Two complex cases

Just finished a teleconference with a 'cast of hundreds' from one of our community clinics and also the inpatient service. 10 year old girl with school refusal from time to time, who has incredible anxiety attacks with screaming, serious upset, and occasional lashing out. The diagnosis is unclear, although the consensus is that she has a vestige of a separation anxiety with ongoing worries about mother's mental wellness and relationships; the precise nature of these has been obscure despite much detailed work by several therapists over a couple of years. We all feel that spending a lot of time worrying about the formal 'diagnosis' has not been useful, and that what works better is to take each little problem and work towards a solution, so that eventually all the little solutions will fit together into a clear jigsaw picture.

However, a distant family member is a doctor, and their reading of the symptom constellation is that the girl has juvenile bipolar disorder - a contentious diagnosis in Australia. Added to this the local education department will not provide extra in school support unless there is a clear diagnosis, and someone in the department has developed a nice little list of symptoms for bipolar, with the implication that if we sign a form to say she has bipolar then the girl will get extra help. She certainly has 7 of the criteria, but from my point of view, these could fit with at least 3 other issues. However, over a barrel, I accepted that we need extra help, so I signed the form last year..... Now of course everyone outside our service thinks the answer to getting change is some miniscule tweaking of medication. We, on the other hand, have tried many times to get change going for this girl - with medication as an inpatient and an outpatient used to target symptoms. This means she has been on one of the prime medications for bipolar for some time - with no success.

What has worked over the last few months is a clear and careful plan, focusing on one symptom at a time, with careful grading and practice of solutions. And our patient has attended school for a whole term. There is still a way to go, and we still need to focus better on mum and her problems, and possibly the mum and dad's relationship. I made the point today that about 5-6 years down the track the jigsaw will be much clearer, and we will all look back with the retrospectoscope, and say: "Oh, is that what was going on?" In the meantime we just have to keep plodding on (and try to avoid labels and medication). Sometimes life is very complex, and you just have to keep putting one foot in front of the other in the sure knowledge you will get to a destination.

The other case happened last night. As you will see if you visit our suicide prevention studies site, one major interest is in self-injury and its complex relationship with suicidality, and occasionally completed suicide. I received a phone call from a young woman who has been cutting herself, and also been in and out of anorexia nervosa over many years. She was at the casualty department waiting and waiting to have a cut sewn up. As is usual she had been treated with contempt, and then was sewn up without anaesthetic. Why is it that perfectly reasonable health staff turn into vengeful angels when faced with self-injury? "You are not really a patient (or perhaps even a person) if what you do is self injury!"

I am not the prime therapist for this woman, but we have presented on the same platform at conferences on self-injury. She phoned because there is a plan in place, and in the notes, which says she is not to be admitted unless 'in extremis'. She just wanted to go home to her family. The emergency staff wanted to take blood to see whether she had also taken an overdose (she had not), then they wanted to admit her on the grounds that this time the cut was deep and took 20 stitches. She was waiting to see a psychiatric registrar. She wondered whether I would speak to the registrar, and explain what I knew of her history, and the written plan, and see whether that would keep her out of hospital. I did, and the registrar was very pleasant. My young colleague told me later the registrar "was horrible. Rude. Short. Grumpy." And these are the so called 'helping professionals'!

Changing my grandson's behaviour??

Well, its been a busy time in the run up to Easter. I have officially become an old aged pensioner (or 'old fart') having had a birthday on the 8th April, and then 2 days later was the 44th wedding anniversary (as my father in law Reg would have said: "You don't get that for murder!"), so with all that and the forthcoming Easter, the blog has suffered (depending on your point of view, if you ever read it). Anyway, enough.

Seeing as we have been talking about behaviour, thought I would share a couple of things about my 5 year old grandson, which have happened in the last week or so. They have some relevance for the case we have been tracking, and again as Reg would have said: "All will be revealed".

