Washington Parent Magazine, December 2002
Kay Kosak Abrams, Ph.D.
It seems that everyone knows about or has heard about "ADHD." Parents rarely call the doctor's office to say, "I think my child has sensory deficits," or "Does my child have social anxiety?" If behavior is out of the ordinary, with respect to social or school adjustment, many parents and teachers largely think, "hmm…maybe it is ADHD."
One 3-year-old child is aggressive after his baby sister arrives. A 9-year-old boy will no longer attend school and complains of stomachaches. An adopted child is acting ambivalent about her mother's affections. A 14-year-old girl is shutting down after months of resorting to restrictive dieting because she is preoccupied with feeling bloated. The son of newly divorced parents is sleeping too much. When is an out of the ordinary behavior a "red flag" for a more extensive problem or simply "a stage" to overcome?
"Normal" behavior is determined by what a culture deems adaptive as well as acceptable. Clinically speaking, maladaptive behavior is behavior that persistently interferes with positive development in social, familial or school functioning. So, talking to a friend or exercising may be considered an adaptive response to a stressor, while nail biting or obsessive worry not adaptive. Similarly, physical activity and fidgeting may be considered normal for a group of boys who need to "get the ants out of their pants." However, to be persistently "driven like a motor" with minimal ability to "put on the brakes," to the point of poor functioning at home and at school, is out of the ordinary and worthy of intervention.
Without a graduate level course on diagnostics, how are parents supposed to have perspective, and how are we to respond to any out of the ordinary behaviors we see in our loved ones?
Behavioral Syndromes and Psychological Disorders
Mental Health professionals rely on the Diagnostic and Statistical Manual (DSM-4th edition), to categorize clusters of symptoms and maladaptive behaviors in order to develop and implement treatment plans that facilitate positive change.
While there is great controversy surrounding our diagnostic system, and rarely does any young child fit squarely into a diagnosis, identifying behavioral syndromes that are maladaptive can transform frustration and anger into insight, acceptance and growth.
Ethics and the Art of Diagnosis
We educate people about psychology and behavior to take away the stigma and to empower family members. By broadening our understanding, we expand our ability to observe and respond to atypical behavior, thus reducing ignorance, neglect and fear.
The descriptions of mental health challenges below are generally illustrative and cannot do justice to the very careful standardized differential diagnostic system. This summary only touches upon some of the behavioral syndromes that might be considered in assessing out of the ordinary behaviors.
Attention-Deficit Hyperactivity Disorder
When a question of attention deficit is presented, we must consider distractibility, hyperactivity and/or impulsive behaviors that are present to the degree that functioning at home, school or work are gravely compromised over a long period of time.
What is loosely referred to as "ADD" (without the "H") typifies the daydreamer who is inattentive and disorganized but not necessarily hyperactive or impulsive. Attention Deficit Disorders are inheritable and neurological in nature and do not surface suddenly, although the inattentive bright "daydreamer" may hide well until academic challenges are greater. Inattention results in frequent careless mistakes, limited ability to listen, weak organizational skills and poor follow-through.
Hyperactivity is manifested by fidgeting and moving as if "driven by a motor," with accompanying inability to "put on the brakes" despite negative consequences. Impulsivity can result in inappropriate boundaries. An impulsive person may be unable to wait her turn and is prone to blurt out answers, interrupt or intrude upon others without recognizing the intrusion.
With classrooms as large as 30 students, teachers may over react to those who cannot sustain attention and compliance. A diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) is appropriate only when excessive motor activity is so persistent that social, familial and school functioning are significantly hampered. When a child is "driven like a motor," to the point that her sense of mastery and self-esteem are lost, intervention becomes essential.
An Adjustment Disorder is the development of symptoms in response to an identifiable stressor. The symptomatic behaviors are representative of marked stress, and an impairment is seen in social or academic arenas. An example of an Adjustment Disorder would be marked anxiety, depressed mood or misbehavior in response to a major change, such as moving, a job change, divorce or other significant loss.
Oppositional Defiant Disorder
Oppositional Defiant Disorder (ODD) involves a pattern of negative hostile and defiant behaviors over time. Loss of temper, frequent arguing with authority figures, noncompliance, blaming others, anger and deliberate annoying behaviors are present. The oppositional child or teenager appears to be reactive and hypersensitive, but rather than be exposed or experience vulnerability, all frustration is projected outward and others are blamed for their distress. Accountability or apology are impossible, and loved ones may find themselves resorting to dramatic threats or punitive responses to force compliance and accountability.
Anxiety is nervousness, worry and/or excessive fear. Physical expressions of anxiety may include compulsive behavior, interrupted sleep patterns, excessive perspiration or heart palpitations. Significant anxiety can lead to panic attacks whereby a child or adult feels out of control and experiences symptoms such as heart palpitations, sweating and runaway thoughts, as well as difficulty breathing.
