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Looking at the cognitive developmental mind, Piaget talked about the sensory motor phase. From a language development point, at about a year, you start to hear single syllable sounds from a one year old – mama, dada. What is most sort of essential about the language of a one-year-old is what I would call the "imperial point". You know, "I want that." Then there’s a parent who’s running around saying, "Do you want this? Do you want that?" What’s relevant about that when we get down and talk a little bit about basic developmental disorder, in fact, kids who are language delayed will still have the imperial point. They may not have the words but they are trying to communicate. Kids with autism frequently are not trying to communicate so that they will not be using gestures to communicate even when they don’t have language.
In terms of play development, I’ve given you a couple of the sort of key norms – the social smile at six weeks, peekaboo at seven months and imitating a more complex behavior at six months. The social smile is interesting and I’m going to try hard not to digress but I can’t resist a little bit. The notion that babies are not related until they get to be six to eight weeks old is a very adultocentric view. In fact, the reason that it doesn’t look like a baby is smiling… newborns recognize preferentially their mother’s voice. What happens is that somewhere around six to eight weeks there’s the neurologic organization to smile with two sides of your mouth at once. So people so, "Oh, no. He/she recognizes me. There’s the smile." But if you’re looking, and frequently primary caretakers are looking for the smile sooner and they get this kind of like one-sided smile and mom says, "See. He’s smiling at me."
From Freud’s perspective, the psychosexual stage is the oral stage and Erickson’s stage is trust versus mistrust. Again, the Erickson’s stages do appear and they’re easy things to just force yourself to memorize.
In terms of the diagnostic entities, one of them is a reactive detachment disorder. It’s the result of pathogenic care. So really it’s abuse and neglect. It occurs before age 5. They talk about an inhibited and disinhibited form. What that looks like clinically, and there’s lots about temperament beyond what we’re going to talk about today, but there probably are kids who are temperamentally introverted versus extroverted.
Clinically what those kids look like is the inhibited kids are sort of passive and withdrawn. When they come into the hospital for a pediatric check after there’s been extreme abuse and neglect, those are the kids that just sort of lie there. They look at you with these kind of big eyes but they’ll let people draw blood and they won’t move. It’s very disturbing. Among the most disturbing things is to see a child who has given up.
The disinhibited form is a little bit different. What you see with those kids is that they will cling to anybody. So when they first come in to the pediatric ward everybody loves them. They hold you tight. They are smiling all the time and they cling to each person but as soon as you are out of their view they’ll cling to the next person. By the time most kids have been on the unit 24 or 48 hours, they’ve burned out all their caretakers. There is something palpable about how they don’t remember you that makes people feel like no matter how much energy and help they provide for this baby short term, the baby is no more connected to them than they are to whoever the next face.
Long term, these are kids who have a lot to get over in terms of the object relations and their Gestalt of whether the world is a safe place because, in fact, before they have words their experience of the world is that it’s not a safe place. They haven’t received good enough mothering in terms of the notion that good enough caretaking or parenting or good enough mothering, there’s some of a myriad of expectable reactions of caretaking – not being left too long hungry, not being left too long wet, ignored, when you get hurt somebody responds. Not any one individual experience but really the day in and day out a million times a day kind of experience and that that has a long term effect.
In terms of pervasive developmental disorders autism, which is probably the one most talked about, the hallmark is impaired social interaction, impaired communication. Though some autistic kids speak, they frequently don’t care whether the person listening is interested. So that’s sort of the experience of kids who will repeat back sort of verbatim things that they’ve heard off the radio like the weather report or the traffic report.
There was a little boy who was in my office not so long ago who sat there and just repeated back what the helicopter had seen with no particular interest in whether I was listening or not. I’ve seen other autistic kids who can read by age 2 ½. Then one I can remember could read right side up and upside down and it didn’t seem to matter to him. But his interactions with other human beings were way off the norms. His brother, who was autistic as
The prevalence of autism is about 2 to 5 kids per 10,000 and it’s a predominance of males greater than females. Asperger’s disorder is extremely rare. I would say I only ever remember seeing it once. The criteria are as they appear here – normal first five months, normal head circumference at birth – and then the losses begin after the five month phase. Then childhood disintegrative disorders. Basically autism that occurs between ages 2 and 10.
In terms of Asperger’s, I put it in here because I started talking about the pervasive developmental disorders at this point, but, in fact, usually an Asperger’s diagnosis is made much later on. These are kids who have impairment in social interaction, stereotype restricted behavior, impairment in social function, but their language and cognitive development is normal. They just don’t get it.
