must be, we’d hate to make them feel guilty about either option. What matters most is the quality of the child’s experience. Whether the child is at home or at preschool, parents and children need enough time together to continue to grow closer and to deepen their understanding and appreciation of one another. And children at home will still need abundant opportunities to be with peers to learn from them, with them and through their interactions.

Parents may feel overwhelmed by the responsibility that the “new brain science” may seem to impose on them to stimulate their children’s brain development – quick, in a hurry – before it is too late. The reality is that while the human brain never grows and develops more rapidly and dramatically than in the first three years of life, children’s most important learning experience will not come from videos or computer programs but from interactions with those who care about them most – parents, teachers, siblings and peers.

Parents are children’s first and most important teachers not because they teach the alphabet, shapes and colors but because they encourage and motivate children’s curiosity and enthusiasm to learn. Parents help children to take in as much as they can learn from their environment by gently buffering them from more stimulation than they can handle. Early on, children teach their parents how to read their cues so that together they can work toward this balance.

The foundations for learning are laid down before kindergarten in the context of children’s interactions with adults and with each other. We have known for decades that the key to school readiness and becoming a lifelong learner lies in the early experiences that help develop important qualities such as persistence, perseverance, curiosity, the capacity to tolerate frustration and the self-esteem to keep on trying even after making a mistake.

Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

Dr. Brazelton, prior to his passing, was the founder and head of the Brazelton Touchpoints Center, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is currently the Director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

Reprinted with permission from the authors.