Parenting as Therapy for Child’s Mental Disorders

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December 22, 2006

Troubled Children

Parenting as Therapy for Child’s Mental Disorders

By BENEDICT CAREY

http://www.nytimes.com/2006/12/22/health/22KIDS.html

BUFFALO — In school he was as floppy and good-natured as a puppy, a boy

who bear-hugged his friends, who was always in motion, who could fall off

his chair repeatedly, as if he had no idea how to use one.

But at home, after run-ins with his parents, his exuberance could turn

feral. From the exile of his room, Popczynski would throw anything

that could be launched — books, pencils, lamps, clothes, toys — scarring

the walls of the family’s brick bungalow, and leaving some items to rattle

down the hallway, like flotsam from a storm.

The Popczynskis soon received a diagnosis for their son, attention-deficit

hyperactivity disorder, or A.D.H.D., and were told that they could turn to

a stimulant medication like Ritalin. Doctors have ample evidence that

stimulants not only calm children physically but may also improve their

school performance, at least for as long as they are on medication.

But like most other parents, the couple preferred to avoid drug treatment,

if possible. Instead, with the guidance of psychologists at the University

of Buffalo, they altered the way they interacted with and his

younger brother, . And over the course of a difficult year, they

brought about a transformation in their son. He still has days when he

gets into trouble, like any other 10-year-old, but he no longer exhibits

the level of restless distractibility that earned him a psychiatric

diagnosis.

“People are so stressed out, and it’s so much easier to say, ‘Here, take

this pill and go to your room; leave me alone,’ ” Popczynski said on

a recent Monday after work. sat on the couch, hunched over his

homework, while her husband, Roman, occupied , 8.

“But what I would say is that if you are willing to take on the

responsibility of extra parenting, you can make a big difference,” said

Ms. Popczynski, an interior designer. “I compare parenting to driving. We

all learn pretty quickly how to drive a car. But if you have to drive a

Mack truck, you’re going to need some training.”

In recent decades, psychiatry has come to understand mental disorders as a

matter of biology, of brain abnormalities rooted in genetic variation.

This consensus helped discredit theories from the 1960s that blamed the

parents — usually the mother — for problems like neurosis, schizophrenia

and autism.

By defining mental disorders as primarily problems of brain chemicals, the

emphasis on biology also led to an increasing dependence on psychiatric

drugs, especially those that entered the market in the 1980s and 1990s.

But the science behind nondrug treatments is getting stronger. And now,

some researchers and doctors are looking again at how inconsistent, overly

permissive or uncertain child-rearing styles might worsen children’s

problems, and how certain therapies might help resolve those problems, in

combination with drug therapy or without drugs.

The psychotherapy techniques intended for the improvement of interactions

between parents and children have been used mostly for children who suffer

from attention disorders or who exhibit aggressive or defiant behavior.

But recently, mental health professionals have been studying their use for

families whose children suffer from depression or other mood problems.

In a comprehensive review, the American Psychological Association urged in

August that for childhood mental disorders, “in most cases,” nondrug

treatment “be considered first,” including techniques that focus on

parents’ skills, as well as enlisting teachers’ help.

And in its just-completed guidelines, even the American Academy of Child

and Adolescent Psychiatry, an organization whose members strongly favor

drug treatment, recommends that children receive some form of talk therapy

before being given drugs for moderate depression, a very common complaint.

“We are at a point where families who bring in a child ought to get a

Chinese menu of treatments that are backed by some evidence, including not

only medication but psychosocial or family interventions,” said Dr.

March, a child psychiatrist at Duke University. “Not to do so when we know

some of these therapies work is, in my opinion, simply unethical. Then let

the family choose which one they want.”

The argument over which is better, medication or psychotherapy intended to

change the behavior of parents and children, is irrelevant in many cases.

A child paralyzed by feelings of severe despair or anxiety, for example,

often cannot begin to engage in any type of therapy without a period on

medication to break the disabling mood. And many studies suggest that the

combination of medication and talk therapy is significantly more

effective, and safer, than either alone.

Drugs, Therapy or Both?

“It’s obvious that medication has been more effective than behavioral

modification in treating the core symptoms of A.D.H.D., but behavioral

treatments can produce real improvement, and for certain kids the

combination of the two treatment appears to be best,” said Dr.

Bukstein, a child psychiatrist at the University of Pittsburgh School of

Medicine who is helping the American Academy of Child and Adolescent

Psychiatry write treatment guidelines. “Children with other behavior

problems in addition to A.D.H.D., for instance, seem to do best with both

treatments.”

The Popczynskis found that a brand of family therapy by itself was

sufficient to put on track at school and at home. Their experience

helps illustrate how a family can, in effect, treat a child’s psychiatric

disorder — and for whom such an approach can be practical.

One thing the family had going for it was location. When ’s mother

began scouring the Internet for resources in the spring of 2003, she

quickly learned that they lived only a few miles from the University of

Buffalo, which runs one of the country’s most comprehensive behavioral

modification programs.