One of the things that I think about or that sort of helps me with the Asperger’s kids is if you’ve known Downs’ kids, Downs’ kids have low sort of cognitive IQ but their emotional IQ is high. They really are quite tuned in to emotion and very affectively present. They’re easy to love. They’re affectionate. They sort of get it. Asperger’s kids are opposite. They get it from a cognitive standpoint but they really don’t get any of the emotions.
Asperger’s kids, particularly in adolescence are incredibly difficult to help to understand the more complex social interactions of adolescence. To try to explain by rules what dating is about, what attractions are about, how you keep yourself safe, what it means to have an appropriate friendship or relationship – unbelievably complicated. These kids themselves sort of suffer feeling like oddballs or being aware that no matter how hard they try, they sort of are missing something. Their parents are generally beside themselves because they have the sense that their child is so vulnerable in the world.
Feeding and eating disorders of infancy are listed because they exist. Clinically, they’re not things that we see. Certainly, pica and rumination disorder are not things we see often in a child psych clinic. Pica is the persistent eating of nonfood substances for more than a month and that requires intervention for safety. The most important one is the eating of lead paint chips or for that matter of eating dirt that has lead in it is problematic. In and
Rumination disorder, I understand that it was something that people found in some of the orphanages in Eastern Europe. The place that I have seen it was when we used to have these sort of long term care units in the hospital. Some of the kids that were on respirators back in a time when you couldn’t go home on a respirator, they would regurgitate because once they start to choke, all their bells and whistles would go off and it would cause the staff to come running. If you set up schedules where the volunteers or the nursing staff could actually carry these kids around, they would stop
Feeding disorders of infancy or early childhood. Inadequate eating for more than a month with significant weight loss. These are the failure to thrive kids and we see a pretty good number of them. I think kids come wired for good eaters or not. Usually that falls within the normal curve but there are
Moving into preschool which is the sort of stage from 2 to 6 or 7 on the emotional milestone front the key concept is magical thinking. Magical thinking is the product of being egocentric. Piaget sort of talked about kids only being able to see things from their own perspective. That kind of egocentricity that they’re sort of the center of their universe. The concrete manifestation of that is if you’re reading with a 3 or 4-year-old, they’ll often hold the book
Add to that associative logic which is the belief that any two things that are true it’s as if they cause each other. That’s what makes the logic of little kids so endearing that they sort of tell you these kind of wonderful stories about how things work and they are unencumbered by facts or causality as we know it. The teaching example I always use is from a number of years ago when one of my children was still in preschool and the other school age
So if you take associative logic, any two things it is as if they caused each other or they make sense as a combination, add to that egocentricity, you get magical thinking. The belief that whatever happens happens because you the preschooler made it happen. So your parents get divorced, it’s your fault. You get leukemia, it’s your fault. Your father dies of a heart attack, the heart attack is your fault.
Now, what you do about that is you need to review, and Mike gave an example of a child whose parents felt they had sort of said to him, "This divorce was not your fault." Then come to found out he still felt that way. You really have to go back over these magical thinking issues over and over
Another one of the sort of key concepts is a kind of worry about body integrity or body wholeness. When Freud talked about castration anxiety, the fear that sort of body parts could be maimed or cut off, a more 1990s understanding of that is that conceptually preschoolers understand their body as a whole. They can’t divide it up into its parts so that when a three-year-old breaks her arm, she is broken. When a 9-year-old breaks her arm, her arm is broken.
As they get older into the school age years, they have the capacity to understand themselves as being made of multiple parts and that probably has something to do with preschoolers being in a preoperational cognitive state, according to Piaget. So for a preschooler, if you line up raisins, take 9 raisins and put 9 of them close together and say, "Which is more? This much?" Then you take the same 9 raisins and spread them out farther "Or this
The most common Piaget example is the one with the beakers – a tall skinny beaker and a short fat one from the same pitcher. You pour from the pitcher into the short fat beaker back into the original pitcher into the tall skinny one and you ask kids younger than age 7 which is bigger and they’ll pick one dimension because they can only hold one dimension in their head at a time and they’ll say this is the bigger one. After age 7, they’ll say,
Preschoolers will stand side by side, one 2 or 3" taller than the other, and the kid who is sort of more powerful in personality will go, "See. I’m taller than you." And the other bigger meeker kid will go, "Yeah, he is." Because they’re not encumbered by reality as we know it.
