May is Mental Health Month, and it started with National Children’s Mental Health Awareness Week, which was the first full week in May. Last week in this blog, I discussed two common mental health diagnoses among children (ADHD and ODD) to illustrate how some mental health problems can be caused mostly or partially by genetic factors.

There are also psychiatric problems that are almost purely caused by things that happen to you—what could be called situational or environmental mental health problems. For example, there are a lot of kids who would be pretty normal if they hadn’t had a forced separation from their parents at an early age, or if they hadn’t been abused, or if they hadn’t gone through some other major trauma.

I will focus this week’s blog on attachment-related mental health problems to illustrate mental health problems that are almost entirely environmentally caused. I say “almost,” because there is variation depending on temperament, intelligence, and other biologically-related factors. For example, two children could both be abandoned on the street, and one might have the resilience to be able to bounce back from this trauma. But most children would be deeply affected by it.

We look at the situation that is unfolding in Texas with the polygamist sect and we know that those 400-plus children are experiencing trauma—they are being yanked out of a familiar, loving, stable environment, and being put in foster homes away from their families, into a cultural environment that they have been raised to avoid, into an environment that would seem scary and dangerous to them.

Many of the boys, for example, are being put in a boys’ ranch type of setting, where they will be living side-by-side with kids who have stolen, run away from home, assaulted others, used drugs, etc. They will be exposed to swearing, TV, music, immodest clothing, and other influences that they believe to be harmful. Who could possibly argue that this would be a setting that would not cause these boys psychological harm? Especially when they have been taught that they needed to keep themselves separate from the outside world? They have been raised to avoid “the sins of this generation,” in the words of one father from the group. Now they are being dumped right into the middle of them.

The infants and children in the group were taken away from their mothers in the middle of the night. We can never go back and undo that damage. They were kept from their mothers when many of them were likely still nursing, possibly causing some of them to be weaned against their parents’ will. Days went by with those babies crying for their mothers, when the mothers could not reach them. The children have not been allowed to be alone with their mothers or fathers, to prevent “witness tampering.”

The children will be placed into a system that is not prepared for this heavy influx of children. Children will be separated from their siblings because the foster system isn’t designed to accommodate large families. Many will be placed far from home as the system stretches to find enough foster facilities. They will have emotional scars from this ordeal; they will be changed forever.

While some children in the group may be protected from underage marriage by the forced separation from parents, every child has been punished because the state didn’t have the patience to respectfully and peacefully ask for the information it needed in order to determine which children were in danger. Certainly the babies were not in imminent danger of underage marriage! The youngest among the children will likely be the ones most affected by the ordeal.

This unbelievable situation reminds us of the insane justification that a major in the U.S. military used in the Vietnam War for the destruction of the Ben Tre village: "It became necessary to destroy the village in order to save it." The atrocity that is happening in Texas should create an outcry across this nation among all people who are concerned about families and children’s emotional health.

Does Attachment Matter?

In my work as a mental health professional, the majority of cases that I see have at least some genetic piece to their cause—such as ADHD, most cases of depression and anxiety, and so forth. Probably the most common mental health problems that I see that are entirely avoidable are attachment problems. What is attachment? Attachment is precisely the kind of issue that the ordeal in Texas is all about.

Attachment is a bond that people form in their closest relationships. When the first bond—usually between a baby and Mom (but this could be any primary caretaker)—is allowed to be strong and steady, the child develops an internal sense of security about herself and the world—she trusts that people will be there for her when she needs help, and that the world is a fairly safe place. While this bond is forming, the infant is appropriately dependent. A parent who accepts this dependence as normal and natural (instead of rejecting it) helps the child to form a secure bond. If the bond is allowed to form properly, the securely attached child will develop into a child who can be appropriately independent as later ages: a child who feels safer exploring and engaging the world, who is more socially outgoing, and who develops into a happier and better-adjusted child.

When that initial bond is not strong—when it is disrupted in some way, the child often develops an insecure picture of herself and her place in the world—she becomes anxious about whether caretakers will be there for her, or avoids relationships because she has learned that people can’t be trusted. She may develop into a child who is clingy, who manipulates or feels she has to be in control, who uses tantrums to get her way, or who is shy and doesn’t do well with change. In these cases, we don’t say that the child “isn’t attached” or “failed to attach.” Rather, we say the child is insecurely attached, and once the problem is identified, we help the child to develop greater attachment security by helping the child heal and develop a stronger bond with her caregiver(s).

