Preparing to be Best Parents & Relating to Children

การเบื่ออาหารในเด็กตามทฤษฎีแพทย์แผนจีน

แนวคิดทางทฤษฎีแพทย์จีนของเด็กเบื่ออาหาร

๑.  ปัญหาการเบื่ออาหารในเด็กในแพทย์แผนปัจจุบัน ส่วนใหญ่จะจัดอยู่ในปัญหาทางด้านจิตเวชศาสตร์เกี่ยวข้องกับอารมณ์ การฝึกอบรม พัฒนาการ การรับรู้ของเด็ก ซึ่งเทียบเท่ากับปัญหาปัจจัยภายนอกในทัศนะแพทย์แผนจีน ซึ่งมีส่วนสำคัญไม่น้อยและต้องให้ความสนใจแก้ไขด้วย

๒.  ปัญหาภายในเนื่องจากระบบกระเพาะและม้าม ซึ่งเกี่ยวข้องกับระบบพลังและความสามารถในการย่อยดูดซึมอาหาร เป็นปัญหาพื้นฐานที่เป็นผลจากภาวะร่างกายของแม่ขณะตั้งครรภ์ หรือการเลี้ยงดู การให้อาหารเด็ก และความอบอุ่นทางจิตของเด็ก ตั้งแต่ตั้งครรภ์ จนถึงภาวะปัจจุบัน

ร่างกายของแม่ที่อ่อนแอ แพ้ท้องรุนแรง กินอาหารไม่ได้ดี ขาดการบำรุงที่ถูกต้องเหมาะสม รวมทั้งการกินอาหารในช่วงหลังคลอด ที่มีลักษณะเย็นมากเกินไป ย่อมส่งผลต่อน้ำนมที่เด็กได้รับ ทำให้ระบบการย่อยดูดซึมของเด็กมีปัญหา เพราะกระทบต่อระบบม้ามโดยตรง

เด็กเล็กควรหลีกเลี่ยงการดื่มน้ำเย็น นมแช่เย็น เครื่องดื่มแช่เย็น ไอศกรีม เพราะความเย็นทำให้การทำงานของระบบการย่อยอาหารต้องหนักขึ้น ทำให้เสียสมรรถภาพได้ง่าย

จิตอารมณ์ที่ตึงเครียด ไม่ว่าจากสภาพครอบครัว หรือการดุด่าว่ากล่าว ย่อมกระทบระบบตับ ซึ่งระบบตับจะไปข่มระบบม้าม (ธาตุไม้ข่มดิน) ทำให้ระบบย่อยอาหารอ่อนแอยิ่งขึ้น เด็กจะเบื่ออาหาร

เด็กที่เบื่ออาหาร(มีการแสดงออกทางระบบม้ามอ่อนแอ) มีผลทำให้เด็กท้องเสียง่าย อาหารไม่ย่อย ไม่แข็งแรง เป็นหวัดง่าย เหงื่อออกง่าย การย่อยดูดซึมลำเลียงไม่ดี

โรคที่เกี่ยวเนื่องจากการอ้วนในเด็ก

ปัญหาทางจิตใจ

การอ้วนทำให้เด็กมีปัญหาเรื่องบุคลิกภาพ เช่น ถูกเพื่อนล้อเลียนว่าอ้วน ไม่เป็นที่ยอมรับของเพื่อนฝูง ทำให้เด็กอ้วนบางคนมีปมด้อยและแยกตัวออกจากสังคม เป็นผลให้เด็กไม่สามารถที่จะประสบความสำเร็จได้เท่าที่ควร ทั้ง ๆ ที่มีความสามารถ

โรคเบาหวาน

โรคอ้วนทำให้มีการต้านฤทธิ์ฮอร์โมนอินซูลิน ทำให้ระดับน้ำตาลในเลือดสูง โดยเฉพาะเด็กที่มีประวัติสมาชิกในครอบครัวเป็นเบาหวาน จะยิ่งมีความเสี่ยงสูงเพิ่มขึ้น

โรคกระดูกและข้อ

เด็กอ้วนมาก จะมีปัญหากระดูกและข้อ ปวดหัวเข่า ปวดข้อเท้า กระดูกงอ เพราะร่างกายต้องแบกรับน้ำหนักมากอยู่ตลอดเวลา ซึ่งถ้าเป็นมากๆ อาจทำให้ข้อหลุดหรือข้อเสื่อมได้