Anxiety disorders include obsessive-compulsive disorder, separation anxiety as well as specific phobias, such as fear of dogs. Anxiety disorders can develop as a response to trauma. Post Traumatic Stress Disorder (PTSD) is also an anxiety disorder which involves anxiety, flashbacks and nightmares in reaction to experiencing or witnessing a traumatic event.
Inappropriate or excessive anxiety concerning separation from home or a primary attachment figure with expressions of distress upon separation and excessive worry about losing an attachment figure are all signs of separation anxiety. Refusal to go to school or elsewhere and/or reluctance to be alone - including reluctance to go to sleep - are also signs of separation anxiety. Repeated nightmares or physical complaints such as headaches, stomachaches, etc., when separated from one's primary attachment figure are also signs of separation anxiety.
Severe social anxieties are expressed in marked persistent fear of one or more social or performance situations in which the person may be exposed to possible scrutiny. She fears acting in a way that will be humiliating or embarrassing. Exposure to the feared social situation provokes anxiety. Therefore, the child or teenager avoids situations that might result in such embarrassment and subsequent anxiety. In its most severe form, the feared situation provokes a panic attack.
Childhood Depression does not look different from depression in an adult. When a person is depressed, she may not cope as well as usual and may feel excessively tired. Loss of enthusiasm for activities previously enjoyed is typical of depression. Excessive sadness or preoccupation with death or loss may be present, as well as sleep problems, moodiness, distractibility and irritability. Children or teenagers who are depressed typically become withdrawn socially and may also become irrational and oppositional.
Reactive Attachment Disorder
Children who develop Reactive Attachment Disorder of early childhood have markedly disturbed or inappropriate social relatedness in most contexts. There is a persistent failure to initiate or respond in a developmentally appropriate fashion to social interactions. A child with an attachment disorder may respond to nurturing with highly ambivalent or contradictory responses, i.e. with a mixture of approach and avoidance or resistance to comforting. A child with an attachment disorder may, in fact, be overly friendly to relative strangers.
This disorder of attachment largely develops out of persistent disregard for a child's basic needs for comfort, stimulation, and affection. Ambivalent feelings about closeness are the result of repeated changes of primary caregiver's that prevent the formation of stable attachments.
Asperger's Disorder is a relatively new diagnosis for children who show marked impairment in the use of nonverbal social behaviors, such as eye contact, facial expression, body postures and gestures to regulate social interaction. There is a failure to develop peer relationships that are appropriate to developmental level. There is also a lack of spontaneous seeking to share enjoyment, interests or achievements with others.
In general, emotional or social reciprocity is absent, and repetitive patterns of behavior may be exhibited. An example is a preoccupation with one or more interests with abnormal intensity or focus. There may even be an inflexible adherence to rituals. Repetitive motor mannerisms such as finger flapping or twisting or even whole body movements may be present. Unlike Autism or Pervasive Developmental Disorder (PDD), there is no clinically significant general delay in language or in cognitive development.
Greater Knowledge Empowers Parents to see the Red Flag
When a 3-year-old cannot resist the impulse to bite after her baby sister arrives, she may be showing signs that the adjustment is temporarily overwhelming her. A 9-year-old who refuses to go to school because of "stomach aches" may be experiencing significant anxiety about a social problem that he had been unable to resolve at school. A 14-year-old who withdraws from her friends and is consumed with dieting may be coping poorly with relatively normal adolescent feelings of insecurity. And, given what you have learned about depression, a child of newly separated or divorced parents may feel overwhelmed with fatigue, a sign that he may need extra support while feeling depressed.
Children, teenagers and adults are usually motivated to see mental health professionals when psychological and emotional symptoms are distressing enough to affect their home or school life. When behaviors become maladaptive and persist over time, healthy functioning for the whole family is disrupted.
Understanding out of the ordinary behavior¾beyond ADHD¾should not be reserved for only those who are bold enough or desperate enough to seek psychotherapy only after problems have heightened to the point of crisis. If our psychological education is broadened, we are all better able to identify and respond to atypical behavior in a manner that is both accepting and promotes growth.
Copyright 2002 - Dr. Kay Abrams
Kay Kosak Abrams is a psychologist in private practice and the parent of three children, ages 8, 11 and 14. She specializes in parent coaching, behavioral assessment of young children and advocacy for students who have learning disabilities. Kay Abrams works with children, families, adolescents and couples. She also has 20 years experience treating eating disorders and founded a "Rediscover Eating" workshop for chronic dieters and compulsive overeaters.
This presentation was the second in the Lecture Series, "It's Just Life: Taking the 'psycho' out of the psychology of everyday living," which began in the Fall of 2002 and is sponsored by Washington Parent. For information or registration, click on "Presentations and Workshops" on the left side of the screen.