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Your Children Like to Give You What You Seem to Expect From Them

During the times when parents are making major parenting errors, they are often giving their children a double message in one way or another. The parents, usually because of their own ambivalence about rules they themselves learned in their own families of origin as they grew up, say one thing but seem to act in ways that contradict what is being said verbally.

In this situation, children make sense of their parents’ confusing expectations of them by taking into account the entire context of the family’s interactions. They use three rules to sort out and hierarchically rank double messages that are given on a consistent basis. These rules are described in detail in my post of March 8, 2011, How Children Respond to Double Messages From Parents, Part I.

The parents’ behavior may seem to indicate to children that the parents have certain expectations about how the children are supposed to turn out, and children will not want to disappoint the parents by defying their apparent expectations. This will happen in spite of the fact that the parents verbally instruct the children not to act in the way the parents seem to expect, and criticize and/or severely punish them when they do. Admonishments, especially verbal ones, will be disregarded. Actions speak louder than words (Principle #1 from the earlier post).

In this post, I am going to list several examples of frequently-seen problematic parenting practices, as well as the consequences that such practices frequently lead to. They may cause relatively mild problems, but often they cause major issues. These patterns have been described to me over and over again by my adult patients as they discuss their family’s behavior over time.

The problems I list all have a common theme: parents trying to micromanage their children's behavior in one way or another. Parents may protest: "I have to focus on my child's troublesome behavior because they won't stop it." They don't realize that it actually works the other way around: the child won't stop the behavior because the parent keeps focussing on it!

After one of these problems goes on for a while, the situation gets more complicated. The parents and children begin to feed into one another's anxiety and compulsive behavior simultaneously.

In order to solve such a problem, the parents have to be the ones who calm down about the issue first, or the children will be very unlikely to ever calm down and start behaving differently. When the parents do stop micromanaging, other difficult but solvable problems predictably ensue. These are discussed in the last paragraph of this post.

In discussing any problematic parenting issues, there is always a rather devilish and perplexing conundrum that makes any such conversation frought with peril. Many troublesome parenting behaviors are driven by a parent's guilt over their own thoughts and feelings concerning their role as parents, and if one discusses what they may be doing wrong, this adds to their sense of guilt. They therefore often become very defensive and, if anything, dig in their heels. Their problematic practices then get even worse than before!

On the other hand, if they do not really understand what they are doing wrong, they also continue doing it. 

A real lose-lose proposition this.

Parental guilt is often increased by negative comments about their parenting practices that come from their own parents, the children's grandparents. This in turn is caused by certain changes in western culture which have been rapidly evolving over the last few decades. I describe these cultural issues in more detail in my last book, in Chapter Two, Don't Blame Us.

Really, looking for someone to blame for family problems is a complete waste of time. The most important questions is, which would you rather do: find fault with people, or actually solve the problems? It is damn near impossible to do both. To naysayers I say, "Grow up!" 

The problems are created over several generations, so let's all just blame Adam and Eve, and be done with it.

And so I proceed.

Some additional points: Some psychologists and parenting experts intuitively understand the type of consequences that I list below, but IMO they miss the real reason why they occur. Most seem to think that the parents are somehow “gratifying” their children in a counterproductive way. However, in my experience, children who are in many of these situations are anything but gratified. 

They are almost always quite miserable, and behave in self-destructive ways to boot. Feeling good and being self destructive are for the most part mutually exclusive.

Rather than being gratified, I believe - as I have said many times in this blog - that the children are sacrificing themselves to give the parents what the parents seem, in the estimation of the child, to desperately need. 

Another frequent explanation, particularly by cognitive-behavioral therapists, is that the problematic parenting practices prevent children from acquiring certain social skills. While that explanation may at times have some truth, many of the "skills" such children are supposed to lack are not exactly rocket science. And these same children often demonstrate in other interpersonal and environmental contexts the very skills they are not supposed to have ever learned!

Critics of course will also point to examples in which the types of parental behavior described in the post do not or did not seem to be followed by the predicted negative consequences. As usual, I need to put in a disclaimer: The consequences of the parental behavior I mention do not alwaysresult in every situation in which the parenting problem is seen. They are not hard and fast. 

