Rearing the “problem child”

Rearing the ‘problem child’

It wasn’t just her son’s temper tantrums that were troubling to Maggie Smith. Most kids have their fair share of those. It was their intensity, and the way they could arrive like inclement weather, and clear up just as suddenly. She first noticed it when he’d sit in his high chair, shaking and punching his fist in the air over things like a dropped toy. By age 2, his temper seemed to be getting worse. “All of a sudden he would stop and act like nothing was wrong and come and give me a hug and say, ‘I love you, Mommy,’” Mrs. Smith said.

(Some names in this story have been changed to protect the welfare of children and their families.) She and her husband, who live in Naples, struggled to find a doctor willing to diagnose or treat a child that young. One doctor, a friend of the family who lives in Chicago, told them when John was 4, “there’s something definitely there, but he’s too young. He’s too young to diagnose anything,” Mrs. Smith said.

And with one income at the time — he’s an auto mechanic and she later became an elementary school teacher — the only doctor they could find who would treat John didn’t take insurance.

Their story underlines some of the difficulties in finding access to mental health care, especially for young children, as well as treating and diagnosing them with behavioral disorders.

“If kids start talking about their problems at an early age, it’s easier for them to continue doing that when they’re older and have difficulties,” said Stacey Brown, a licensed mental health counselor in Fort Myers. “If there is a mentalhealth issue in the family, it’s better not to sweep it under the rug and not talk about it.”

“This is one of my biggest fears right now, that people are going to start stereotyping children with mental-health issues and it’s going to become a big misunderstanding. Just because one person did that doesn’t mean my son’s going to do it.”The Sandy Hook Elementary School shooting in Newtown, Conn., in December focused a national spotlight on mental health. Political leaders, school officials, care providers and others are talking about what can be done to prevent the next young, disturbed gunman.

That prevention, for children such as John, begins in pre-adolescence. Psychologists say common and rare mood disorders and neurological conditions — everything from attention-deficit hyperactivity disorder to the potential for psychopathy — can be detected and treated in children only a few years old. A New York Times Magazine cover story in May, for instance, described how psychologists treated pre-adolescent children diagnosed with callousunemotional disorder. That and antisocial personality disorder, psychologists say, indicate a child could be at risk of becoming a psychopath or sociopath as adults, characterized by their lack of empathy or remorse. But many healthy young children and those with other mental illness might show similar signs that could be misunderstood.

Port Charlotte resident Shannon Adams’ son, Arthur, is on the less-severe end of the autism spectrum. At age 13, maybe not unlike many early adolescents, he’s still fine tuning the effects of his words and actions on other people’s feelings.

Ms. Adams said, “He lets people know, ‘I’m sorry if I said something wrong, I have Asperger’s. He’s learning not to tell a big fat lady in an orange shirt that she looks like a pumpkin. So he’s learning. And there’s a lot of other things we’re going to have to teach him.”

After the Sandy Hook shooting, there was some speculation that the killer, Adam Lanza, was on the autism spectrum. There’s no way to know for sure because of health-care privacy rules, but even if he was, the aggressive behavior sometimes seen in autistic children is reactionary and not the calculated type of killing seen in Newtown, said Fort Myers psychologists Drs. Sheba and Nolan Katz.

Autism is a distinct neurological condition that isn’t related to mood disorders, but children on the spectrum may have difficulty relating to other people. That is distinctly different from not caring if they relate to other people, which is more sociopathic, said Mr. Katz, who along with his wife is a certified school psychologist and on the board of the Adonis Autism Assistance Foundation.

“There have been a lot of upset parents,” he said. “Autism is now being thought of in the light of what happened in Sandy Hook.”

In light of Sandy Hook

Then again, what isn’t being thought of in the light of Newtown these days? Some of the answers we are seeking to explain Adam Lanza may be red herrings, suggest the Katzes. For instance, a healthy diet never hurt anyone. What if people found out that violent criminals in general ate too many candy bars?

“You might find with these school shooters that they all had a poor diet,” he said. “Would anybody believe that it caused them to kill people?”

Recently, a candid blog post called “I Am Adam Lanza’s Mother,” about a mother’s distress over her young son’s defiant and at times violent temper, became a cultural touchstone for parents of children with mental illness when it went viral. Lawmakers from President Barack Obama to Florida’s Congressional leaders are trying to come up with a plan to avert the next tragedy.

One provision of the Affordable Care Act will require insurance companies to fund mental-health care at a level equal with physical health care. That may help heal the stigma of shame associated with mental-health treatment, said Jay Glynn, CEO of Charlotte Behavioral Healthcare.

The White House also made improving access to mental-health care one of four major provisions in a plan to help stop violence in the wake of Sandy Hook. Part of the provision included setting aside funds to help schools identify children with a wide range of mentalhealth issues and get them treatment.

A portion of the Mental Health First Aid program will focus on ages 12 to 25. The administration set aside $20 million for the next fiscal year for grants to train emergency services personnel, police, teachers and administrators, faith leaders, and others in a five-step program to identify and get help for young people with mental illnesses.

Meanwhile, at age 9, Mrs. Smith’s son, John, is being treated for an alphabet soup of behavioral disorders through a Collier County program. Health Under Guided Systems or H.U.G.S. began in 2010 with a Winter Wine Festival grant. It has helped provide mental-health screenings for more than 2,500 children as young as 3 months old, up to age 18. About a quarter of them were treated for behavioral disorders.

This has benefited John hugely, Mrs. Smith said (as well as herself, her husband and John’s two younger siblings). A psychologist is helping develop tactics to help him achieve specific goals. He’s in Cub Scouts and on the honor roll at school. Prescription medication is part of his regimen as well.

