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Sunday, April 5, 2009

Signs of trouble

Let me give you a flavour of what is troubling me. I want to examine some of these problems in much more detail, but at this point will just give a potted history. Then when I can find the time I will tease out the details, try and make sense of them, discuss why they trouble me, and try to suggest and discuss some solutions which work, but also try to suggest some preventive measures. I will also provide references to other material which may help you, the reader, if you identify with the problems and are struggling too. Of course I don't promise to have all the answers, and I need you to provide some feedback, and perhaps make a contribution to Child2100. Together we may be able to contribute some wisdoms.
I saw a new case the other day where a 9 year old boy (let's call him Karl) was presented. He is the 6th child in the family, arriving after the mother had decided to separate from her highly abusive husband; this is now a fact, and Mum is struggling on as a single Mum. As a consequence in the first few years, while Mum was sorting out her life, the boy had spent a lot of time staying with extended family members for the first 3 years of his life, eventually returning home for good, and settling into a school and the neighbourhood.
The current story is of angry and acting-out behaviour at home, in response to frustration, which sometimes gets out of hand, and the boy becomes abusive, and cannot be controlled with words. He then runs away, and family members have to chase him, or they alert the police to try to find and return him. Alongside this, Karl has similar problems at school, where he can be disruptive in class, and has lashed out at teachers and students. There has been a recent escalation in these behaviours, and Mum is predicting that he is beginning to become like an older brother of 18, with whom she has had serious problems escalating to criminal behaviour. When the mother runs out of energy, strategies and alternatives, Karl is sent to an uncle's house, or to an older sister's house, for time out. At one level this seems a great idea; terrific to be able to use the family in this way. It takes the heat out of the problems at home. However, I would argue that it is also storing up problems for the future. Mum was persistent at interview that the only way to help Karl is to provide some medication to quieten him down, so that she can control him at home, and the school may also be able to stay in control.
I have every sympathy with Mum and her request. However, when I saw Karl on his own, he was not the angry abusive kid described; rather he was a delightful cooperative chatty boy full of fun and teasing (yes, I realise it is a strange situation and he may have been on his best behaviour). He is confused by the chaos of his environment, upset that he lashes out, and wishes he did not; he wants to make some change, but does not know what to do.
At this point, there is no clear diagnosis, and I don't like prescribing just for some sort of control. Most of the drugs we have access to are dangerous, have side effects in the short and long term, can be misused, and in any case have rather poor research to suggest they work. And they don't solve the real problems; they just sort of cover things up. At best they may contain and control while we help Karl and his mum to learn some new skills. but is that the real issue? Surely a mother of 6 children has learned some terrific skills along the way? So will Mum want to engage in a helping process? Will Karl be able to sustain some therapeutic discussions? And what is it that we can actually do? And then what does it tell us about child parent relations in the future, and what they may mean for our countries toward the 22nd century?
And Karl is one of many; disordered behaviour is now the most common presentation in our clinics; and yet it is really hard to turn around. So, I have raised lots of questions. Tomorrow I may try to add something, to deepen the discussion.

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