เด็กเล็กที่อ้วนมากๆ จะมีปัญหาทางพัฒนาการที่ต้องใช้กล้ามเนื้อ คือ จะเดินไม่คล่องตัว การเคลื่อนไหวอุ้ยอ้าย การคว่ำตัวลำบาก การเดินหรือการวิ่งจะเหนื่อยง่าย

โรคระบบทางเดินหายใจ

เมื่อเด็กอ้วนมากจะมีการอุดตันของทางเดินหายใจได้ง่าย โดยเฉพาะเวลานอนหลับปอดขยายตัวได้น้อย และมีออกซิเจนในเลือดต่ำ คาร์บอนไดออกไซด์ในเลือดสูง เกิดอันตรายถึงแก่ชีวิตได้

โรคความดันโลหิตสูง

โรคนี้พบมากในเด็กอ้วน เพราะความอ้วนเป็นปัจจัยเสี่ยงที่สำคัญต่อการเป็นโรคความดันเลือดสูง โรคหัวใจ

ไขมันในเลือดสูง

ทำให้เกิดโรคหลอดเลือดตีบแข็งและโรคหัวใจ

โรคผิวหนัง

ทำให้ผิวหนังเสียโฉม เพราะผิวจะแตกและลาย มีลักษณะดำบริเวณคอ รักแร้ ข้อพับต่าง ๆ มีสีคล้ำโดยเฉพาะในกรณีที่อ้วนมากๆ แล้วก็มีแผลที่เกิดจากการเสียดสี แผลแตก เกิดการอักเสบตามมา

REFERENCES AND SUGGESTED READINGS

American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders.  Second Edition.  Washington, D.C.: American Psychiatric Association, 1968.

ANTHONY, S. The Discovery of Death in Childhood and After.  Baltimore: Penguin Books, 1971.

BANDWIN, A. Aggression: A Social Learning Analysis.  Englewood Cliffs, N.J.: Prentice-Hall, 1973.

–Principles of Behavior Modification.  New York: Holt, Rinehart and Winston, 1969.

BAROFF, G. Mental Retardation: Nature, Cause, and Management.  New York: Wiley, 1974.

BOWLBY, J. Separation. London: Penguin Books, 1971.

CHURCHILL, D., ALPERN, G., AND DE MYER, M., eds. Infantile Autism.  Springfield, Illinois: Thomas, 1971.

CLEGG, A., AND MEGSON, B. Children in Distress.  Baltimore:  Penguin Books, 1968.

COLEMAN, MARY, ed.  The Autistic Syndromes.  Amsterdam: North Holland Publishing Company, 1976.

COPELAND, J. For the Love of Ann.  New York: Ballantine Books, 1973.

DAVIE, R., BUTLER, N., AND GOLDSTEIN, H. From Birth to Seven.  London: Longman, 1972.

DOUGALS, J. “Early disturbing events and later enuresis.”  In I. Kolvin, R. MacKeith, and S. Meadow, eds. Bladder Control and Enuresis.  Philadelphia: Lippincott, 1973.

EHRMAN, L., OMENN, G., AND CASPARI, F., eds. Genetics, Environment and Behavior: Implication for Educational Policy.  New York: Academic Press, 1972.

EVERARD, M., ed. An Approach to Teaching Autistic Children.  Oxford: Pergamon Press, 1976.

GLASSER, W. Schools Without Failure.  New ork: Harper & Row, 1969.

GOLD, P. Please Don’t Say Hello.  New York: Human Sciences Press, 1975.

GREENFELD, J. A Child Called Noah.  New York: Holt, Rinehart and Winston, 1972.

GROSSMAN, H., ed. Manual on Terminology and Classification in Mental Retardation, 1973 Revision.  Washington, D.C.: American Association on Mental Deficiency, 1973.

HEBER, R. Epidemiology of Mental Retardation.  Springfield, Ill.: Thomas, 1970.

INGRAM, T. “The classification of speech and language disorders in young children.”  In M. Rutler and J. Martin, eds.  The Child With Delayed Speech.  Philadelphia: Lippincott, 1972.