At the same time, she worries that some children similar to hers, who are getting treatment for behavioral issues, could be treated as potential criminals by adult figures who would otherwise embrace them wholeheartedly.

“This is one of my biggest fears right now, that people are going to start stereotyping children with mentalhealth issues and it’s going to become a big misunderstanding,” Mrs. Smith said. “Just because one person did that doesn’t mean my son’s going to do it.”

Preventing the next crime

A health-care delivery system that is more willing and able to treat mental illness from cradle to grave — just like broken bones, cancer or colds — will ultimately keep some young children out of jail or worse, said Kathryn Hunter, director of the National Alliance on Mental Illness in Collier County.

Serious mental illness occurs in 5 percent of the general population, but is roughly four or five times that in jails and prisons, says Florida Partners in Crisis, a group that advocates publically funding mental-health services.

“We recently worked with a young child who was at risk of being suspended in kindergarten,” Ms. Hunter said. “When we can get in there early, hopefully those children will be diverted from the Department of Juvenile Justice as a teenager and subsequently from the jail population as an adult.”

Last week, Ms. Hunter spoke to the Florida House Healthy Families Subcommittee, along with other representatives from the Departments of Education, Juvenile Justice and Children and Families.

“There is really no money put toward prevention or early education,” Ms. Hunter said. “I think Sandy Hook was kind of the final straw after a lot of tragedies. I think that from where I was sitting, they’re looking at implementing policy to drive a continuum of care that would promote healthy families.”

Even in Florida, which ranks next to last among the 50 states when it comes to funding mental-health services, year after year of budget cuts have forced some schools to cut back on counselors.

“Each one of our elementary counselors has two schools instead of just one,” said Donna Widmeyer, Charlotte County School District deputy superintendent. “That’s not something any of us like, it’s something that had to be.”

That would be roughly one counselor per 1,200 students. While counselors may respond to specific incidents such as fighting or helping parents find a therapist, they are limited not just by their scarcity. In addition, the counselors are asked to wear other hats, such as helping the school prepare to administer state tests. “Parents tend to think the counselors actually do counseling like therapy,” Ms. Widmeyer said. “Well, that’s really not what we do.”

The American School Counselor Association recommends one counselor per 250 students, although in a 2010 survey, almost no states met that average. Some states, though not Florida, fund their own mandates. Georgia requires one counselor per 675 students in kindergarten through first grade; Arkansas one to 450. Florida has an average of one counselor per 452 students as of 2010.

Labels for children

Labeling children with disorders such as oppositional defiant, bi-polar, attention deficit hyperactivity can become a self-fulfilling prophecy, said Fort Myers psychologist Dr. Rose Thorn. That’s partly because most people don’t understand the nature of what a diagnosis is, she said.

The names of diagnoses better serve health-care professionals who need to have a quick reference to a patient’s symptoms rather than a general public notorious for using them as a headline for someone’s character, she said. “I think people look at it as being much more authoritative than it is. Diagnosis in children is extremely open to question… Once we start looking at a person as being defective, as being a problem, our way of relating to them changes.”

Dr. Christopher McGinnis, a behavioral pediatric and family psychologist, agrees. He wrote in an e-mail: “Mentalhealth diagnosis typically only relabels the problem and offers no additional useful information. It also can have a negative impact on prognosis when the child and adults hear of the diagnosis and believe it means there is something broken or wrong with him. A diagnosis of oppositional defiant disorder, for example, only relabels the fact that he is oppositional and defiant and does not mean that there is something wrong with his brain on a chemical or structural level.”

While Dr. Thorn concedes that treatment of some children takes more “creativity” than others, she rejects the notion that any child could be born incurably lacking empathy. Instead, she argues that human beings are inherently adaptable, and that empathy, being in our best interest, can be taught or strengthened in any individual. “We don’t have sharp eyes or claws or scales,” Dr. Thorn said. “The only thing we have is our adaptability. That’s why we are successful as a species. Our adaptability is infinite from conception to death and maybe beyond, who knows? There is no child, no person, no old dog that can’t learn a new trick, no person that cannot change.”

Even adult psychopaths, who make up about 1 percent of the population but commit a “disproportionate amount of violent crimes,” according to the FBI website, tend to be misunderstood as inherently evil.

“Not all psychopaths are criminals,” the FBI website notes.

A small subset of children with conduct disorder develop anti-social personality disorder, or callous-unemotional could develop into a psychopath characterized by a lack of empathy or remorse. “It’s not as much that they’re unaware of certain codes of conduct; it’s more of a disregard for them,” Mr. Katz said.

Health-care professionals also warn that as a child’s brain develops, behavior can shift dramatically from year to year. There’s a risk that diagnosing young children with mood disorders such as attention-deficit hyperactivity — all of which indicate increased aggressiveness to some extent — can encourage “profiling,” said Cindy Krosky, a licensed clinical social worker who will be the keynote speaker for Child Care of SW Florida Inc.’s Early Childhood Conference on March 2.

Even children who seem to be the worst off often change dramatically in their teenage years or as adults. One child Ms. Krosky banned from her home years ago is now an Eagle Scout with a full college scholarship, she pointed out.

“I say that because if we had profiled him, this would have been one of those people I’d say lock ’em up because we’re going to read bad things about them later,” she said. “This was not the same child I saw between the ages of 6 and 8 that literally turned my stomach to be in their presence because they were so rude and disrespectful and antagonizing. I think if you and I look at ourselves, I’m not the same person I was as a child. I’m not even the same person I was five years or 10 years ago.” ¦