Kids have minds of their own. Other adults in the house or even in the community may provide a counterweight. Some parents behave more consistently, others much less so. Some are consistently inconsistent. Parents might get sick and tone down their rhetoric for extended periods. A zillion other things may come into play.

There is a chaos effect: small changes in initial conditions can lead to big changes down the line. However, if parents make the kind of errors I describe, the odds are very high that the predicted consequences will indeed occur. We’re talking probabilities here!

So, without further ado, here’s a list of common parenting errors created by parental ambivalence about their own behavior. By no means is it a complete one:

If you constantly try to fix a child, the child will find different ways to keep being broken so you can continue in your efforts.

If you continually bail children out of their own messes, they will continue to make messes for you to bail them out of.

If you give your kids money whenever they ask and almost never say no, they will continue to ask you for money, and may seem to develop problems supporting themselves when they grow up.

If you constantly try to mediate disputes between your children, they will continue to fight one another so you can continue to mediate.

If you blame yourself for your children’s failings, your children will blame you for their own woes. (In a perverse and ironic way, their problems are partly your doing. But it’s your guilt about your own behavior that creates the problem, not your basic character or intrinsic worth).

If you repeatedly tear apart your child’s room looking for drugs when there is no evidence that he or she is using, just to make sure he or she is not using, the child is more likely to use drugs so you can find what you are looking for.

If you continuously help children with their homework instead of telling then to figure it out for themselves, they will continuously need your help.

If you keep making a huge deal about something your children do or say, they will keep repeating whatever it was so you can continue to obsess about it.

If you instantly replace any items lost by your child, your child will continue to lose things.

If you do nothing when your children disrespect you, or if you just whine and scream at them about it, they won’t ever respect you.

If you look uncomfortable getting presents on holidays and birthdays, your children won’t give you any, or will give you thoughtless gifts. (If you then question them about it, they will get angry or passive aggressive, and may start giving you things, but looking as if they are only doing so because you asked, not because they care about you).

If you seem to get a kick out of a child’s misbehavior, they will continue to misbehave, no matter what else you say about it.

If you set a low bar in your expectations for your child (academically, for example), they may meet the bar, but they will not exceed it.

If you compulsively pay more attention to your children's needs than you do to those of your spouse, they will make gallant efforts to regulate the amount of intimacy you have in your marriage by inserting themselves between the two of you.

Last - and this is perhaps the most pernicious of all - if you constantly give in to your children's demands out of guilt, but then get angry at them because they are too demanding, then they will fear for your mental stability. In response, they will try to regulate your emotions like a thermostat: If you start to get too angry they will try to make you feel guilty, but if you start to feel too guilty, they will try to piss you off royally.

Whenever you try to stop doing any of these things after having done them for a long time, expect a negative reaction, because you will be confusing your children. They thought they had you all figured out, and suddenly you are not performing to their expectations. Therefore, their behavior will get even worse in order to see if you really mean what you say and are going to continue to be different. Their behavior will, however, eventually get better if you stay the course.

Childhood Bipolar Disorder The View From Abroad

Is Pediatric Bipolar Disorder (PBD) a “culture-bound syndrome” of the USA?

The following is a guest post from Dr. Peter Parry, an Australian psychiatrist and senior lecturer at the University of Queensland, who is a co-conspirator of mine in the fight against the pernicious practice of psychiatrists and pediatricians diagnosing acting-out children as having the major psychiatric disorder bipolar disorder (manic depressive illness).

A “culture-bound syndrome” [http://rjg42.tripod.com/culturebound_syndromes.htm]  in psychiatry is used to describe psychiatric disorders that generally occur in exotic indigenous communities and developing countries due to cultural factors.  Examples include “Koro” - a disorder of group hypochondriasis that occurs in epidemics in parts of south-east Asia where men start to believe that their penises are shrinking into their abdomens; “Dhat” - a disorder in India associated with anxiety and fatigue in men related to fear of losing too much semen; “Bebainan” - a disorder where young women from Balinese nobility, who in everyday life must behave with extreme politeness and be very demure, vent their anger in seemingly irrational brief rage attacks.  The last of these can be seen to have a useful function for individuals whose emotional lives are otherwise highly socially constrained.