KAGAN, J., AND MOSS, H. Birth to Maturity.  New York: Wiley, 1962.

KENNEDY, W. Child Psychology.  Englewood Cliffs, N.J.: Prentice-Hall, 1971.

LOVASS. I.  The Autistic Child: Language Development Through Behavior Modification.  New York: Irvington Publishers, 1976.

MARTIN, G., AND PEAR, J. Behavior Modification: What It Is and How To Do It.  Englewood Cliffs, N.J.: Prentice-Hall, 1978.

MENKES, J. Textbook of Child Neurology.  Philadelphia: Lea and Fibiger, 1975.

MORLEY, M. The Development and Disorders of Speech in Childhood.  Baltimore: Williams and Wilkins, 1965.

PARK, C. The Siege.  New York: Harcourt Brace Jovanovich, 1967.–,and SHAPIRO, L. You Are Not Alone.  Boston: Little, Brown, 1976.

PIEPER, E. Sticks and Stones.  New York: Human Policy Press, 1977.

RIMLAND, BERNARD.  Infantile Autism: The Syndrome and Its Implications for a Neural Theory of Behavior.  Englewood Cliffs, N.J.: Prentice-Hall, 1964.

RINN, R., AND MARKLE, A. Positive Parenting.  Cambridge, Mass.: Research Media, Inc., 1977.

RITVO, BERNARD. Autism: Diagnosis, Current Research and Management.  New York: Spectrum Publications, Inc., 1976.

ROBINSON, N., AND ROBINSON, H. The Mentally Retarded Child.  New York: McGraw-Hill, 1976.

RUTTER, M., GRAHAM, D., AND YULE. W. A Neuropsychiatric Study in Childhood.  Philadelphia: Lippincott, 1970.

SCHOPLER, E., AND REICHLER, R. Psychopathology and Child Development: Research and Treatment.  New York: Plenum, 1976.

SCHULONAN, J., KASPER, J., AND THRONE, F. Brain Damage and Behaviors.  Springfield, Ill.: Thomas, 1965.

STEWART, M., AND OLDS, S. Raising a Hyperactive Child.  New York: Harper &Row, 1973.

STEWART, M. AND GATH, A. psychological Disorders of Children: A Handbook for Primary Care Physicians.  Baltimore: Williams and Wilkins, 1978.

THOMAS, A., CHESS, S., AND BIRCH, H. Temperament and Behavior Disorders in Children.  New York: New York University Press, 1968.

WATSON, L. Child Behavior Modification. New York: Pergamon Press, 1973.

–Behavior Modification of Mentally Retarded and Autistic Children: A Manual for Nurses, Teachers, and Parents.  New York: Pergamon Press, 1973.

WHITE, R. The Special Child: A Parents’ Guide to Mental Disabilities.  Boston: Little, Brown, 1978.

WING, L. Autistic Children: A Guide for Parents and Professionals.  New York: Brunner/Mazel, 1972.

NOTES ON CHILD MANAGEMENT

Throughout the past quarter century, psychologists have developed effective principles of managing child behavior.  Highly sophisticated procedures are required to control the more difficult behavior problems.  Some general guidelines that can be applied to all children in most situations follow.

Learn to view a child’s behavior in terms of specific responses that you can count.

Broad labels, such as aggressive, withdrawn, or overanxious, are not useful in developing a program to change behavior.  It is helpful to specify problem behavior by observing that Bob hit Samuel three times during recess.  This approach enables the parent or teacher to apply the appropriate consequences to specific responses.  This is clearly the most efficient method of changing behavior.  Reward desirable behavior and ignore undesirable behavior.

We all know that behavior which is rewarded or reinforced in more likely to occur in the future.  Children will respond to positive incentives (reinforcers) such as food, attention, praise, money, tokens, and toys.  The procedure of administering these reinforcers immediately after the child’s desirable behavior is called positive reinforcement.  Reinforcement should be used often and applied to the child’s achievement of small steps toward his or her goal.  The teacher or parent can gradually require more work for the same reinforcers.  Effective reinforcers vary with individuals.  Some children respond better to praise and attention, whereas concrete rewards, such as raisins or tokens that can be exchanged for candy, may be more effective for others.  The adult must determine the most effective reinforce through trial and error.

