Does My Child Have a Psychiatric Disorder? 25 Jul 2016

Caregivers need to protect space between reassurance and diagnosis

When parents bring their young child to see me in my behavioral pediatrics practice, they seem to be at war with themselves. They simultaneously seek reassurance that there is “nothing wrong” and validation of their often deep and longstanding struggles.

Our current health care and education systems are constructed in a way that puts the question “what” front and center. The focus, both for parent and clinician, is on making a diagnosis.

This drive to name the problem leaves us with an inaccurate and potentially harmful choice between “normal” and “disorder.” In contrast, when we can protect a kind of virtual space between these two extremes, we can learn how a child’s behavior, from his perspective, might make sense.

Behavior is a form of communication. Understanding that communication leads us to know what to do to help a child and family. When we are able to listen for the “why” without pressure to name the problem, the solution often presents itself. Consider the following example.

Four-year-old Michael came to my office at the recommendation of his pediatrician and preschool teacher for an “ADHD evaluation.” Usually I meet first with both parents, but his mother Angela came alone. I opened up the visit with an invitation to tell me her story.

Michael had been a challenging child from birth, intense and difficult to soothe. Angela had struggled with postpartum depression. When Michael turned two and began in a developmentally appropriate way to say no, Angela found herself full of rage. She told me how such typical behaviors as resisting a bath would precipitate an extreme reaction from her, sometimes even harshly grabbing Michael by the shoulders and shaking him. She felt terrible shame about her behavior. Her voice began to tremble. She wept in the safety of my office as she let herself experience the grief around her troubled relationship with her son.

When I saw Michael and his mother together the next week, Angela joyfully reported at the start of the visit that, while mealtime had been a primary battleground, Michael had eaten an entire spaghetti dinner by himself. The whole tone in the household had shifted dramatically, as Angela, feeling some relief from her debilitating feelings of guilt and shame by sharing them with me, began to enjoy her son for the first time in years.

In turn, once Michael connected with his mother in more positive ways, he reconnected with his own natural appetite. As we worked together in the coming months his behaviors Angela and the teachers had been attributing to ADHD began to subside. The relationship between mother and son took a different direction.

Here we have a situation that was not “normal.” Clearly both mother and child were struggling. Yet Michael’s behavior represented not a disorder, but rather an effort to communicate his distress. He was attempting to find a way to connect with his mother.

As I describe in my new book The Silenced Child, even the notion of an “ADHD evaluation” conveys a level of certainty that is not consistent with contemporary developmental science. While the constellation of behaviors we call “ADHD” has some known genetic components, there is not a gene for ADHD.

The rapidly growing field of epigenetics show us that when we can change the environment to decrease the level of stress, as occurred in this vignette by “simply” listening, we have the opportunity to change not only behavior, but gene expression and so structure and function of the brain.

Michael’s history of “difficult” behavior in infancy suggests that his challenges might have a genetic component. But when we can support and listen to parent and child together in the early years when the brain making hundreds of connections per second, we have the opportunity to set development on a healthy path.

An abundance of contemporary research in neuroscience, psychoanalysis, and developmental psychology tells us that being curious about the meaning of behavior, rather than simply naming and eliminating it, offers the path to growth and healing.

Multiple forces in our culture, as I also describe in my new book, can get in the way of listening for meaning. For young children and families, both reassurance and diagnosis of a psychiatric disorder represent variations on not listening. In contrast, when we protect time for listening with curiosity, free from pressure to either reassure or diagnose, we allow parents to connect with their natural expertise and help get development back on track.

Claudia M Gold M.D. Claudia M Gold M.D. Child in Mind

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