Before I get to the anal stage, 4 to 6 is the Oedipal… I’ve listed some of the language development and play development issues. Let me just say what fantasy play is. Fantasy play or symbolic play is make believe. It can be your dinosaurs roaring at each other. It can be cars smashing into each other. It can be putting your teddy bear to sleep. It can be giving your baby doll a bath. It can be being Peter Pan yourself or Dorothy. All those things are fantasy play. It’s make believe and that’s what’s missing in PDD or one of the things that’s missing in autism or a phase of developmental delay.
Some of the key diagnoses that most commonly come to light during this age are language related communication disorders, expressive language disorder, mixed expressive/receptive language disorder. They are as they’re named and I’ve given you some of the data and also some of the sort of age markers. It doesn’t seem like the best use of your time for me to read that.
The phonologic disorders, it’s the speech sounds. Again, here are some rules of thumb. At 3, your own parents should understand about 80% of what you say. Not that what you say necessarily makes sense. It may be so idiosyncratic that if you hadn’t gone to McDonald’s with the 3-year-old you wouldn’t know why they were telling you what they were telling you but the actual pronunciation of the word. About 80% of what a 3-year-old says
Stuttering is a disturbance in fluency. There’s also cluttering. Stuttering is trouble getting started on the first word. Cluttering is when the meter of the sentence, several words get squished together and you get the sense that the person is jumbling words together. Some of them are kind of fast and
There are some other disorders that come under the anxiety heading. Selective mutism. These kids will not speak in specific social settings but will speak in other settings. They have the capacity to speak. It’s functionally limiting. The duration has to be more than a month and the child usually will communicate with others but nonverbally. It is associated with anxiety and shyness. It’s less than 1% of the kids that we see in a health clinic. Onset is usually before age 5. It’s a duration of months usually but can continue for years.
Again, like many things in the DSM, particularly in childhood, it can be multidetermined. So one of the common reasons that kids will, in the Boston area that I’ve seen, be selectively mute is because English was not their mom’s first language. She speaks a little bit of English, she’s very shy about speaking in public and then her daughter won’t speak at kindergarten either. If you can help the mom to feel less self conscious. Often, the moms speak really well, they’re just shy, the child will then start to talk if the mom starts to talk.
Some kids may turn out to have Asperger’s or PDD. The not speaking, when you actually get a chance to listen to their language, it’s idiosyncratic and the parents haven’t been able to sort of give you quite the history about how idiosyncratic their language is. They won’t use anyone’s real name. They sort of replace certain words. The language itself is funny but having not heard it, you’ve not realized that that’s the issue. Trauma is another etiology for selective mutism. It’s now called "selective". It used to be called "elective".
In terms of separation anxiety disorder, there’s an early onset subtype with onset before age 6. Developmentally excess fear of separation from home and family or attachment figures. Duration of more than one month. Onset before age 18 and it’s functionally limited. This is complicated because separation anxiety is normal and something like 10% of first graders will have a very difficult time separating from their moms. I had heard the
So the prevalence throughout childhood and adolescence is 4% for separation anxiety and there is a familial association as there is for anxiety in general. Certainly it may follow a life stressor. One of the main things that I do with my time these days is to work with the adult oncology population. I work with adults who have cancer and who are parents to help them to talk to their kids about the parent’s illness. Many of their kids in the context of the parent’s life threatening illness will have anxiety symptoms and separation anxiety, both probably in response to the emotion in the household but also to their parents coming and going not always as planned because of hospitalizations and exacerbations.
The elimination disorders, encopresis and enuresis. Encopresis is the passing of feces in inappropriate places for age. You have to do it at least once a month for three months and you have to be chronologically and developmentally older than age 4. The primary type is the kids who have never been
Enuresis is similar in the sense that there’s a primary and a secondary form. There’s also a nocturnal, diurnal or both with the primary and secondary types and the prevalences are as they are listed. At age 18, there’s still 1% of males who are enuretic. They’re in now the sort of nasal sprays so that there’s some of the kids who may not be on treatment all the time but it can be a big deal for them to be able to use a nasal spray before they go to camp or for a sleepover. Again, there’s a strong familial association.
ADD. There is certainly a wave of presentation of ADD, ADHD in preschool. You can almost make a diagnosis of ADHD in any preschooler if you’re not used to being around preschoolers. This is when preschool teachers are helpful. Most parents will tell you that their child is inattentive, hyperactive, impulsive, all these things. Actually one of the complaints about the checklist is that in some ways it becomes kind of a list in how many ways can I indicate that my preschooler is driving me insane as opposed to something that is more thoroughly diagnostic.
