Mental illness in children is different. The worst mistake is to assume these young humans are little adults. They’re not. There are so many variables, most of which is a developing brain in an increasingly hostile culture.
Depression in kids does not look like it does in adults, with depressed mood, sleepiness, lack of enjoyment of life and decreased libido. Irritability is the hall mark symptom in kids. Manifest in emotional meltdowns. And anger. Children’s psychiatric illnesses are largely undifferentiated, and sometimes hard to tease out. One kid will turn out to have major depression, another schizophrenia, still another a personality disorder, and the last will outgrow everything. Trauma is often, but not always a common denominator. No set rules. Kids are what their grandmothers ate.
PTSD is a diagnostic category that emerged from the Vietnam War. The range of symptoms seen among the returning veterans did not fit other categories of mental illness. The cluster of symptoms was not just depression or simple anxiety, and not only related to the use of drugs or alcohol.
The PTSD complex included flashbacks of traumatic events, extreme vulnerability, irrational fears, nightmares, depression mixed with anxiety and rage. Vets were placed on cocktails of prescription medication – with mixed results – as the diagnosis became widely accepted and many millions of dollars were invested by the federal government to understand the syndrome better. PTSD was made an official disease in 1980; 2700 years after Homer described the effects of war on warriors in his Iliad.
More recently, the category has been refined to fit kids who have been subjected to violent and abusive events. Perhaps they witnessed parental abuse and violence or had been physically or emotionally abused. These kids may lose control of their emotional regulators. Their emotional centers were hijacked.
The part of the brain that processes emotions and perceived inputs like fear into rapid burst of hormonal outputs is called the amygdala or emotional regulator. It is the part of the deep ancestral brain that responds directly to environmental signals, premonitions, and threats. The conscious neural connections to protect this part of some children’s emotional brain from being directly activated can be poorly developed, perhaps destabilized by childhood trauma or even stress in utero.
Ordinarily children learn how to control their emotional states. This is one of the major tasks of childhood. Kids subjected to trauma during vulnerable developmental periods may miss the development of emotional control. This emotional dysregulation flows through many childhood disorders. It is almost a universal symptom.
A kid’s symptoms can be a proxy for both parents’ and society’s issues. Environment, culture, and genetics all contribute influence. Throw transgender confusion into the mix. Gas on a fire.
There is pressure on providers to apply a label. For parents, it may seem like a relief to have a diagnosis. Any diagnosis. Progress toward understanding. It’s an Illusion. Yet, the diagnosis flow as from a geyser. Surely, you’ve seen that chart.
Depression, anxiety, histrionic personality, schizoid-affective disorder, eating disorder with anorexia and bulimia, conduct disorder, borderline personality, and manic-depressive disorder. Maybe a handful of other “disorders” form the DSM.
Equally impressive is the list of medications, all with dates connected to disorders. All the SSRI’s, Ritalin, antipsychotics from Abilify to Seroquel to clozapine – and a long list of antianxiety medication in a broad range of dosages.
Sometimes the problem consists of too much care rather than too little. Patients become a grab bag for every imaginable disease. Labels on top of labels. Kidnapped by the system.
The family often suffers because no professional has told them that no one can predict where these early symptoms might lead. You just cannot know. There are no predictive tools or models. There is a thin line between illness and health, and nowhere is it thinner than here.
It’s a hard sell. Parents or caregivers are transfusing the child’s irritability, moodiness, impulsivity out of their own emotional reservoirs. It’s exhausting. Still, they remain committed. Even as the parents pursue their careers, try to keep their marriage intact, be present for their other children, maintain friendships. Doing life among emotional vampirisms. Discernment is required to know who the patient is.
Consider here the ethical principal of nonmaleficence. No harm. Keep children safe from drugs and impulsive decisions with lifetime consequences. Including those pushed by well-meaning adults and peer pressure, where the child is sacrificed on an avalanche of affirmation, that is gender transition, with promises the dysphoria will melt. It won’t.
Sometimes, the best advice may be, “your child has an inability to regulate his emotions, so you are providing him with an environment to regulate them. You must wait and be patient. What will evolve will evolve, or he will outgrow most of the behaviors. You cannot ask more of yourselves.”
“Your child is most blessed to have parents who provide them with love, safety, and nurturing. This is your gift. Truly, there is nothing more you can do. The psychiatrists have no idea, and no way of knowing what will turn out. Worse for you, they cannot say this to you. Their way of saying they don’t know is what you have heard. More consultations will only be more confusing.”
Not that we don’t treat. We do. But we keep it simple. And we don’t over promise to parent’s expectations of our pharmacology or omniscience. We’re cautious when making judgments regarding battles we have not fought and experiences we have not shared.
Tim Powell MD