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Section 23
Communication Breakdown

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In May 1997, the U.S. House of Representatives passed a new bill designed to "crack down" on juvenile crime by rewarding states that agree to prosecute more under-age perpetrators as adults. Prosecuting children as adults satisfies our urgent desire to do something about adolescent aggressors who kill parents, classmates, even total strangers. Conveniently, it also covers up our own failure to pay attention. Teenage murderers do not rise up fully formed on their thirteenth birthday. Their deterioration began years before, in a childhood custom-designed to bring out the worst in them.

It's not as if these troublemakers were invisible. Aggressive, angry children typically command more than their fair share of attention-from families struggling to manage them, schools frustrated by efforts to educate them, angry communities sick of enduring them. In fact, of all the problems common to troubled children-defiance, lying, stealing, truancy, academic failure-none is more likely to translate as a cry for help than aggression.

"Aggression is the number one problem in child psychiatry," contends Carl Feinstein, director of clinical services for child and adolescent psychiatry at Stanford University Medical School and former medical director of the Center for Autism and Related Disorders at Baltimore's prestigious Kennedy Krieger Institute. Other experts who treat childhood behavior problems concur. Tony Rostain says of the children he treats for AHDH at the Philadelphia Child Guidance Center, "probably 75% aren't brought here for their attentional problems, but because of their aggressive behavior." Karen Bierman, a psychologist at Penn State University who heads a research team evaluating a comprehensive intervention program for troubled children, believes that persistent aggression "is one of the most prevalent and intractable mental health problems of childhood and adolescence," and that teenage delinquency, as well as antisocial aggression in adults, "rarely. . . begin without warning signs in early childhood."

How can we be so aware that some children are already too aggressive, and yet so powerless to stop them from evolving into violent adolescents? Are indulgent, preoccupied, self-centered, divorced, or unmarried parents to blame? Television? An extinction of family values? Or have we also overlooked the biological significance of childhood?

Everyone who has taken a psychology course or read a newspaper has heard that "today's child victims are tomorrow's perpetrators." The idea that violence is recycled across generations has been repeated so often that it's taken for granted. But not all abused children grow into juvenile delinquents or antisocial adults. And not all studies that have looked for a link between abuse and subsequent violent behavior have found one.

A recent study, sponsored in part by the National Institute of Justice, provides the best evidence yet that children who are abused and neglected are at greater risk of arrest for a violent crime later in life. Children who had documented evidence of abuse or neglect were nearly twice as likely to be arrested as juveniles than children with no history of abuse, one and a half times more likely to be arrested as adults, and significantly more likely to have committed a violent offense. Children who had been physically abused were the most likely to be arrested for violent crimes. But surprisingly, children who had merely been neglected (who constitute 52 percent of the million-plus confirmed cases of child maltreatment each year) were only a percentage point behind.

Hypervigilance, misinterpretation, and an exaggerated response to perceived threats are the behavioral consequences of the strain imposed by the need to compensate for such a heavy load. Even if "abuse excuses" try our patience, it is clear that trauma and abandonment cannot be good for the developing brain.

"Trauma effects are especially important early in development because they encourage adaptation," observes stress researcher Frank Putnam. "And early adaptation resets physiological systems in ways that leave them very different from normal."

The mother on the other end of the line was trying to strike a balance between sounding calm enough to avoid being judged incompetent and desperate enough to get the talk show host, a local child psychologist, to take her seriously. The problem, she explained, was her two-and-a-half-year-old son, a difficult baby who had matured into a tyrannical toddler.
"He's just unmanageable," she pleaded. "I know two-year-olds have tantrums. But he won't do anything we ask him to without a fight. I've tried asking him politely, saying please and thank you-and he hits me. If I put him in timeout, we end up fighting about him staying in the chair. I've tried being firm, I've tried demanding, I've even bribed him-I admit it. All he does is yell and scream."

"Two is such as exciting age," coos the psychologist ingratiatingly. "Your son can do so many things all by himself now. But he still needs you."

No doubt about it. The exciting little person in question can be heard voicing his need for Mom at stadium-concert volume.

If the psychologist hears, she's not responding. "He's trying to come to terms with his new-found maturity," she prattles on. "You should just spend lots of time playing and having fun. Take him out to places like the mall, so he can try out his new way of looking at the world. He needs to know that someone is celebrating the joy of childhood with him."