There’s a broad range of how people feel about medicating kids in preschool. I think the conservative stance is that you need to medicate kids who are not able to be safe in the environment in which they live. So that if in the circumstances that they live which you have a sense is better than calling DSS or wanting to have them pulled from their home because it’s a reasonably expectable environment, if they can’t be supervised by the supervisors that they’ve got or kept safe in the environment that they’re in, then that’s a reason to consider medication. The prevalence is 3-5% in school age
Heading into the school age years, latency, ages 6 to 12. Latency is Freud’s term because he had the notion that sexuality was latent during the 6 to 12 year old phase. The emotional milestones include chumship or having a best friend, developing a sense of agency – "my own best effort gets things done", developing self esteem which comes from being somebody that people would want to be friends with and the accruing of increasing numbers of skills.
Cognitive development is typified by causal logic. Now my son, who was already in grade school when his sister said that he didn’t want a dog because he was a boy, his response was, "I don’t want a dog because I know our aunt’s dog bit someone." So whether you agree with that or not, it makes some sense. Kids now have concrete operations. That’s that capacity to understand that the experiment with the pitchers, there are an enormous number of gross motor developmental acquisitions. Kids should learn to swim by the time they’re 7. They don’t necessarily. It depends what they get exposed to but it’s a lot harder to teach a kid older than 7 to swim. So get your child out there and do it.
Riding a bike around about the same age. Many kids will be riding a bike by age 5. Take them to a sloped parking lot when there are no cars, lower the seat as low as it goes so they can flat foot the ground and let them glide. Once they get truncal balance, the pedaling part is easy especially if they’ve ever had a trike. If you’re a geriatric parent as my husband and I are, running along holding onto the seat of a bike is about the worst thing you
Moral development is conventional. You have to follow the rules. A rule is a rule is the adage that goes along with school age. Another good rule of thumb is that up to age 7 in school kids are learning to read. From age 7 on they’re reading to learn. So it’s learning to read and reading to learn. My favorite pearl from a principal is when she was a first grade teacher and she would put out the checkerboard for the kids to play checkers or Candyland she would say to them, "Do you want to play by the rules on the box or do you want to play so that you win?" In first grade, some of the
Language development. It should be mature. Kids are learning to read and to write. You want to pick up any kids who are not reading by the end of first grade. So that’s the year that they’re 7. What happens all too often is that kids are promoted to the second grade. They can’t read. In the second grade, you need to be able to read the directions to do the worksheets and do the various things that you’re assigned. People drag their heels. The school system hasn’t got the money. The classes are big. The child’s not disruptive. They just kind of get moved along. By the time they get to the third grade, if they still really can’t read now school has been such an unpleasant experience for them, they’ve had reinforced for six hours a day 180 days a
In terms of play development, kids are going to do board games. They’ll be out playing sports. If you watch school age kids on the playground, the rules there outside, particularly boys, the sports rules get more and more elaborate. We have a basketball hoop in our driveway and it got to a point
In terms of where you want them to be psychologically at the end of school age, you want kids to have what I call a sense of agency. To feel like their own best effort works. You want them to have a concept of who constitutes a quality adult so that they notice that some kids have moms or dads that aren’t that nice. That the cafeteria lady who yells at everybody in the line maybe shouldn’t be working with kids. You want to teach them both a
You want them to have had the experience, hopefully, of a best friend but at least of close friends to have the sense of someone that you can play and play and play with without so much conflict, without needing grownups to intervene on your behalf. Somebody that makes you feel like you’re really fun to be with and you want that to be consolidated before you add sexuality which confuses everything.
You want kids to have a sense they’re for who they are, not what they look like. They are attractive. You worry about the kids who in school age want to keep their best friends away from somebody else, who are very invested in excluding other kids who have a sense that friendship is liked a fixed pie. If somebody else gets more of my friend, I lose that piece and so they get very competitive because once they enter adolescence and you
Oppositional defiant disorder is basically kids who are difficult – not bad, just difficult. Their hostility tends to be directed at authority figures – parents and teachers – but there are other people that they often get along with really well. They’re kids that with some empathy often you can sort of do an end run and make a pretty good alliance with them. They’re not without compassion for others, it’s just that they have this sense all the time that the
Tic disorders. Tourette’s, multiple motor tics. You need to have at least one vocal tic at some time. The tics occur many times, usually daily for more than one year. We know that tics are also associated with obsessive compulsive disorder. There is a functional impairment, onset before age 18 is the most common. The median age of onset is 7. That appeared on the boards once too. I can’t think why that would be important but it was there.
