Behavioral disorders in children
By Jerome L. Schulman, M.D.
At times, all children behave in ways that puzzle or worry their
parents. Many children may even show what seem to be symptoms of a
behavioral disorder. Symptoms such as extreme aggressiveness, fears, and
compulsions indicate a behavioral disorder only when they are severe or
occur frequently. Be careful not to let your concern about your child’s
behavior exaggerate the significance of a symptom. Fortunately, most
children are mentally healthy.
Behavioral disorders and developmental challenge are different from one
another, but sometimes it is hard to tell them apart. Emotional problems
may make learning so difficult that even a normally bright child may
appear developmentally delayed. (See [The developmentally challenged
child] in For Special Consideration.)
The importance of physical health
Before concluding that a behavior problem is the result of emotional
disturbance, you should be certain that your child does not have some
physical illness. Many symptoms of behavioral disorder can be created or
made worse by a physical illness. Regular medical checkups are
important. They become even more important if your child is having an
emotional problem.
Where emotional problems can occur
A child may be thought of as living in four worlds and being expected to
behave in
certain ways in each of these worlds. If the child’s behavior is
frequently very different from what is thought of as normal, there may
be a behavioral disorder.
Family and home—the first world
A child’s first world is the family and the home. One’s attitude toward
oneself, toward other people, and toward life in general begins here. In
a normal situation, there is a bond of affection between the parents,
and between the child and each parent. They enjoy each other’s company,
but each has other interests. Gradually, the child moves from almost
total dependence in infancy to almost total independence toward the end
of adolescence. Throughout these years, the child is expected to pay a
reasonable amount of attention to family rules and to perform tasks that
are reasonable in terms of age and ability.
A child may have a behavioral disorder if there is not a good
relationship with parents, if independence proceeds too slowly or too
rapidly, or if family rules and tasks are ignored. Attitudes toward
other children in the family are hard to classify because quarreling and
jealousy are a normal part of the brother-sister relationship. They
seldom indicate a behavioral disorder.
School—the second world
A child lives in this second world about 1,000 hours a year during
childhood. A child’s tasks in school are, within reasonable limits, to
perform well and to conform socially, to be interested in studies, to
see learning as an opportunity for a full and
productive life, and to become interested and involved in
extracurricular activity.
All parents have ambitions for their children. A problem may occur if
the child’s ability does not match the parents’ expectations. The
child’s attitude toward school may become bad, or achievement may fall
below ability. Also, if behavior at school makes frequent discipline
necessary, it may indicate a behavioral disorder for which help is
needed.
Friendships—the third world
As children move from infancy into childhood, they encounter a third
world—the world of friendships. This world becomes increasingly
important as children grow older. Childhood associations are extremely
important. Children begin to learn social customs and patterns of
behavior by imitating adults and by influencing and being influenced by
other children. Much of the ability to be good at adult relationships
grows gradually out of a good childhood beginning. Normally, the child
should want to be with friends and should feel wanted by them. They
should enjoy being together.
Parents should be concerned about the child who is always alone, the
child who tries to buy friendship with bribes, the child who either acts
the fool to get other children to laugh at him or her or who is
aggi’essive toward other children, and the child who always prefers to
play with much younger or much older children. And certainly parents
should be concerned about the older child whose friendships lead to
antisocial behavior such as vandalism or stealing.
The inner world—the fourth world
The child’s inner world is in some ways the most important and the most
difficult to understand. It is the world of thoughts, fears, hopes,
attitudes, and ambitions. Children see themselves in many ways. They may
think of themselves as smart or stupid, lovable or unlovable, ugly or
good-looking, good or bad. Together, these self-evaluations make up what
is known as the self-image. When a child has a strong and continuous
feeling of not measuring up to other children, it is reasonable to
assume that there is an emotional problem.
Everyone has to face problems of one kind or another throughout life. In
spite of this, the well-adjusted person continues to find life a source
of satisfaction. Such a person is usually optimistic about the future.
If this feeling of optimism never occurs, then there is an emotional
problem.
Specific symptoms
The most serious symptoms of behavioral disorder may be referred to as
thinking disorders. They may occur singly or in combination. A child who
is unable to respond to people or surroundings or is completely without
a sense of time has a thinking disorder. The child may hear voices or
see things that do not exist. This should not be confused with the
behavior of the normal child, who may sometimes play with and talk to an
invisible friend.
Obsessions are thoughts that occur repeatedly until they interfere with
normal thought processes. At times a normal child may have an experience
similar to an obsession, such as a tune that keeps running through the
mind. This is short-lived and does not interfere much with normal
thought processes.
Compulsions are urges to repeat certain acts over and over even though
there is no reason to do so, such as the uncontrollable urge to
repeatedly wash the hands. This is not the same as a child’s urge to
avoid stepping on cracks in a sidewalk, which is more a game than a
compulsion.
A phobia is a fear so terrifying that it prevents the child from
carrying on normal activities. It is one symptom of a behavioral
disorder that gives parents much concern. This is not to be confused
with the normal child’s dislike of school at certain times, or with a
young child’s fear on first entering school.
Anxiety is a nameless dread not related to anything specific. Anxiety is
harder to understand than a phobia because the cause of the child’s fear
is hard to pinpoint.
Extreme aggressiveness, such as a compulsion to hurt other children or
to be cruel to animals, must also be considered a symptom of a serious
behavioral disorder if it is frequent.
Some symptoms of behavioral disorders interfere with the normal body
functions. Among these are tics, hysteria, enuresis (regular
bed-wetting), and encopresis (the constant inability of the child to
control bowel movements).
Tics, or habit spasms, are sudden repeated movements of muscle groups.
Generally these occur in the muscles of the face, but they may involve
any muscle group. The child has no control over a tic.