Across town, Laurel's parents have talked to three different doctors in two years, trying to understand why their eight-year-old daughter slaps, kicks, and insults her five-year-old brother relentlessly. They've heard from one psychologist that they're "too authoritarian"-but another insisted they were "too indulgent." They're simultaneously "inconsistent" and "overly rigid," "too detached" and '(too overinvolved." They've learned how to improve their parenting skills and set up "incentive programs," but Laurel's hostility seems impervious to time-out, sticker charts, and lost privileges. The one thing they haven't learned is how to end the fighting. As for Laurel, the only thing she's learned from any of these experts is that her parents are incompetent. "If we can't control her now," her mother worries, "what will we do when she's a teenager?"

These examples demonstrate how we fail troubled children so consistently: we refuse to see childhood aggression for what it is, when we can no longer overlook it; we don't know what to call it; and when we finally think we've identified it, we still don't know what to do about it. Intervention often focuses on reforming the parents, while sidestepping the question of why the child is lagging in his or her social development or how the relationship between parent and child has gone wrong.

Look behind an aggressive child and you may well find parents who are preoccupied, incompetent, or negligent. Or you may find parents who recognized trouble but prayed that the child would "grow out of it." You may find parents who asked for help and were told that nothing was wrong or that it was their fault, or confused, frustrated, disappointed parents who have tried to follow through on expert advice and failed, even seen the problem grow worse. What you're certain to find is an ignorance of the fact that aggressive adults often start as children who hurt others, children whose social ineptitude already reflects destructive interactions between the brain and an environment that is threatening, unfulfilling, or incomprehensible. Worse, you're likely to find a failure to appreciate that unlike adults, children have nervous systems that are still immature, and their behavior, as a result, is still wide open to change.

Kids are aggressive for the same reason as adults-a vicious circle between brain, behavior, and environment-and they're aggressive in the same ways. Some overreact, to people and situations they perceive as threatening; some underreact, especially to punishment. The spiral may be set in motion by loss, abuse, neglect, fear-or it may have more insidious roots in the temperamental traits that require special management skills.

Children with a slow-to-arouse, fearless temperament, for example, can be easily mismanaged into antisocial tyrants. Because their sluggish sympathetic nervous system assigns lower emotional values to negative events, they seem impervious to punishment. They're more interested in rewards, but the motivational power of candy and gold stars eventually pales in contrast to the thrill of conflict. Intellectually, these children may come to recognize that a system of rules governs social conduct, but the rules themselves hold about as much meaning for them as the tax code.
Child development researchers who study children with autism say that they lack a "theory of mind"-the ability to recognize that other people have their own thoughts, beliefs, and feelings. Uninhibited children on their way to an antisocial personality also fail to recognize that others have feelings. Because the world of emotion is incomprehensible to them, they remain indifferent, cognizant only of their own needs and wants.

Poor emotional understanding results in a social learning deficit. Without emotions to guide them, insensitive children can't seem to figure out how to tailor their behavior to mesh with others, and their negligence often results in inappropriate reactions to emotional situations. For example, if a playmate falls, skins a knee, and starts to cry, a socially aware child will also become distressed or attempt to comfort her companion. Emotionally insensitive children, on the other hand, may act aggressively instead.

Learning is an essential part of changing inappropriate behavior. But unless environmental interventions include the intensive remedial instruction in social skills emotionally insensitive children need to catch up with their more socially sophisticated peers, the aggressive behavior is going to persist. And without relief from the relentless stress of living with the aggression, parents and siblings are going to find it increasingly difficult to cope.

Experts who work with physically disabled children have developed exercises designed to improve mobility, strength, and fine motor control. Similarly, professionals who work with the social, emotional, and cognitive challenges of developmental disorders like autism have come up with strategies to teach social skills to children who need extra help. These techniques include visual aids, such as charts and storyboards, which outline an easy-to-follow script for social interactions; videos illustrating appropriate behavior; modeling; and role playing. The goal is to create a consistent, structured environment in which children are surrounded by examples of acceptable social behavior and opportunities to practice non-aggressive solutions to social problems.
- Niehoff PhD, Debra, The Biology of Violence; The Free Press: New York, 1999

Personal Reflection Exercise #9
The preceding section contained information about communication breakdown. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 23
According to Carl Feinstein what is the number one problem in child psychiatry? Record the letter of the correct answer the Answer Booklet.