For Children With Psychiatric Disorders, Can Better Parenting Make A Difference?

For Children With Psychiatric Disorders, Can Better Parenting Make A Difference?

Parenting therapy for child's mental disorders (December 22, 2006) -- 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, Peter 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 Peter and his younger brother, Scott. 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,’ ” Lisa Popczynski said on a recent Monday after work. Peter sat on the couch, hunched over his homework, while her husband, Roman, occupied Scott, 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. John 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. Oscar 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 Peter 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 Peter’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 William 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 Peter and Scott became more precise, as well. Saying “Clean your room” is too vague and covers a half-dozen tasks, Roman Popczynski, the boys’ father, said. Peter 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.

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.

Popczynskis started slowly. They measured how many marks Peter recorded normal day, at first rewarded him if he reduced number by even one: with an extra 15 minutes Game Cube, example. had more good days than bad ones course week, got choose from bag toys $1 store.

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Last updated: 12/06

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For Children With Psychiatric Disorders, Can Better Parenting Make A Difference?