Reactive Attachment Disorder (RAD) is the extreme form of attachment problems and is relatively uncommon, but lesser varieties are more common—some studies estimate that about 30 percent of children are insecurely attached to some degree. Sometimes it is barely noticeable or only shows up in a few situations; other times it may seem like “everyone in the grocery store” can tell what the problem is! Among children with other mental health problems, we often see some evidence of attachment difficulties, especially where there has been trauma, abuse, or family disruption. Severe attachment problems can be mistaken for ADHD, ODD, bipolar, and some other disorders when a professional has not been trained to discern the difference.

“Too Attached”?

When I look at attitudes in our society about attachment, I feel deeply concerned that the rate of these problems will only continue to increase in our society. For example, the apparent ignorance of child protective services (CPS) in Texas about the effects of their actions on attachment. There seems to be a widespread assumption in society, and I hear this even among professionals, that separation from a parent at an early age is harmless, and can even be beneficial—that it can help a child grow.

I know one woman whose ex-husband wants to have their toddler daughter half the time, but during most of that time the little girl would not even be in his care. Instead, the daughter would either be in daycare or with the father’s girlfriend. When the mother voiced concern about this arrangement, a Department of Human Services (DHS) worker told the concerned mother that “daycare will be good for her,” and that the daughter needed to learn “how the world works.” How could anyone with a basic understanding of child development and attachment possibly believe that attachment disruptions with unfamiliar caretakers would be beneficial to a child?

This mother was also told that regular separation would be for the best, because her toddler daughter is “too dependent” on her—the daughter cries when separated from her mother, and there are (supposedly) too many hugs and kisses that the mother and daughter exchange when they are reunited! The ex-husband sees these as evidence that the daughter is “spoiled,” and has vowed that he’s going to “break her.” Again, these comments show a gross misunderstanding of child development and attachment. At such an early age, it is normal for a child to be distressed by separations from the caregiver and to seek a caregiver for comfort. Certainly a child can be “broken” of these natural separation responses, but is that the only thing that will be broken?

The toddler who is nonchalant or uncaring about separations is often praised as a “good child” because he’s so easy to drop off at daycare. But is this really a good thing when our children are easy to leave?

Sometimes these children are vulnerable to developing dismissive attitudes about attachment as an adult. For example, they can grow up with intimacy issues and have difficulty expressing emotions. Think about a child who is left to cry himself to sleep, or who is forced to endure prolonged separations from his parent before he is emotionally ready for it. When a child learns early in life that his dependence on a caregiver is a source of pain, and his feelings and needs will go unacknowledged and unheeded, he shuts off access to a vulnerable part of himself. He learns not to trust others with those feelings. He learns not to express his emotional needs.

What kind of a husband and father would such a boy grow up to become? An adult who is dismissing of his own attachment needs will be more likely to be dismissing of his children’s attachment needs also…and the cycle continues for another generation.

So if it’s not ideal for a child to be calm and uncaring when dropped off, what is the normal response? A securely attached toddler would be upset by the separation, but would eventually calm down—being consolable or soothable is also a sign of secure attachment. And if the caregiver comes back when the child is still upset, we could expect to see the child to feel reassured and consoled when reunited with her caregiver. Having this stable bond with her caretaker is essential for the child’s long-term mental health.

Unfortunately, in so many situations, nurturing this bond is not put as the first priority.

I have heard parents say that they avoid “giving in” to providing a nurturing response to their child because they don’t want their child to become “too attached.” They want to be able to lay the child down for a nap or drop the child off at daycare and not be bothered by any fussing. Ironically, it is the child whose attachment needs are adequately met in infancy that is the least needy later in life—the early investment pays huge dividends later on!

It Starts with Birth

So what are a child’s needs? Let’s look at early infancy. There are food, shelter, warmth, sleep, cleanliness; these are physical needs that we all (hopefully) recognize. So if you meet all of these, and nothing else, will the child thrive? Absolutely not.

In the decade after the collapse of the Soviet Union, for example, we heard horror stories of infants in Eastern Europe that were left in cribs for hours in orphanages, unattended because there were not enough staff to pick them up and give them emotional nurturing. The result was thousands of children with severe attachment problems. They would not respond to a smile. They avoided touch and were stiff when held. They bit and scratched themselves. They seemed to shut out the world. When they grew older, they seemed to have no social conscience.