In a couple of blog posts on “The Geography of Pediatric Bipolar Disorder” [http://www.psychologytoday.com/blog/your-child-does-not-have-bipolar-disorder] on Psychology Today  I concluded by posing the question: “is Pediatric Bipolar Disorder (PBD) a culture bound syndrome of the USA?”.  As I explained in the first post, PBD, despite becoming the most common diagnosis for pre-pubertal children in US inpatient units 10 years ago [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2001259/], has barely rated in the rest of the world. 

This is not to say that there haven’t been a few academic research centers who have investigated PBD in places like Spain, Switzerland, the Netherlands, Brazil, India and Australia.  These research centers have usually collaborated with prominent American PBD research centers such as Prof Biederman’s center at MGH-Harvard.  In clinical practice outside the USA there have been a few isolated pediatricians and rarely child psychiatrists who have adopted the American clinical practice of diagnosing PBD in pre-pubertal children.  But the vast majority of practicing clinicians and academics in child psychiatry and pediatrics in Britain, Europe, Australia, New Zealand and to lesser extent Canada have simply not accepted PBD as a valid diagnostic entity in clinical practice.

Here in Australia, one group that seriously researched the PBD diagnostic constructs was based in Sydney.  Their follow-up research found that few cases went on to true bipolar disorder.  Prof Philip Hazell who led much of this research was quoted in the Australian media [http://www.theaustralian.com.au/news/health-science/moody-teens-wrongly-diagnosed-with-bipolar-disorder-psychiatrist/story-e6frg8y6-1226191879545] saying “There are about 10 times as many people with 'lookalike' mood dysregulation as there are people with bipolar disorder”.

Now it is true that bipolar disorder often first manifests in adolescence and early manic or hypomanic symptoms can be mistaken for extreme adolescent emotionality, risk-taking or substance abuse.  But until an unequivocal manic episode erupts it is difficult to make the diagnosis.  The “BCOS study” [http://www.jad-journal.com/article/S0165-0327(07)00047-X/abstract] was a study of 240 adults mostly in their 40s with classical Bipolar-I or Schizoaffective Disorder in Melbourne and Geelong in Australia.  The BCOS study found that the diagnosis was often made years late.  The study asked the adults when their symptoms first began.  The median age of onset for the first hypomanic/manic episode was 24.1 years old.

Yes bipolar disorder is a severe mental disorder that needs to be detected earlier in life than it often is.  But it is still a disorder that doesn’t usually start until late adolescence or young adulthood.

Another study that asked middle aged adults with bipolar-disorder when they thought their first symptoms of bipolar disorder began was published in the British Journal of Psychiatry [http://www.jad-journal.com/article/S0165-0327(07)00047-X/abstract].  The authors of this study were quite favorably disposed towards PBD.  The remarkable aspect of the study is the discrepancy in recall of symptom onset between the European subjects with adult bipolar disorder (Dutch and Germans) and the American subjects.

Is there something about childhood in the USA that brings on a severe psychotic mental disorder such as bipolar disorder so much earlier than in other countries?  Or is there simply an over-diagnosis fad in operation, one that colors the memory recall of childhood?  Notably the American adults in this study had features more suggestive of milder “bipolar” and more personality and substance use problems than the Europeans who had more classic euphoric manic symptoms.

A 20 year follow-up study [http://www.jaacap.com/article/S0890-8567(09)64566-4/abstract] in New Zealand (NZ) was published in the Journal of the American Academy of Child & Adolescent Psychiatry in 1991 (before the creation of the PBD phenomenon).  It was based on all inpatient admissions to the child and adolescent psychiatric ward for a catchment area of 1 million people.  In those 20 years there were 59 children under age of 18 who presented with a confirmed psychotic illness that included schizophrenia, schizoaffective disorder or mania/bipolar disorder.  Age of diagnosis was based on reports of first symptoms, not date of admission to the inpatient unit.  Of these 59 children and teenagers, only 3 were aged 12 or under at onset of symptoms.  One of these 3 children was reported to have had their first manic episode at age 9, the youngest who later turned out to have schizophrenia was aged 7 at onset of first symptoms.

The lead author of the study is now Emeritus Professor of Child & Adolescent Psychiatry in Auckland, NZ, Prof John Werry.  In a survey that I and colleagues organized of Australian and New Zealand (ANZ) child psychiatrists [http://onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2008.00505.x/abstract] on PBD that found high levels of skepticism (including that only 3% thought that PBD was not over-diagnosed in the USA), Prof Werry sent a hard hitting comment for public airing:

“I do not see any juvenile bipolar disorder below adolescence and I think that the American view is mostly nonsense as do many of my American colleagues.”