First, my grandson has had some trouble finally getting in charge of his waterworks, and has been increasingly upset by the wet beds. In private discussion with my daughter in law, we decided to keep intervention simple. I recommended three things, keeping several ideas in reserve. First that they try to reduce late evening drinks. This is a logical move based on the physiology that there is maximum output from a drink at about 90 minutes, and most fluid passed by the kidney within about 150-180 minutes.

Next, I like ideas about operant conditioning, and no bedwetting occurs every night. So the idea as a parent is to wait until a dry night! Then you get very excited, applaud wildly, and make it absolutely clear to the child that you are pleased, and that he should be too. Finally, the child gets a small reward - anything from a star which gets stuck on a chart, to something negotiated and agreed with the child,  and that will not break the family budget! Anyway it has worked so far; so we may not have to use the other methods; just keep them up my sleeve.

The other story is about last Friday night. We were all having an Easter dinner and, about 8.30pm, my grandson is getting a bit bored. There he is behind me lying on a pathway made of small pebbles. First one got lobbed in my direction, then another. Not thrown with malice you understand; just boredom. So what do you do? Parenting and Grandparenting take so much patience don't they? There are of course many solutions, and I am sure you can think of lots. I just sat and waited. The little stones were not hurting, and I reckoned he would just get bored. Took 14 to get there, but he just got bored. Then he went meekly off to bed.

What would you have done?

On changing behaviour

We all do it; that is we all influence others to change how they are in the world, or what they do around us. Without having been trained, we all understand 'operant conditioning'. You do something nice for me; I reward you with a smile, a comment or a hug. Usually (unless you have mixed feelings about me and wish secretly that I would go away, or my hug comes with bad breath), that reward just slightly increases the chances you will do whatever it was again. Conversely if you say something unpleasant, or do something that upsets me, I may respond with a frown, an angry comment, or a slap (Mmm, that last has been pretty rare in my life; think the last one was to my nearly 30 yr-old daughter when she was 18 months and threatening to cross a busy road without me; told her twice, then picked her up over my shoulder and smacked her bum; she has never forgotten or forgiven, I think).

Anyway back to the blog. We build patterns between us that are full of my responses to you and your responses to my responses. Some people are remarkably subtle about their responses, and if you were a child in their family, you would have been 'trained' to recognise just the mere hint of an eyebrow being raised. In turn, you come to expect that others will pick up on your 'trained in' subtlety; and that may lead to problems if you are trying to relate to someone who does not come from a subtle family, and only recognises 'in your face' feedback (coming from their type of family where the volume button was constantly on 'high' when they were a child).

So let's apply this to Karl (see last 2 blogs). I think overall the volume seems to have been on high most of the time in his family (perhaps particularly in responses from Dad), though I also think that feedback may have been erratic with sometimes over-the-top responses for small naughty things; conversely low volume (subtle) or no feedback for positive things. So, I am going to have to try and 'learn the language of Karl's family'. Not so I can join in; rather so that I can help Mum to perhaps be more consistent in her responses, and perhaps be a bit more explicit to Karl so he knows what the responses to his actions mean. I feel a big job looming; guess we will have to find out what sort of family Mum comes from...

Of course these are micro changes, and we will need to build them into secure patterns if we are to get consistent changes happening. These patterns in their large forms are inherent in the best researched forms of treatment for behaviour disorders (see Multisystemic Therapy or MST), and also if we want to really try to understand how prevention might work (see Lacourse, 2002).

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.

The Future Beckons

I will not be here in 2100, yet I can still have concerns about how the world is shaping, what it might look like a few years from now, and what we could be thinking about to reduce the possibilities of an increasingly feral future. From my small corner of the world I am more and more worried that we have all these big picture worries at the international and national level, but we don't seem to think much about the day by day experience of ordinary families, and how this might influence children growing up into a world that will be very different to ours.

So I am going to draw on my 42 years of being a doctor, my 35 years of being a shrink, my 40 years of experiences as a father and grandfather, and see if I can make some sense of what I am experiencing at this point toward the end of what has been a stellar professional career. My hope is that we may begin a rich dialogue which might give us some ideas about the changes we have to make for our children to grow stronger, and prepare them for whatever the future holds.