In the U.S. we usually don’t see children that have gone through this degree of attachment trauma. Instead, we are more likely to see children who were treated like a burden or afterthought, who were yelled at, who were not picked up enough when they cried, who were allowed to cry themselves to sleep as infants. We see children who received little or poor amounts of touch and eye contact from their caregiver during feedings, who were placed in playpens, cribs, car seats, or strollers for long hours when awake instead of being held, played with, sang to and talked to.

We see children who are attached to a binky or blanket and are inconsolable when it is missing, who are babysat by TV programs or movies, and children who maybe only see their parent(s) for a few hours each day. We see children whose paid caretaker has been changed multiple times in the first three years of life, who have had multiple attachment disruptions. In short, we seem to be raising an entire generation of children where attachment problems will be commonplace.

The Ties that Bind

We live a society that is increasingly dismissive of children’s attachment needs, that assumes everything will be okay when children are put last. So many of us today were raised in less than stable environments, and we may think that this is normal, and then underestimate our children’s needs for our attention and nurturing. Among the nations of the world, parents in the U.S. spend less time on average with their children than any other nation, including the old Soviet Union. We spend long hours at work, and when we come home, our children may seem like strangers.

Is it any wonder that our children are reaping a windfall of rising mental health problems? Our choices about the time we spend with our children—and the quality of our interactions with them—have direct consequences on their emotions and behavior. Today we see an increase in aggression and defiance, in distractibility and impulsivity, in anxiety and depression, in addictive behavior and anti-social behavior. Is this avoidable? Some of it isn’t—some of it is genetic. Some of it is genetic but wouldn’t be triggered if our kids didn’t have such stressful, problematic lives, bad diets, environmental toxins, inadequate discipline, poor sleep patterns, and attachment disruptions. These and other factors may trigger inherited genetic weaknesses for mental health problems. Unfortunately, some of our kids’ problems can be caused by things that are entirely avoidable.

The New Normal?

A recently released studyby the National Institutes of Health (NIH, published in the March/April 2007 issue of Child Development) found that the more time children spent in daycare before kindergarten, the more likely they were to show aggression and defiance at age 10. These behaviors included demanding attention; arguing; bragging and boasting; cruelty, bullying or meanness to others; destroying things belonging to others; disobedience at school; getting into fights; lying or cheating; and screaming.

The researchers pointed out that those behaviors they saw were within the normal range and were not considered clinically disordered. Jay Belsky, one of the authors of the study, stated that children who have been in daycare probably aren’t abnormal enough that he could pick them out of a classroom just by observing them. Indeed, once children get into public schools, their behaviors tend to rub off onto peers, making it more difficult to tell the difference.

The study also found a benefit of daycare: slightly increased reading and vocabulary skills. Does this make up for the negative effects? Few of the parents I see in therapy would seem to want to have a child who is more aggressive and defiant, and who also knows how to use her mouth better. Especially if the words coming out of it are too mature for her age and not ones her parents want her learning.

With the widespread use of daycare in today’s society, are we willing to accept these behavior trends as the “new normal”? Do we need to find better ways of shielding children from these effects and getting help to the ones who have already been affected? Daycare is only one factor affecting children’s mental health; there are many other factors—for example the amounts of sleep children receive each night and parents’ effective use of authority, and how parents and teachers respond to a diagnosis. Giving children the best possible chance at a life relatively free of mental health symptoms is a complex undertaking.

As we celebrate Mental Health Month in May, let us use this opportunity to take a look at the kind of outcomes our society is creating for children. We need an increased awareness of the causes of children’s mental health problems, and which of them are avoidable. We need a greater awareness of the treatment options available. We need an increased commitment to giving our kids the nurturing, the environment, the tools, and the support to reaching their fullest possible potential.

The #1 Child Mental Health Disorder

As part of National Children’s Mental Health Awareness Week (May 4-10, 2008), we need to get out the word about the risk factors and causes of mental illness. Yesterday I wrote about sleep problems, which tend to occur at a very high rate among children with mental health problems. A resource that I often refer to for these is Solving Your Child’s Sleep Problems, by Richard Ferber. It has recently been revised, and there are other more up-to-date books also available.

When children have mental health problems, it is important to understand that some are not the fault of outside factors, such as sleep difficulties (though these can always make things worse!). There are disorders that are genetic—you simply have them because you were born with the genes for them. Even among these, genes alone don’t determine how you will fare with mental illness.