Ignoring behavior is a powerful technique for eliminating undesirable behavior.  Simply walking away is an effective response to a child’s whining or temper tantrum.  It is important to avoid eye contact or verbal exchange after an undesirable behavior.

Another more elaborate form of ignoring a child’s behavior is to isolate the child in time out.  This is a highly effective technique in which a child is placed in a small, well-lighted and ventilated room for several minutes following the undesirable behavior.  A rule of thumb is to leave the child for one minute for each year of age; for example, an eight-year-old should stay in time out for eight minutes.  The room should be devoid of attractions such as toys, books, or record players.

Generally, physical punishment is an ineffective, inefficient approach to discipline.  First, physical punishment is only effective when the child is in the presence of the punishing agent (teacher or parent).  Most children return to the same activity when the teacher or parent is not in the immediate environment.  Second, physical punishment only temporarily suppresses the undesirable response.  If the incentive (e.g., attention, praise from peers) remains, the behavior is likely to recur.  Third, physical punishment may produce unpredictable behavior because of the negative emotion that is created.  The child usually responds with anger, which may motivate him or her to retaliate in passive ways (e.g., for getting to deliver Mom’s message that she needs the car today).  Fourth, children learn by example.  Physical punishment therefore teaches the child to control others by physical aggression.  Finally, most adults perceive a spanking or a scolding as punishment.  However, the parent or teacher may be inadventently reinforcing the behavior with a spanking.  Any form of attention (even negative kinds) may be highly rewarding to some children.  For these reasons, physical punishment should generally be avoided, yet it can be usefully applied when a child’s behavior creates danger (e. g., playing with matches or crossing the street without permission).

Be consistent in your child’s discipline.

This is an extremely important guideline in approaching your child’s behavior.  Inconsistent discipline patterns usually produce confusion, anxiety, and undesirable behavior.  Inconsistent discipline can be avoided through discussing both behavior patterns and the consequences that will be invoked for unacceptable behavior.  Parents should also communicate with grandparents, babysitters, other siblings, and teachers about treatment of the child’s behavior.  It is vitally important to avoid threats that will not be carried out.  Define acceptable behavior to the child and clearly explain the consequences of both acceptable and unacceptable behavior.  It is more effective to demand desirable behavior than to correct undesirable behavior.  Again, the parent and teacher should have clear ideas as to what behaviors are acceptable and unacceptable, and then they should apply consistent consequences to these behaviors.

Encourage independence and responsibility.

This important guideline has been espoused by Dr. Robert Lesowitz in his book, Rules For Raising Kids.  Dr. Lesowitz points out that many young people fail to adjust to their freshman year at college.  He largely attributes this failure to the lack of freedom to make important decisions coupled with the responsibility expected of these people during childhood and adolescence.  Indeed, a child whose parents deny his or her independence in such matters as choosing clothing, setting routine study time, selecting friends, or earning money may have a difficult adjustment period after leaving home.  On the other hand, a child to whom freedom without responsibility is granted may experience and even more difficult adjustment.  Children should gradually be encouraged to be independent in such areas as cleanliness, grooming, assuming household chores, and successfully completing schoolwork.  This freedom and responsibility pattern should continue until self-sufficiency is achieved-by late adolescence or early adulthood.

Encourage success experiences

One of the most important aspects of development is a child’s self-concept.  This refers to how a child views his or her self, and this information is obtained from other people and from the physical environment.  If a child feels successful, his or her self-concept is usually positive.  Success can be encouraged by providing activities within the child’s range of ability.  Children should generally be allowed to set their own goals.  Children usually choose goals that are neither too easy nor too difficult to attain.  Arbitrary standards for success and failure should be avoided.  In his book, Schools Without Failure, Dr. William Glasser asserts that many of our children develop poor self-concepts because of failure experiences in school.  He attributes much of the absenteeism, dropping out of school, delinquency, and general incompetence to unnecessary failure experiences that occur early in school.  Dr. Glasser’s concern about early failure experiences may be applied to the child in all spheres of life.  A sense of competence, self-worth, and confidence can be instilled only through a success-oriented approach based on positive rather than on aversive contingencies.