In a study involving 128 families, psychologists at the university had

found that about a third of parents who completed the program saw enough

improvement in their children that they had decided that medication was

unnecessary. The other two-thirds put their children on stimulant

medication at school but at doses significantly lower those typically

prescribed, said Pelham, a psychologist who is director of the

Center for Children and Families at Buffalo and the senior author of the

study. Eighty percent of the families who participated in the program,

with follow-up parent training, decided that their children did not need

medication at home.

“Most parents seeking help for a child with a psychiatric disorder never

hear about programs like this,” Dr. Pelham said. “The only option they’re

given is medication. Now, it may be that the best treatment for that child

is medication. But how do you know if you never try anything else?”

Behavior modification for A.D.H.D. and for related problems, like

habitually disruptive or defiant behavior, is based on a straightforward

system of rewards and consequences. Parents reward every good or

cooperative act they see: small things, like simply paying attention for a

few moments, earn an “attaboy.” Completing homework without complaint

might earn time on a Gameboy. Parents remove privileges, like television

and playtime, or impose a “time out,” in response to defiance and other

misbehavior.

And they learn to ignore annoying but harmless attempts to win attention,

like making weird noises, tapping or acting like a baby.

Tracking Behavior

These skills are hardly unknown to seasoned parents. But most also know

that stress or anger, even when dealing with a child who has no serious

problems, can sour the best instincts. That is why family-based programs

insist that parents try to maintain a clear, neutral tone when instructing

their children, or penalizing them.

Bluntness, for example, is a virtue. Saying to a child, “Would you put

your toys back in the box, please?” turns a command into a question.

Saying, “Let’s put your toys back in the box,” implies collaboration. An

unadorned “Put your toys back in the box” is clearer for everyone,

psychologists say, especially so for a child who is highly distractible.

However it is dressed up, family therapy like this teaches parents to

provide what many critics say children these days are missing —

discipline. But therapists make a careful distinction between corrective

action and cruelty, between firmness and frostiness. Overly punitive

parents increase the likelihood that a child will develop mood problems,

some studies suggest. So parents learn not to become scolds, but to bring

their children into line without demeaning them.

In some programs, parents play-act situations in front of their peers, who

critique the performance for emotional tone and the clarity of parents’

statements. As a result, the parents say, they become immediately more

deliberate at home. “You end up constantly saying things like, ‘That’s not

an appropriate behavior,’ using this unnatural language,” said Ms.

Popczynski. “But the point is you don’t get into it with them. The first

thing I noticed was that I wasn’t yelling all the time. The house got a

lot quieter right away.”

Their instructions to and became more precise, as well. Saying

“Clean your room” is too vague and covers a half-dozen tasks, Roman

Popczynski, the boys’ father, said. might wonder where to start, or

just decide it was too much to worry about, and give up, his father said.

“Put your laundry in the hamper” is much more likely to get results, he

said, and lead to the next clear step, like “Put your toys where they

belong.”

Multiple commands are also confounding: “Put away your crayons, clear away

the table, and organize your homework, please” leaves a child wondering

which to do first, and whether it is too much work to finish. “It

overloads a kid, and then he feels like he’s failing, which only makes it

worse,” said Mr. Popczynski, who is a UPS driver.

Starting Slowly

Like most who try to use behavior modification techniques, the Popczynskis

relied on a daily report card to keep a running tally of ’s specific

problem behaviors, like wandering attention, ignoring commands or

defiance, and his efforts to correct them.

For instance, at the beginning, , then 7, would get a check mark

every time he ignored more than two commands to do his homework, put away

his toys or brush his teeth, but he would earn immediate praise if he got

started. He received check marks when he slid off his chair at dinner, and

earned approval if he stayed seated.

At bedtime he accumulated marks if he pulled delay tactics. A tantrum

resulted in instant punishment: a timeout of 5 to 10 minutes, shortened

for good behavior. The report card was posted on the refrigerator.

The Popczynskis started slowly. They measured how many marks

recorded in a normal day, and at first rewarded him if he reduced the

number by even one: with an extra 15 minutes on Game Cube, for example. If

he had more good days than bad ones over the course of a week, he got to

choose from a bag of toys from the $1 store.

Mr. and Ms. Popczynski continued to raise the standard, one checkmark at a

time, until hit zero consistently.

“You want them to be able to succeed,” Mr. Popczynski said. “If you make

it too hard, they’ll just give up, and so will you.”

The Buffalo program is more comprehensive than most: psychologists run a

summer camp here, employing the same principles, and, during the school

year, regularly visit the teachers of every child in the program. Those

teachers who agree to cooperate — most do — keep daily behavior report

cards for the child too, in effect providing full coverage for a child’s

every waking hour.

Even then, the therapy is far from a silver bullet or an automatic

replacement for treatment with Ritalin or other drugs that are routinely

prescribed for attention disorder based on many studies showing their

effectiveness. The constant tallying and reminding is too exhausting for

some parents, especially those raising children on their own and juggling

outside jobs. The Popczynskis did well in part because ’s

difficulties were not severe, he was a capable student and his most

disruptive behavior came out at home, Mr. Popczynski said. And the couple

were able to share the many duties.