The second author of the NZ study was one of his “American colleagues”, Dr Jon McClellan, a child & adolescent psychiatrist who returned to the USA and is based in Seattle.  Dr McClellan was one of the very few child psychiatrists to have a dissenting article [http://www.jaacap.com/article/S0890-8567(09)61468-4/abstract] on PBD published in the Journal of the American Academy of Child & Adolescent Psychiatry.  With regard to PBD his article concluded:

“the rate of psychotropic agents being prescribed to preschoolers is skyrocketing…Labelling tantrums as a major mental illness lacks face validity and undermines credibility in our profession.”

One very prominent US psychiatrist, Prof Allen Frances who was chair of the DSM-IV task force, has called PBD a “fad” [http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1551005] diagnosis.

What I found when attending the American Academy of Child & Adolescent Academy (AACAP) meeting in Hawaii in 2009 is that Werry, McClellan and Frances were spot on.  Many US child psychiatrists were very troubled by the PBD diagnostic fad, the bad effects on the children and families of a spurious diagnosis and wrong treatment, and the undermining of credibility in our profession.  I received mainly supportive comments from my US colleagues when I presented my poster of our Australian and New Zealand survey showing high levels of skepticism about PBD in ANZ.  These comments helped to explain what it was about the culture of the USA that had spawned the PBD fad epidemic.

Firstly – the US health system is mainly a private insurance system and much more fragmented than the universal health cover that exists in nearly all other 30 developed nations in the OECD [http://www.oecd.org/dataoecd/24/8/49084488.pdf].  US health insurers are more likely to restrict reimbursements on the basis of diagnosis than health insurers in other countries.  Also pharmacotherapy is favored over the psychotherapies. 

At the Hawaii AACAP conference an American child psychiatrist told me that if she is seeing a boy with emotional and behavioral problems embedded in difficult family dynamics, with some insurers she has to phone the insurer in the first session and is asked to give a diagnosis. If she says she has no diagnosis at that early stage, the insurance clerk says no reimbursement. If she says the diagnosis is a “parent-child relational problem” (which is a non Axis I DSM diagnosis) she may also be told no reimbursement. If she says it is an “adjustment disorder” (an Axis I DSM diagnosis) then she may be allowed 1 or 2 sessions to fix the complex problems. But if she says it is “bipolar disorder” then ongoing sessions are likely to be reimbursed. 

This is effectively diagnosis by medically untrained health insurance clerk.  It is also an expensive system, the USA spends 17% of its GDP on health care whereas other OECD nations spend between 8% and 11%.  A lot of money goes into paying medically untrained clerks and profits to shareholders.

Secondly the pharmaceutical industry has focused its influence on medical research and public opinion more in the USA than elsewhere.  The pharmaceutical industry is globally the most profitable industry on the planet.  In 2002 the 10 Pharma companies in the Fortune 500 had greater profits than the other 490 world’s biggest companies combined.  In 2008 they averaged 18% profits whilst the rest averaged 0.9% profits in the global recession.  Pharma spend 3 times as much on marketing to the medical profession and (mainly in the USA) the public than they do on Research and Development.  The biggest market for medications, particularly psychotropics, is the USA and direct to consumer advertising (DTCA) is only legal in the USA and New Zealand (but NZ has a tiny market).  Thus the American public have been flooded with advertising of psychotropic drugs and often ads about bipolar disorder whereas the public in other nations have not (though the internet is changing this).

Another US child psychiatrist colleague told me at the ANZ child psychiatry conference in 2007 that in working as a locum in NZ he had never had parents come to see him stating their child had “such and such diagnosis” and demanding a related medication, rather they asked him what he thought.   Conversely parents invariably were fixated on a diagnosis and drug or two when they came to consult him in the USA.  He had also trained at an academic child psychiatric unit prominent in PBD research and was trained to ask himself “is it bipolar?” and diagnosed half a dozen cases of PBD, yet in NZ he’d never seen a case of PBD and had started to question his training.