Teach children by example.

Psychologists have studied the process of modeling and have concluded that children behave in a similar manner to others in the immediate environment.  Not only will children model specific responses, they will model general behavior patterns.  For example, children with two parents who smoke cigarettes are twice as likely to smoke.  Children of parents who do not drink alcohol (no appropriate model for drinking) and children of alcoholic parents (inappropriate models) are more likely to be alcoholics than children whose parents drink in moderation.  Parents and teachers may observe periods of rebellion in which the child rejects the adult model.  These periods are usually an expression of independence and often dissipate if ignored.  Children are quite perceptive in detecting discrepancies between the adult’s stated views and the adult’s behavior.  This hyprocrisy is rejected, and the adult’s behavior becomes a destructive influence on the child.

When in doubt, seek professional help.

The parental role is one of the most demanding, responsible roles in any society.  This is also the role for which we are least prepared by formal education.  Most parents rely on tradition and common sense in rearing their children.  Frequently, parents may be unwittingly defeating their goals of providing the best parenting for their children.  Most qualified psychologists, psychiatrists, and social workers have received a great deal of training in managing problem behaviors.  Many of these professionals charge reasonable prices based on ability to pay.  Therefore, parents and teachers should seek professional help when psychological or behavioral problems are observed.

These guidelines for child management are by no means exhaustive of the principles involved in competent parenting.  Yet, the reader should have acquired useful information regarding the recognition and management of children with psychological disorders.

THE TREATMENT PLAN : GETTING HELP

Treatment philosophies and approaches vary widely among mental health professionals.  Yet certain elements should exist in any therapeutic mileu.  There should be an atmosphere of respect.  Respect for the individual is best demonstrated through nonjudgmental, sincere communication.  Honesty is an integral part of the therapeutic environment.  The client should expect empathy—but not sympathy—during the course of treatment.  Empathy is simply the ability of a person to understand and feel from the perspective of another individual.

Actual therapy may take one or more of several forms.  Individual play therapy, group therapy with peers, family counseling, parent education, and behavior modification are some commonly used approaches.  It is important that adults responsible for the child play a vital, if not primary, role in the child’s treatment.  Adults who spend considerable time with the child are obviously in the best position to institute changes.  It is unrealistic to expect significant improvement without the extensive involvement of parents and teachers.

THE FIRST VISIT : GETTING HELP

The first visit to a mental health treatment center (public or private) usually includes an intake interview.  The intake interview is used to obtain relevant information about the child and his or her family.  The therapist or intake worker will probably ask not only about the problem but also about social history, health history, previous mental health contacts, developmental history, discipline patterns, and alcohol and drug use in the home.  This information is necessary to a variety of treatment decisions.

Other topics, such as cost and confidentiality, should be discussed in detail during the initial contact. This is also a good opportunity for the client to form an impression regarding the desirability of the therapist.  The client should carefully explain the problem and the desired objectives of treatment.  The details of the treatment plan should be discussed with the client.  The client should be told the expected length and the methods of treatment, as well as the probable outcome of the therapy.

COST : GETTING HELP

Probably the major consumer concern is the cost of mental health services.  Although there is some variability, most private psychiatrists and psychologists charge approximately forty dollars an hour.  At the rate of one or two hours per week for several weeks, private treatment can be an expensive proposition.  Many therapists will arrange modifications in fee based on ability to pay.  Scaled fees based on income is the general practice of public agencies like community mental health centers and federally funded child guidance clinics.  Most of these agencies provide services for anyone in need, regardless of the individual’s ability to pay.

Should the child require a residential treatment program, the consumer can generally expect exhorbitant prices in private care facilities.  The widely acclaimed Brown Schools, residential treatment facilities for child with various disorders, charge approximately one thousand dollars a month.  Very few people can afford this type of care.  Public residential placement for children with severe psychological disorders is inadequate in most states and virtually nonexistent in others.  State programs offer financial assistance to families who must seek private care because of the lack of public alternatives.

