Back to School, Back to Problems:
Symposium: Coney Island Hospital
Sharon R. Kahn, Ph.D
[This paper was originally presented at a hospital symposium on September 24, 1999]
Children, in the process of becoming adults, have to master some really complex tasks. They not only have to obey all the rules and customs that apply to the adults of the United States, but, have to comply with special rules that apply only to children--the prohibitions and regulations to which children are held by adults. Think about it--you don't ordinarily tell an adult to sit still, to finish their vegetables, to say, "thank you," to go to bed now, to sit up straight, or to use a special wooden block as permission to use the bathroom. Simultaneous with this, children operate within two parallel worlds, each of which demands mastery of uncodified rules and customs: the world of their peers and the world of their teachers.
All of these worlds within which the child has to operate depend upon the successful execution of cooperative relationships to others--to parents, to siblings, to teachers, and to peers. The success or lack thereof of this is the basis by which you as a parent or you as a teacher may wish to refer a child for therapy. Obviously, for some children, genetic factors play some role and may set some limits, but therapy can expand the possibilities. For example, Down Syndrome used to mean that every child was fated to have some degree of mental retardation. However, with early diagnosis, children can receive a very stimulating, constant therapy and adherents of this therapy have even reached normal intelligence and graduated from college. So it is with psychotherapy as well. It can expand the personal choices and options.
Life is about change. As the Zen master once said, "We want to control time, to savor the happy moments or to avoid the sad ones, but ultimately, that is impossible. For if we could reach out and grab the wind, it would no longer be the wind. And life is like that--ultimately, we cannot control we befalls us, but we can control our reaction to it.
Children's lives are filled with uncontrollable changes and stressors unpredictably impinging upon them. Even if ultimately, these stressors enrich their lives, they still demand some sort of adjustment. Adults make all kinds of decisions for them--to change apartments, to change cities, to change schools, to change partners, to increase the number of children in the household, etc. Sometimes, the changes children are subject to may not even be known to their parents--the child witnesses something en-route to at school, at a friend's house, etc. Even if these changes are in the long run, positive, children will manifest all sorts of responses to these changes--and their responses will be behavioral in manifestation. This behavioral will be manifested in one or several of the worlds which children occupy--home, school, or playground. Sometimes, the behavior may be a sort of regression to an earlier stage of development. Most children, if they were functioning adequately before the stressor will adjust within a few days and revert back to their typical level of functioning. However, if this regression persists and interferes with the child's functioning with school, family, or friends, then therapy is an option which one might consider at this time.
Children give off clues with their body and with their energy levels. Just as when they were toddlers, hopping from one foot to another, and you knew they had to go to the bathroom, you might sense that something is bothering them, from these behavioral changes. Children react behaviorally because they can't make the connection between the stressors and their reactions. It is unlikely that a child will directly tell an adult what is wrong--they just don't have the skill with abstract words or the emotional knowledge to do so. They are still very dependent upon their parents to set up certain types of relationships for them. In all my years of working with children, not once has a child ever called me up out of the blue and said, "Dr. Kahn, I need help." And only once has a child ever initiated the referral to therapy by asking her parents to get her someone to talk to (and that was a child where both sets of parents and both sets of stepparents were in psychotherapy and frequently discussed their progress with each other). So given that your child is not directly going to ask for this, you must be the detective and analyze their behavior. There are two gross manners by which children manifest behavioral changes--I like to call them the disappearers and the disturbers. Research indicates that the majority of children who manifest the symptoms of "disappearance" are girls, and those who manifest the symptoms of "disturbance" are boys. However, there is some overlap between the categories, which is why I put all the symptoms on this one sheet. The disappearers are the withdrawn, sad-looking children who stare out the window in school. They don't cause trouble and they don't call attention to themselves. However, they still need help in order to adjust to whatever is making them so sad or so worried, because whatever they are paying attention to, it probably isn't the academic tasks they need to be focussing on in school. Furthermore, their brooding sets them apart from their peers and they end up missing out on important social skills learning. They don't feel good about themselves. They don't have a positive sense of identity. They don't feel effective in their own life. They don't feel that they can make a contribution. Disturbers are usually what many teachers refer to as the acting out children--they make their distress manifested to everybody. They are the ones who get attention. So, in a way, the acting out child is one who intuitively behaves in such a way as to guarantee that sooner or later, he will receive the help he may need. Disturbing behaviors can be very functional, for example:
1. Preserve positive identity: The child may not be able to learn the material, may need more time, or more individual attention to order to master some subject matter. Disrupting the class can be a way to avoid feeling inadequate in front of peers.
2. Inappropriate reading of social cues: Some children have a difficult time differentiating "accidental" from "intentional" behavior. Such a child believes that when he is shoved in line or trips over another child's foot that this was an intentional act on the part of the other child, and demands an aggressive response in return.
However functional the behavior may be, living with the disturber or trying to teach the disturber takes quite a toll on the adult. Some disturbers have a way of making adults feel quite angry and frustrated with them, and then also guilty that they don't love the child as they out to. Life with a disturbed child can precipitate quite a cycle of negativity and crisis. It can be difficult to remember when you last felt loving to such a child. Referral to therapy can be quite a relief to all--the parent, the teacher, and the child.
What happens in therapy?