It often diminishes in intensity in adolescence. I remember a kid who described it as being like… I think it was actually his dad who said it was like the child would get into the car and without putting the key in the ignition the car would start. That he was sort of all the time kind of exploding and ticking. You can have motor tics separate from vocal tics and you can have transient tics. They meet the criteria as indicated. I work in a pulmonary clinic with the cystic fibrosis patients but the pulmonary doctors see a lot of habit coughs that I recognize as being tics.
Sometimes you get… this is really esoteric, but also some stress induced asthma stuff will give you a cough. In the greater Boston area a disproportionate number of these habit cough kids are ice skaters, sort of competitive ice skaters. I think it’s some combination of exercise induced plus cold and they get these coughs. Probably stress is a piece of it too because they’re all the performer kids.
In terms of adolescence, the emotional milestones include identity formation. The image that I always hold in my head of adolescence is of hollow chocolate bunnies that you get at Easter. That they sort of are defining themselves with all these sort of outward show of who they are but when you sort of bite into them, they’ve got kind of a hollow core. It’s a lot easier for them to say what they think is "whack" and "stupid" and what they don’t believe in. They’re big on reminding us as parents that we’re hypocritical and finding our flaws. Sometimes one has the sense that they are looking for things to say things that you have to say no to. Ask me something I can say yes to.
People sometimes refer to it as the second separation. The first separation is when 1-year-olds set off walking and separate from their parents that way. The second separation is adolescence where you’re defining yourself as different from your parents. So if your parents are Republican you need to be a Democrat and vice versa.
There’s a lot of focus and self consciousness to do with body image. Cognitively they have abstract thinking. That capacity to think about thoughts. Their idealism and their thinking about thoughts is incredibly appealing. I often end up reading essays that really bright kids are writing for college and I smile to myself. There’s not like a noun in any of the sentences. It’s sort of like, "What are you talking about?" You know, it’s this kind of heady
The moral development is post conventional. There are gender differences in this notion of post conventional morality that is beyond what we’re going to talk about but post conventional is understanding that even something that is morally correct for you, if it’s not for the greater good it may be the wrong thing to do. It’s the covert example of breaking into the pharmacy in order to steal the drug that you haven’t got the money to buy for your
In terms of language development, there’s lots of jargon and the use of idiosyncratic language with their peer group and the whole purpose of it is that it should change all the time so that by the time the language of the 10th graders is being spoken by the 8th graders, the 10th graders are no longer using that word anymore and God forbid your parents should understand it. Freud viewed this as the phase where people are moving towards genital
I want to say two things because I can’t resist the fact that I’m in front of a mike about talking to adolescents about sex and drugs. In almost any behavioral things the key is to appeal to adolescents ability to choose and not to make yourself an authority. That they have to buck against you… they will prove that they will buck against you if you tell them that they have to do something so that what you want to do is to give them a good reason.
Around sex what I say to kids is that whatever you’re doing I would rather hear about it than not hear about it. So it doesn’t do either of us any good if you’re doing things that you’re not telling me about but as a grownup let me give you a spiel here for waiting. The first thing is that if you do wait, it’s not like it’s going anywhere. You’re going to always have the opportunity to do it and my experience is that the best thing about being a teenager is to
Play therapy, which is usually for young kids. Primarily for preschoolers but sometimes for school age kids. Treat a symptomatic young child by utilizing fantasy play to work through the anxiety or traumas in displacement which means you don’t have to really talk about it. In fact, as child psychiatrists if kids are telling us a story in the doll house, we don’t go, "Hey, that’s you. So that’s how your dad treats you?" Or "Oh, that must be your mom." Because what you’ll do is you’ll stop the play and the notion is that they can work through their concerns if they’re allowed to play freely and that play is facilitated.
What sometimes leads someone to choose to have a child therapist do the play with the child is because either it’s difficult for parents to know how to play with their kids or have the time to play with their kids or other caretakers to or it’s difficult to allow them to elaborate the story that they want to tell.