The pharmaceutical industry provides considerable funding to researchers and to academics to provide “continuing medical education” (CME) to other doctors.  Internal industry documents [http://www.healthyskepticism.org/global/news/int/hsin2009-12] revealed that Pharma saw broadening of bipolar diagnoses in adults and children as useful to selling more atypical antipsychotic agents.  Such CME is a global phenomenon and has been harshly criticized [http://www.psychiatrictimes.com/display/article/10168/1570483] in recent years.  However proponents of PBD providing CME were mainly confined to the USA.

A key researcher in neuroimaging children diagnosed with PBD, Dr Mani Pavuluri, presented findings at the Hawaii AACAP meeting.  The research appeared to be of high technical quality.  The findings (overactive right amygdale, underactive right frontal lobe) were identical to findings in children who had suffered attachment trauma and abuse.  I and others in the audience asked why not call such children “affect dysregulated” rather than PBD.  Dr Pavuluri agreed that would be a more neutral term, but stated “if we don’t call them bipolar we don’t get funding for our research”.  Such a dependence on a presumed result favored by funders reverses the scientific process.

Also at the AACAP Hawaii conference I asked Dr Melissa DelBello about attachment trauma in her group’s research, the interchange was recorded by Dr. David Allen on this blog here [http://davidmallenmd.blogspot.com.au/2010/04/attachment-latest-dirty-word-in.html].

I did an extensive review [http://cdn.intechopen.com/pdfs/29393/InTech-Paediatric_bipolar_disorder_are_attachment_and_trauma_factors_considered_.pdf ] of the PBD literature for exploration of attachment, trauma and abuse as possible contextual factors and found that the PBD literature was extremely lacking in consideration of these very obvious markers of distress in childhood. 

Why this is so is a very interesting question.  Denial and repression of trauma is a feature of humanity, be it at individual, family or societal levels.  Whether this is more the case in the USA is unlikely but it is possible that American parents have been more indoctrinated with the neurobiological paradigm for children’s behavioral problems and this helps them avoid “parent blaming”.  As an aside, I find it helpful to discuss with parents how parenting in modern societies is incredibly difficult compared to how parenting evolved in small hunter-gatherer ancestor tribes. 

But other modern societies have similar epidemics to the US PBD epidemic.  Instead of PBD in Europe, Canada and Australasia there is a tendency to also over-diagnose autistic spectrum disorders and ADHD as ways of overlooking more complicated attachment, trauma, family dynamic, learning difficulties, bullying and other contextual problems.  To a great extent I think the simplistic checklist approach to diagnosis fostered since DSM-III plays a role in this [http://www.clinicalpsychiatrynews.com/views/commentaries/single-article/diagnostic-labels-and-kids-a-call-for-context/5783d363fe823984bafbef98b0ffaa75.html]

According to DSM-IV: “Not all (culture-bound syndromes) are considered pathological in their society of origin, and may be seen as "idioms of distress”, a way of communicating distress in a way which is culturally understood and, to varying degrees, accepted.”  Thus for a society that has been “educated” to see mental, emotional and behavioral problems as based in neurochemistry fixable with medications, where “parent blaming” is considered unsociable, where health insurers value pharmacotherapy over more talking therapies and insurance clerks request more serious diagnoses from clinicians before reimbursing sessions, and where funding of research comes largely from pharmaceutical companies – to diagnose the moodiness and rages of distressed toddlers, preschoolers and older children as bipolar disorder has to varying degrees become accepted. 

Prescribing polypharmacy psychotropic cocktails to toddlers can be seen as the ultimate in a Huxleyan “brave new world”, the ultimate end point of “Pharmageddon” [http://www.socialaudit.org.uk/60700716.htm].  The recent book by Dr David Healy expands on how we arrived at such a point [http://www.ucpress.edu/book.php?isbn=9780520270985].  PBD can also be seen as an emblematic diagnosis for an era of “mindless psychiatry” [http://www.tandfonline.com/doi/pdf/10.1080/15299732.2011.597826].

The US is not alone to suffer from these factors, but it seems to suffer more than other jurisdictions and hence PBD can be seen as a culture bound syndrome of the USA.  That is not to say it couldn’t spread to other nations if the same predisposing factors were to arise, and ADHD and Autistic Spectrum Disorders do to some extent represent a similar phenomena outside the USA.