Now that I've presented a brief and general overview of the signs which warrent clinical interventions, you may be wondering if you decide to refer your child for therapy, what will happen? How can psychotherapy help your child? Children who are referred for treatment usually aren't having many positive, joyful experiences. They probably aren't learning well in school, they are having problems making and keeping friends, and they don't feel good about themselves inside. Good therapy is about improving functioning in several crucial arenas:
1. Psychotherapy is about making connections--what happened, what led up to it, what were you thinking and feeling, and how did you respond. What sensations is the child holding in their body and what corresponding emotions do they represent? This by itself can offer a very powerful perception of self-control and accomplishment.
2. Psychotherapy is about increasing awareness that there are alternatives: How did you respond, looking back, how else could you have handled it? What if you were to do this or that? They learn that they can chose some behaviors.
3. Psychotherapy is a laboratory for learning alternative ways of responding and of rehearsing these alternatives.
This list makes child work seem very orderly and rational. Although all of this is embedded within the nature of the work, child therapy proceeds in a much looser fashion than how I described it. The therapist helps the child through a playful and permissive atmosphere. Psychotherapy offers an escape from most of the rules and constraints of home and school. The child is freed from having to be "nice" or "polite" or "respectful." This, however, does not mean there are no boundaries. There is a freedom from some social conventions, there is a freedom of expression. The child is free to let off some steam in the presence of an adult without fearing that he will be abandoned, punished, or lose love. However, there is no freedom to physically hurt the therapist, harm objects in the office, or cause harm to any other children. Therapy is a safe place to develop and to accept the feeling of one's own vulnerability.
Sometimes, if the referral is precipitated by poor school-work, we may recommend psychological testing of your child. These tests offer a detailed picture of how your child is functioning at that time--what are their relative strengths and weaknesses, what are their learning styles.
Sometimes, during the referral process, you and the psychiatrist may decide to place your child on Ritalin or another medication. You may wonder, if they take their medication regularly, why does he still have to come for therapy too? Therapy will be necessary even if your child is offered medication. Medication helps to increase the child's ability to benefit from a therapeutic situation. Medication turns up the signal to noise ratio in your child, so he can be receptive to what the therapist says. Medication can increase the teachable moments for your child. By itself, medication doesn't teach appropriate social behavior or help your child learn alternatives to aggression. Medication doesn't solve the problems incurred by living in a crowded, hectic urban environment. Medication doesn't remedy the gaps in knowledge created by months of inattentiveness in school. That's what therapies offer. With medication, the teacher can instruct him, the therapist can reinforce him.
Finally, I just want to conclude by inviting parents to be as involved with their child's psychotherapist to the fullest extent that they are able. Psychotherapists are not mind readers or magicians. We are like detectives. We are experts at cracking the symptoms and problem solving.
Ultimately, psychotherapists want to share their expertise with the parent. You know your child much better than anyone else does. The therapist needs the parent as an important partner in the therapy team. The parent is an important contributor--what happened in that child's day. Children tend to skip over anything that makes them feel bad about themselves or weak or incompetent. Chances are, they will talk about their strengths in therapy, or how other children in their class are "bad." They're unlikely to tell us how they can't sleep at night because they heard shootings, or they have nightmares about their class bully. You are the one that they are most likely to turn to. No therapist is likely to have the impact on your child that you will.
Together, you and the therapist figure out the best way to help the child. Both the parent and the therapist are members of the same team. We both want the child to be a more effective student, to be a more cooperative family members, and to become an adult with a positive sense of identity. We both were once former children and we both can connect with the experience of being ignorant, powerless, and controlled by others. That is why it is crucial to the success of the therapy to meet frequently with the therapist, even if the child is away at camp or on a class trip and cannot come with you. Several very successful cases in the literature were those of parents who were coached by a therapist and where the child was never even brought in.
Unless your child is referred by the court, or there are special circumstances precipitating the referral, you and your children have confidentiality. Without your signed consent, I cannot even tell someone that they are even in therapy here.
Important signs of distress:
Changes will be manifested in child's ability to function in school, to be a good family member, or in their ability to make or keep friends:
1. Activity level (either more or less)
3. Sleep patterns (either more or less)
4. Response to new events/people (intensity of response)
5. Ability to transition from one activity to another (fussing, bellowing, oppositional)
6. Regression to an earlier level of functioning (toileting accidents, frequent crying, frequent whining, clinginess, etc)
7. Level of cooperation with school routines
8. Willingness to play according to rules and take turns with peers
Common behavioral symptoms of distressed children:
Every child will occasionally show some of these symptoms. Some of these symptoms will only be apparent in school or with peers. However, if your child persistently has several of these symptoms or they increase in intensity, or if these problems interfere with your child's daily life, you may wish to refer your child for an evaluation for psychotherapy.
Problems sustaining attention in school or at play
Does not seem to listen when spoken to
Fails to finish school or non-school activities
Out of seat frequently in class
Frequently interrupts others
Difficulty in taking turns
Frequently initiates fist-fights
Physical cruelty to animals or humans
Refusal to attend school
Frequent complaints of stomachaches or nausea
Refusal to leave parents/clinginess
Failure to speak in social situations
Lack of interest in usual activities
Sad or irritable mood; tearfulness
Significant weight loss
Feelings of worthlessness
Excessive anxiety or worries about school or non-school activities
Drop in grades
Anticipates the worst, broods