The classic one for people like me, working moms, is the child who says, "Okay. I’m going to work and you cry." And you say, "Oh, no, no. I’m not going to cry because I know you’re coming back." The kid says, "No, no. You’re going to cry. I’m leaving and you’re going to cry." "But no. I don’t want to cry because I know I’m coming back." Because the parent has this investment that actually it shouldn’t be hard and the good thing about kids
Family therapy treats a symptomatic child who’s acting out the tensions in the family by addressing the family as a whole, looking at the problem as a family problem and trying to bring secrets to light. Parent guidance therapy offers support and new strategies to parents so that they can better parent their symptomatic child. Children’s therapy groups can be sort of all comers but frequently there’s either an age, like latency aged boys group or an adolescent girls group or it’s around children whose parents have cancer or adolescents who are substance abusers.
Psychiatric hospitalization. These are all just sort of levels of treatment. Specialized classrooms. Specialized schools are listed. Mike talked about the role of guardian ad libitum as a person appointed by the court if the family has a status in the court like they had a divorce. Then if the sense is that the child’s interests are not best served by either parent, then appoint a guardian ad libit to really be a referee and take the child’s needs first is what happens. The rules about filing in every state are that you would need to file in Massachusetts with the Department of Social Service but if you think a child is at risk.
Care and Protection is a court order that takes custody away from parents when a child is at immediate risk. That’s something that sometimes happens in the hospital if a child needs emergency surgery and the parent is unwilling or unable to give permission, we’ll get a C&P acutely and then the hospital is transiently the guardian and then often the Department of Social Services will step in.
In terms of school aged children, in terms of a divorce about half of them will have a lower grade point average. The drop is about a full grade during the one year after the divorce. 90% of those return to their baseline functioning afterward. Boys tend to be more aggressive. Girls tend to get a bit
In terms of clinical issues, I mentioned the parental depression. In men there’s usually an increase in other psychiatric disorders. One of the major risk factors in divorce is poverty and it’s interesting that 50% of all women end up in poverty at the end of the divorce process. It’s one of the major contributors for putting families below the poverty line in the United States.
In terms of predicting difficulties, the single major factor that predicts child psychiatric disorders in divorce is ongoing discord. If the divorce ends bitterness between the parents, there’s a lot of fighting and the divorce improves things then there doesn’t seem to be as much long term difficulty in terms of the child’s behavior. But if the divorce doesn’t end the discord and in about 10% of divorces they are in court after the divorce then that’s particularly damaging to children. In followup studies, virtually every child who has been in ongoing discord has ended up with psychiatric disorders and in treatment.
One of the interesting features of divorce is what I’ve alluded to before which is the subway effect of the impact of having been in a divorce as a young child or as an adolescent now which is worse. Originally it was thought that young children suffered the most being in the divorce process and that that subway effect would hit them when they became adolescents and then young adults in their own relationships. Well, it’s very hard to study because it takes such a long time to track and to measure. It seems that early adolescents are at greater risk than young children. It seems young children can adapt to the divorce process and to their more limited world while the adolescent sees this as more of a basis of equality in interpersonal relationships and trust.
In probably the best followup study, she looked at 75 kids who she had followed for 15 years through a divorce process. In the first sample when they first looked at the kids, clearly the factor that made the most difference was ongoing discord. But the second set, they looked at relationships and intimacy of divorced children years later and they found that those children who had a difficult time of discord, where the divorce occurred during early and mid adolescence, they seemed to have difficulty with intimate relationships in their own young adulthood and that there seemed to be a pretty clear
It’s interesting that given the number of divorces and how prominent this issue is we really don’t have a lot of data on the consequences. There were some studies where there seemed to be some subtle consequences that were pretty important. The major controversy in divorce, of course, is custody. There has been a movement toward joint custody. Custody is divided into physical and legal. On the joint custody front sometimes that’s
If the joint custody is imposed on discord it’s a disaster because then the kids are facing two hostile parents very frequently every week. In the examples that I’ve dealt with there have actually been rules that the child has to walk 30 or 40 feet between the car and the house even though the parents have joint custody because the parents don’t want to have any contact and have gone so far as to have court orders. In one particular family, they set up a post and that post was the distance that was allowed the father to come in the car. This was in a rural area and there was snow and rain and wind and you see these little kids walking through a demilitarized zone from the post to the front door carrying a suitcase. That’s the bad side of joint custody. So if you see joint custody with ongoing discord, that’s something you really have to get involved in because it’s going to tear the kid apart.
Let’s move on now to adolescent suicide and depression. Clearly one of the nightmares that child psychiatrists deal with is adolescent depression and adolescent suicide. In terms of a population phenomenon, childhood depression and early adolescent depression is among the most under recognized problems in child psychiatry. When you look at the epidemiology of what gets referred, destructive disorders like ADHD, conduct oppositional and