It's Nobody's Fault (41 page)

“W
ORKING WITH SICK
kids every day must be really sad. Doesn’t it get to you?”
Hardly a day goes by that I don’t hear that question. I certainly understand what makes people ask it of someone in my line of work. Of course, it is sad, very sad, to see children in pain. Seeing any living thing experience distress and dysfunction—we’re back to those two D’s again—is upsetting. When the distress and dysfunction belong to a child and the treatments don’t work, it can be heartbreaking. I’m a father as well as a doctor, so I know full well that the troubled children I treat every day could just as easily be one of my own three sons.

Nearly 20 years ago, when I decided to become a child and adolescent psychiatrist, I thought that I’d be able to help certain kids have an easier time growing up. I guess I saw myself as the Judd Hirsch character from
Ordinary People
, the wise, kindly, hip psychiatrist whose very special relationship with a teenager helped the boy get through a difficult period in his life. I didn’t know then that the field I chose was about to take a giant leap forward, that I was going to do a lot more than help children and adolescents cope with their troubles. The progress that has been made in our understanding of the brain’s involvement in children’s psychiatric disorders and the use of medication has meant that my colleagues and I have been able to change, and sometimes even
save
, the lives of young people, just like neurosurgeons and cardiologists. I ended up getting a lot more than I bargained for.

So I tell people no, my job
isn’t
sad and most times it
doesn’t
get to me, because I know there’s almost always something I can do to make a child’s pain go away. I can relieve the suffering of his or her parents as well, first by reassuring them that what’s wrong with their child is not
their fault and then by telling them how we can make the child better. I hope I’ve gotten that message through loud and clear in these pages.

I’m in the business of helping troubled children live normal, happy, productive lives, and there’s nothing sad or dispiriting about that. On the contrary: working with sick kids every day is a joy. I hope you find the same joy bringing out the best in your child.

W
HAT FOLLOWS
is a list of some of the terms used frequently in
It’s Nobody’s Fault.
I describe them here not as they are defined in textbooks or medical dictionaries but as they apply to the field of child and adolescent psychiatry and suit the purposes of this book.

BEHAVIORAL THERAPY. A goal-oriented approach based on the principle that all behavior is learned and that undesirable behavior can be unlearned through training. The focus is on the here and now, on figuring out how to change behavior, not on finding out
why
the child feels or behaves a certain way.

BEHAVIOR MODIFICATION. The core of behavioral therapy, this is the therapeutic approach by which undesirable behavior is “unlearned” and replaced by different, more desirable behavior. Positive and negative reinforcement play an important part in behavior modification. A system of rewards and mild punishments (usually loss of privileges) can be a big help in motivating a child to change the way he reacts to a given situation. The role of parents is extremely important in behavior modification.

CAT. Computed Axial Tomography. This is an advanced form of X-ray that permits us to look at structures of the brain.

CO-MORBIDITY. A situation in which a person is diagnosed with two or more disorders at the same time. One disorder is said to be co-morbid with another. Co-morbidity is extremely common in the brain disorders of children and adolescents. Few of these disorders are completely “clean.”

COGNITIVE. Having to do with thinking. Cognitive functions include remembering, understanding, judging, and reasoning. Cognitive
behavioral therapy requires an ability to talk about your own thoughts and feelings, so it is more likely to be effective for older children than it is in the treatment of the very young.

CONCORDANCE. This term, which is usually used in genetics, refers to the similarity in twins with respect to the presence or absence of a disease or a trait. Higher concordance rates in identical twins than in fraternal twins indicate that there is a genetic component to that disease. Twin studies of the brain disorders in these pages all show a higher concordance rate in identical twins than in fraternal twins.

DNA. Deoxyribonucleic acid. The stuff of which genes are made. DNA is largely responsible for the transmission of inherited characteristics, including brain chemistry.

DISINHIBITION. An increase in hostility, aggressiveness, irritability, and impulsivity. This reaction can be caused by certain antianxiety agents, specifically the benzodiazepines. This side effect usually disappears when the dose is lowered and always disappears when the medicine is discontinued.

EEG. Electroencephalogram. This is a graphic depiction of the brain’s electrical impulses. Since 1929 the EEG has been used to detect the presence of brain malfunctions, including the seizures associated with epilepsy.

FAMILY THERAPY. Psychotherapy in which problems are understood and treated in the family. How a child’s disorder affects all the members of the family and how the family affects the child are addressed. The goal of family therapy is to bring about a change in the way family members interact. Unlike parent counseling, where a therapist advises the parents, family therapy requires the cooperation of the entire family to make changes and find solutions.