Hysteria is best described as the loss of a physical or sense function
because of emotion. Hysteria may cause blindness or the loss of the
sense of touch. It may also cause paralysis of arms or legs.
Enuresis and encopresis may be considered symptoms of a behavioral
disorder if they occur in a child who has previously been bowel and
bladder trained.
What to do about behavioral disorders
If your child frequently shows symptoms of a behavior disorder, do not
ignore the symptoms and hope they will disappear in time. Your child is
too important for you to rely on chance.
Parents should discuss the problem together. It is extremely important
that the discussion take place during a time of calm and good feeling
rather than when parents are upset and angry because the child has
behaved badly.
During the discussion, parents must decide how the family as a group,
and each member, behaves differently from the average. Do not hesitate
to admit that your own behavior may be different. In a variety of ways,
everyone is likely to be on one side or the other of the average.
Also, you must be able to admit that while the ways you do things may
work well with some children, and may even be necessary, they have not
been successful with the disturbed child. This admission calls for a
willingness to accept the fact that your behavior is related to your
child’s difficulty, and that a change in your approach to the child may
be a solution to the problem.
Parents may have problems
The perfectionist parent believes there is a place for everything and
that everything must be in its place at all times. As a result, demands
on the child are often unreasonable. The child’s room is never kept neat
enough to please the perfectionist parent. If the child gets a “B” on an
otherwise straight “A” report card, the child is criticized and made to
feel inadequate. The child is constantly compared to others, but no
matter how hard the child tries, the perfectionist parent is never quite
pleased. Emotional problems of the child can often be related to this
abnormal demand for perfection. The perfectionist parent should try to
be less rigid about rules and to look for behavior that can be praised.
The inconsistent parent creates an uncertain environment by changing
rules so often that the child cannot know what is expected. Most parents
are inconsistent at times, but when they constantly change rules
relating to the child’s behavior, it is damaging to the child and should
be corrected.
The overprotective parent shields the child excessively, either
because the parent cannot bear the thought that the child is growing up,
or because of undue concern for dangers in the world outside the home.
This attitude may inhibit the development of independent skills. The
parent who recognizes that overprotection is a problem can find a
reasonable guideline for correcting it by studying the behavior of
parents with well-adjusted children.
The indulgent parent buys the child’s affection by never setting any
limits. This may also be the source of the child’s behavioral disorder.
Children are much more comfortable when they have rules to follow. Rules
prepare a child to face the many situations where individual desires
must be put aside in favor of group needs.
Quarreli\’ng parents may also contribute to a child’s problems, if the
quarreling is constant. The obvious solution is to avoid quarreling in
the child’s presence and to compromise their differences.
The uninvolved parent has little to do with the child. Such a parent
will be unable
to convince the child of his or her love, interest, and concern.
Children need models after which they can pattern their own behavior. To
be effective models, parents must be available and interested in the
child.
The punishing parent tends to deal with problems by thinking up new
and unusual punishments. Although punishment may be essential on some
occasions, it should not be excessive, and there should be sufficient
praise to counterbalance it. If a child shows symptoms of a behavioral
disorder, and has been punished a great deal, it is reasonable to assume
that more punishment will only tend to aggravate the condition.
Changing tactics
When parents recognize that previous methods of handling their child
have been unsuccessful, and even harmful, they should plan a new
program. If the child is old enough to reason with, the process will be
made easier by a frank discussion when all are feeling friendly. The
parents should tell the child how concerned they are and how much they
want to help. They should indicate to the child how they plan to change
their behavior, and they should agree to meet on a regular basis to
discuss progress. The child should be allowed to speak freely during the
discussions, and nothing the child says should be held against him or
her.
If the child’s behavior has become a problem at school, it is important
that parents discuss the problem with the child’s teacher and other
staff, such as the principal, the school psychologist, a social worker,
or the school nurse. These people are interested in the child and can
offer advice and guidance. This may be extremely valuable in helping
parents understand why their child is behaving badly.
When to seek professional help
Usually, it is difficult for parents to admit, even to themselves, that
their child may need psychological support. And it is reasonable for
parents to assume that they can work on some of their child’s problems
with
out outside help. If there is any improvement, they should continue. But
if in a reasonable time, there is no improvement, it is time to seek
professional help.
If the child’s problem is in the category discussed under “Specific
symptoms,” parents should consult their pediatrician or the family
doctor. If necessary, the parents will be referred to a psychiatrist, a
clinical psychologist, or to the local mental health clinic. Often it is
easier for an outsider, especially one with specialized training, to
approach the problem with greater objectivity or from a different point
of view.
When parents seek help for their child, they must be prepared to accept
the fact that they may be partly responsible for their child’s emotional
problem. Parents should be willing to learn how they have contributed to
the problem and to work with the doctor to produce good results.
Children with behavioral disorders tend to respond favorably to
treatment, especially when all members of the family are trying to help.
The treatment of an emotionally disturbed child often requires a great
deal of time and patience on the part of parents and child guidance
specialists.
For one thing, a disturbed child is, as a rule, completely unaware that
anything is the matter. For another, disturbed children seldom want to
change their ways. The professional working with the child may need time
to bring the child to the point where the child wants to do something
about the behavioral disorder.
Parents should not be discouraged if psychiatric treatment or treatment
in a child guidance clinic fails to produce immediate results. Diagnosis
and treatment take time, and the results may be slow in coming. A severe
behavioral disorder usually takes a long time to develop. It follows
that as long a time may be required to correct it.
Fortunately, many of the emotional illnesses of children can now be
treated successfully. Ongoing research in the important field of mental
health should offer even more help in the future.
Mark S. Puczynski, M.D. Consulting Editor