A boy with Attention-Deficit/Hyperactivity Disorder (ADHD), for example, which is the most commonly diagnosed children’s mental health problem, may fare very differently depending on how his parents and teachers respond to him. If he has highly involved parents and teachers who educate themselves about ADHD, help him learn skills to manage his ADHD, get him into treatment that includes more than just medication, and work with him on managing his symptoms, he will fare far better than a child whose parents and teachers don’t want to be bothered with it and just want a pill to make it go away.

Why do I say “he” when talking about ADHD? Girls also have ADHD, yet the disorder tends to be noticed in boys more often than it’s noticed in girls. Even though boys and girls may have similar raw rates of the genetic causes of ADHD (we don’t know enough to say if they do or don’t), the response they get from their environment is often very different.

For ODD, Genes Alone Aren’t Enough

There are also some psychiatric problems that a child can have a genetic tendency toward, but may not be triggered unless the child has a great deal of stress or some other life event that causes it to show up. For example, some kids have a family history of bipolar, depression, anxiety, schizophrenia, or some other problem. They may have inherited a genetic tendency for getting a mental health disorder. But it may not show up as long as the kids have stable, low-stress lifestyles.

For example, most kids with Oppositional Defiant Disorder (ODD, which includes rebellion and problems with authority), have a strong-willed personality. But this factor alone doesn’t cause ODD—you need to also have the right mix of environmental factors to develop it—genetics alone isn’t enough to set it off. Triggers can include an absent or emotionally distant parent, parents who tend toward power struggles themselves, inconsistent parenting, problems with peers, and substance abuse.

Because ODD is a relational and not a purely individual problem, I usually recommend family therapy that includes teaching the parent(s) new skills and behaviors. This doesn’t mean that parents are blamed for the problem; of course the child needs to change. The adults in the child’s life are also an important part of that change. Even when parents aren’t part of the problem, they are in the best position to be a part of the solution.

Comorbidity—How Can ADHD Increase the Risk of ODD?

In my clinical work as a therapist of children, I have seen each of these disorders, ADHD and ODD, occur separately. But I am surprised at how often they occur together. This may say something about the strain on parents that comes with having a more difficult child—ADHD can be hard for some parents to understand. I have a book on my shelf called It’s Nobody’s Fault: New Hope and Help for Difficult Children and Their Parents, by Harold Koplewicz. This is just one of many books available to help parents of a child with a this disruptive behavior disorder. I see parents who insist that their child is just lazy, that he needs to have more discipline, that if he would just try he would be able to do everything that other children do. Undoubtedly these expectations, when they are unreasonable, put strain on the parent-child relationship, and set him up for developing ODD.

Sometimes these perceptions of laziness or lack of effort can be true—to an extent. But a child with ADHD does have a real problem, and it is a problem that is not of his choosing. Parents and children may need professional help to see what he is more capable of, and what expectations are unreasonable.

I have met children whose parents had high expectations, and they were thus able to help their child manage his ADHD, so well that as they grew to adulthood, they were able to function without medication. I have also seen children wilt under the criticism and unrelenting demands of an unsympathetic parent. It is important to have a balance.

Rebalancing Parenting

Parents can find a wealth of resources for help with rebellious children. One that I have been very impressed with is Parenting Your Out-of-Control Teenager: 7 Steps to Reestablish Authority and Reclaim Love, by Scott Sells. He has another book for therapists, called Treating the Tough Adolescent. What I appreciate most about his approach, besides the fact that he helps parents get in charge, is that he does this through both the soft and the hard side of parenting. So many parents that I see with a rebellious child want to really crack down on the rules and get control back through the hard side—discipline and consequences. But when this is main or only focus (as is so easy when dealing with ODD, which tends to create angry, exasperated parents), the parent-child relationship tends to suffer. Dr. Sells teaches that the soft side of parenting—building a bond with the child—is necessary if you want the hard side to succeed. He recommends, for example, regular parent-child outings that build the relationship, and the kicker is that these need to be unconditional—they cannot be “lost” through misbehavior. The child needs to know that your love and care for him doesn’t depend on him being “good.” I have used this concept of working on the soft and hard side of parenting together with many other disorders, and found it to be very successful. In fact, I would say that I’ve found the soft side needs to come first, and be given even more attention than the hard side. I’ll give two illustrations why.