INTELLIGENCE. A person’s ability to learn and to understand and process information for problem solving. An intelligence test is used to measure those aspects of mental development that are relevant for academic achievement. A person’s IQ—his intelligence quotient—rates his intellectual ability, according to verbal skills and performance skills.

MRI. Magnetic resonance imaging. MRI is a neuroimaging technique that uses magnetic fields instead of radiation and allows us to examine the structure of the brain, especially the existence of tumors, vascular malfunctions, and brain deterioration.

NEUROANATOMY. The structures that compose the brain and the nervous system.

NEUROIMAGING TECHNIQUES. Techniques that provide data on brain activity and function. As far as the brain disorders of children and adolescents are concerned, these techniques are useful not for the purposes of diagnosis but for increased knowledge of how the brain functions and how it reacts to medication, among other things. Some of the most commonly used neuroimaging techniques are MRIs, PET and CAT scans, and SPECT.

PARENT COUNSELING. A therapeutic approach in which parents are educated about their child’s brain disorder and given information and advice on general issues and on the specific problem they may be having with the behavior of their child.

PARENT TRAINING. This is a systematic goal-oriented process in which parents are taught, quite specifically, how to manage the behavior of their troubled child by means of positive and negative reinforcement. For instance, parents might be taught how to encourage alternatives to such negative behaviors as temper tantrums, aggressiveness, and destructiveness. This technique is used for children of all ages; but it is especially appropriate for parents of young children.

PERFORMANCE ANXIETY. The apprehension and nervousness that come before an event requiring the demonstration of a child’s or adolescent’s abilities—a test, piano recital, oral report, and so on. Simple performance anxiety, which is a perfectly normal response, does not negatively effect the youngster’s performance. Pathological performance anxiety, which is not normal, does impair a child’s ability to perform.

PET SCAN. PET stands for positron emission tomography. This neuroimaging technique produces images of the brain’s activity as a patient is directed to complete specific tasks, such as reading or naming objects. Measurement of brain metabolism with the use of PET scans has been helpful in identifying differences in the brains of adults with specific brain disorders and showing us how the brain responds to various medications.

PSYCHOTHERAPY. The treatment of mental or emotional disorders by psychological means, usually involving communication between patient and therapist. Psychotherapy may involve individuals, families, or groups, and there are many different methods employed to bring about change.

PSYCHOTIC. This term describes someone whose ability to distinguish what is real from what is not real is impaired. A person who is psychotic creates his own “reality”; he may have delusions and hallucinations. Faced with concrete evidence that what he believes is true is not true, he stays with his own version. (See
reality testing)

REALITY TESTING. A person’s ability to distinguish reality from fantasy or his inner wishes and feelings from the external world. For example, a paranoid person believes that somebody out there is trying to get him. He doesn’t recognize that his fears are in his mind. When someone has hallucinations, he truly believes that the voices are real. When he’s treated with medication and starts to improve, he begins to wonder if the voices are real. Once he’s better, he’ll say that he used to hear voices that he thought were real, but now he knows they weren’t. Having good reality testing means being intact again.

SEDATION. The state of being sleepy. Sedation is a side effect of many psychiatric medications, including the antianxiety agents, some antidepressants, and certain neuroleptics.

SELF-MEDICATION. Using alcohol and illicit drugs, such as marijuana, in an effort to improve one’s mood and general feeling. Untreated adolescents with brain disorders frequently turn to self-medication.

SOCIAL CUES. The facial expressions and body movements that express a person’s intentions and reactions. Some kids with brain disorders are impaired in their ability to recognize and respond to social cues in their family and friends.

SPECT. Single photon emission computed tomography. This neuroimaging technique measures blood flow in the brain and the utilization of glucose, the form of sugar used by cells. It also highlights which parts of the brain are active and determines whether or not blood flow and activity are typical. SPECT is used primarily as a research tool for brain disorders in children and adolescents.

TEMPERAMENT. A set of character traits that an infant is born with. Sometimes thought of as a child’s basic
disposition
, temperament is the foundation of his personality.

TITRATION. The process of determining the exact dose of medication needed for a child or an adolescent with a brain disorder by evaluating his response to the medicine. Specifically, we look for a decrease in symptoms and the presence of side effects.

TRAUMA. An event, injury, or emotional shock that has a negative effect on a person’s mental or psychological state of mind.

VISUAL IMAGERY. A technique used in behavior modification in which the child or adolescent pictures himself in a certain situation and, guided by a therapist, learns how to cope with the feelings that the situation brings on. Guided visual imagery is especially useful in combating phobic reactions and anxiety.