Yet most parents in the program have found that their children do best

with a combination of the medication and family treatment, albeit with

significantly lower doses of the drugs than typically prescribed.

Dawn Van de Wal, a single mother of three in Buffalo, said that over the

last six months she has learned to contain and redirect the behavior of

her exuberant 9-year-old, TJ, who has received a diagnosis of

attention-deficit disorder. TJ can still become extremely frustrated when

required to sit for long periods and concentrate on schoolwork, in the

absence of his mother.

“I still give him medication for school, because the fact is that right

now he needs it to get through the day, but it’s a low dose,” Ms. Van de

Wal said while TJ practiced headstands on the couch. “He doesn’t take it

at home, though, and I plan to reduce the dosage in time as much as I

can.”

She added, “I don’t want him to look back and think the successes he’s had

are all due to a drug.”

In surveys and in dozens of interviews, most parents of children with

psychiatric diagnoses say that they prefer to avoid using medications, if

possible. It is not so easy to do. Insurers as a rule do not fully cover

behavior modification therapies because they cost substantially more than

drugs.

The therapies require an enormous commitment from already overloaded

parents, and some children are too severely troubled to respond. Many

clinics do not even offer the programs.

Psychiatrists, pediatricians and family doctors also tend to be more

comfortable writing prescriptions for psychological reasons.

Shifting Perceptions

“It’s a tremendous relief for the physician to prescribe something,

because these kids are very tough, and it feels horrible to sit there and

not be able to help,” said Dr. , a child psychiatrist

practicing in Arlington, Mass., who has argued for more caution in using

medication. At every level, she said, the mental health system strongly

favors drug treatment.

Yet the increasing number of studies that support family-based behavioral

treatment is shifting perceptions. The largest study comparing medication

with behavioral modification therapy for attention deficit problems,

released in 1999, found that drugs were more effective in improving

children’s ability to focus and keep still. But more than three-fourths of

those treated without medication did well enough that their parents were

able to keep them off drugs. And behavior therapy significantly improved

children’s reading performance and their relations with parents and

teachers when combined with medication, the study found.

Researchers have also studied a different approach to behavior treatment,

called cognitive behavior therapy. This approach engages children

directly, and signs up parents as helpers. The children meet in groups to

speak with a therapist, and learn elementary ways to identify and manage

their anger, frustration and hopelessness. The parents learn in sessions

how to reinforce those lessons at home.

Studies find that up to three quarters of children who suffer from

depression, anxiety or obsessive-compulsive disorder find relief of their

symptoms with the help of this kind of therapy, which usually involves

once-a-week sessions for a few months or so.

Brzycki, a freelance editor who lives in Lawrenceville, N.J., said

she noticed several years ago that her son was struggling more than usual

with Tourette’s syndrome, a neurological disorder that causes involuntary

facial tics and limb movements.

The condition did not stop him from making friends or doing well in

school, Ms. Brzycki said, “but I think it was first grade, I realized that

he was stifling the tics at school, and it created this boomerang effect,

and they came out like mad at home.”

At the urging of a doctor, she took the boy, by then 9, to a program at

Temple University in Philadelphia that specializes in treating childhood

anxiety, which can exacerbate Tourette’s. Therapists teach children to

identify the thoughts that amplify their worries, and then defuse or

moderate them. Ms. Brzycki and her husband attended sessions, too, and Ms.

Brzycki learned she was unwittingly contributing to her son’s anxiety.

“The main thing that came out for me was that I was being overprotective,”

she said.

She added: “As a parent you want to protect a child from stressful

situations, but by doing that you’re creating an avoidance mechanism that

can turn a minuscule anxiety into the big, bad wolf. I had to loosen my

grip” and let him face his fears.

Now in fourth grade, her son has helped make a DVD about Tourette’s

syndrome that he has shown to classmates. He has a close circle of

friends, his mother said, and his tics seem to have diminished lately. But

he sometimes still feels self-conscious and will talk himself through it,

with his parents’ help if needed.

Family-based therapy for a difficult childhood disorder is in almost all

cases a way of life, not a weeks-long or months-long cure. If parents are

serious about finding alternatives to drug treatments, experts say, they

have to be willing to make difficult, and long lasting, changes to their

behavior and the home environment, and to allow the child to progress at

his or her own pace.

“You can’t let your foot off the accelerator with something like

behavioral modification for A.D.H.D., for example,” said Dr. le

Carlson, director of child and adolescent psychiatry at Stony Brook

University School of Medicine, who used the treatment for her own son.

“It’s like making changes in diet and exercise to lose weight: you don’t

lose 20 pounds and then you’re home free and can eat ice cream and cake

again. No, it’s a complete lifestyle change, and when you have a child

with any of these psychiatric difficulties you have to stay on the

program, for as long as it takes.”

- - - -

Troubled Children

Doses of Reality

This is the last in a series of articles about the increasing number of

children whose problems are diagnosed as serious mental disorders. The

earlier articles examined one family’s experience, the uncertainty of

diagnosis, the use of combinations of psychiatric drugs and the transition

to adulthood.

Previous Articles in the Series »

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