John Gottman, author of some powerful books on improving marriage (such as the bestseller, The Seven Principles for Making Marriage Work), has done some of the best research available on couple relationships. By carefully studying the interactions of couples and then tracking whether those marriages ended in divorce, he found that in order for a marriage to be stable, there has to be at least five positive interactions for every one negative one. Positives could be a compliment, a smile, working together, and so forth. Negative could be criticism, rolling your eyes, getting defensive, etc. When the ratio of positive to negatives became less than 5 to 1, he found that marriages tended to become unstable, and eventually lead to divorce.

So what does this have to do with parenting? Parents and children can’t divorce, can they? Actually, many of the same dynamics that lead to marriages failing are the same that lead to rebellious and oppositional parent-child relationships. The biggest difference is that the relationship can’t end with a divorce. But the parties can and often do wish they could be rid of each other, and sometimes it does end with either the child running away, the parent sending the child to live with another relative, or the child being placed in a program for troubled kids.

It is important also to know a further finding in Gottman’s research on marital stability. Simply having a marriage last is fine, but what about having a happy marriage? He found that couples who had a 10 to 1 ratio of positive to negative interactions tend to have happy, satisfied relationships. Surely there is a lesson here for parenting as well. This conclusion is supported by the research-based parenting education program called “Incredible Years.” It teaches parents that when discipline is the main focus, the parent-child relationship is out of balance: like a pyramid balanced upside down on its tip. To illustrate the proper balance of relationship-nurturing to discipline, they have created a helpful concept called the “Parenting Pyramid.” Here is a link: http://www.incredibleyears.com/resources/parent-program-pyramid.pdf What it illustrates is that the actions on the bottom of the pyramid form the foundation of a parent-child relationship: things like empathy, attention and involvement, play, problem-solving, listening, and normal talking together. These help to increase the child’s problem-solving skills, cooperation, self-esteem, and attachment (bonding with the parent). This is what grows and sustains the relationship!

At the top of the pyramid are behaviors that you need to use sparingly or rarely, and the less often you use them, the more effective they will be! These are consequences, such as time out and loss of privileges. Use these to decrease aggression. Many parents use these far more often, for example to increase normal compliance and obedience. The pyramid suggests more appropriate measures for increasing these: setting clear limits, setting household rules, and using consistent follow-through. When these are done in the proper balance, you won’t have so much aggression and need for consequences. For more information on the Incredible Years program, you can find their website at www.incredibleyears.com .

May is Mental Health Month. The National Federation of Families for Children’s Mental Health has declared May 4-10, 2008 as National Children’s Mental Health Awareness Week. Throughout the nation, agencies, schools, and community service providers are using this week to get out the word on children’s mental health issues: their causes, options for treatment, prevention information, and opportunities for support.

One Therapist’s Perspective

I work as a mental health professional at a community mental health center in a small city in the Midwest. I and other professionals like me help individuals, couples, and families; we help children, adolescents, and adults. In our work we see children every day for a wide range variety of mental health problems. The majority tend to have either behavioral or emotional problems. Many of the kids we see have difficulty with aggression or defiance, there are a lot of mood disorders, and sleep problems are also common.

Getting adequate sleep is a surprisingly common difficulty among children with mental health issues. It is hard to say which is the cause and which is the effect, but getting adequate sleep can be a hugely beneficial change for a lot of these kids. A child in elementary school typically needs 10 to 11 ½ hours of sleep per night, and kids in high school need 8 ½ to 9 ½ hours. The kids who come to my office often have much less—I sometimes see children who average as little as 5 to 6 hours per night. Of course this would worsen any problems a child may have with irritability, inattention, and moodiness. Sleep is the brain’s way of repairing and refreshing itself. Sleep deprivation isn’t just an annoyance or inconvenience; it is also a mental health risk. Those who do not get adequate sleep risk developing additional mental health problems.

The work that I and other mental health professionals accomplish includes educating both kids and parents about prevention (such as sleep), focusing attention on strengths and skills they already have that will help, teaching new attitudes and skills for managing and overcoming problems, and bringing together people involved with the problem to work out solutions. Although many of the mental health problems we see are not preventable, the effects of them can be managed and diminished.

Many changes can help a child with a mental health issue to improve and fare better—for example, by changing sleep patterns to get a full night’s sleep. Many children with mental health issues can lead happy and productive lives with treatment, support, and hard work from themselves and their caregivers.

This week I will publish a series of blogs on the topic of children’s mental health, focusing especially on prevention. The next will focus on the most commonly diagnosed childhood mental health disorder: ADHD. I will also address one that I sometimes see occurring with it, the childhood diagnosis with an odd-sounding name: Oppositional-Defiant Disorder.