WHERE TO FIND PEOPLE WHO CAN HELP : GETTING HELP

After examining the appropriateness of the referral and deciding on the type of professional who may be able to help, it is necessary to find these professionals.  One method of reaching a professional is to look for Social Service Organizations in the yellow pages of the telephone book.  Community mental health centers, child guidance clinics, and social workers are listed in this column.  The cities in the United States that are covered by public mental health services are listed in Appendix I.  Psychiatrists are listed under physicians and Surgeons, and psychologists are listed as Psychologists and, sometimes, as Marriage and Family Counselors.  The National Association for Mental Health (NAMH) is a citizen and consumer’s group that maintains branch offices in most areas of the country.  Addresses of local NAMH organizations are presented in Appendix II.  The NAMH will supply a comprehensive directory of services upon request.  Furthermore, directories of mental health services are offered by the National Institute of Mental Health (c/o Government Printing Office, Washington, D.C.20402; cost: $7.00) and the National Society for Autistic Children (169 Tampa Avenue, Albany, N.Y.12208).  The addresses of other sources that provide extremely helpful information concerning mental health services are listed in Appendices III, IV, and V.

Community mental health centers are presently accessible to more than half the population.  Funds for the initiation of these centers have been largely supplied by the federal government with the idea that mental health centers will eventually achieve economic independence.  Unfortunately, this is an unrealistic goal for many centers, particularly those in poverty-stricken areas of the Southeast.  Superior services are available in many mental health centers, and the multidisciplinary approach is usually implemented.  Yet the quality of professional service varies drastically from one mental health center to the next.  Standardized certification procedures now being used should eventually ensure uniform quality of service.

All children who need help have the right to treatment.  Plans have been made to provide government-sponsored mental health programs that are accessible to every citizen.  However, services are not available for many people who need them.  Parents with handicapped children have a number of avenues in their goal of obtaining assistance.  Again, these alternatives are thoroughly explored in You Are Not Alone.

WHO CAN HELP : GETTING HELP

Many of the problems associated with children’s psychological disorders can be effectively treated by the family doctor, the teacher, or the knowledgeable parent.  Frequently, however, the child’s behavior may require more specialized treatment by mental health professionals.  Lamentably, the mental health field has been fertile ground for charlatans, particularly because of recent expansion and the lack of clear definition and organization.  But standardization of the qualifications of mental health professionals is becoming more prevalent, and the quality of services provided to the consumer is generally improving.  An excellent guide to mental health services has been offered by Clara Claiborne Park and Dr. Leon N. Shapiro.  Their book, entitled You Are Not Alone, offers clear, comprehensive, and reliable information concerning the nature of mental problems and how to get help for them.

As Park and Shapiro point out, the primary mental health professionals include psychiatrists, psychoanalysts, psychologists, social workers, nurses, and paraprofessionals.

A psychiatrist is a medical doctor (M.D.) who specializes in emotional problems and mental illness (medical model).  A psychiatrist usually spends three years (subsequent to medical training) working under supervision in a hospital or a mental health clinic.  The psychiatrist who chooses to be board certified must spend an additional two years working within the specialty of psychiatry before taking a set of grueling written and oral examinations.  It should be noted that any physician can legally be referred to as a psychiatrist; therefore, the patient must investigate the credentials of the psychiatrist.  Pertinent questions concern the institution of medical training, place and length of residency, and board certification.  Most psychiatrists would not be offended by these questions, and those who are highly qualified usually enjoy the opportunity to answer them.  If a psychiatrist is annoyed by the questions, it may be advisable to consult another therapist.

A psychoanalyst is usually, but not always, a psychiatrist; however, most psychiatrists are not psychoanalysts.  A psychoanalyst usually bases his or her practice on Freudian theory (i.e., psychoanalysis).  Training for psychoanalysts usually consists of years of intensive study and self-analysis.  Psychoanalysts maintain that they are more prepared to help people with problems after studying mental processes in themselves.  Although psychoanalysts are highly trained and skilled experts, psychoanalysis is usually not the most practical or parsimonious treatment for childhood psychological disorders.

Psychologists are professionals who have obtained considerable graduate training in the study of behavior.  If the psychologist is referred to as doctor, this signifies that he or she possesses a Ph.D. degree.  Other psychologists generally hold a M.A. or M.S. degree.  The clinical psychologist is an expert, by virtue of training and experience, in abnormal behavior.  Clinical psychologists usually spend four years in graduate study concentrating on theory, testing, and research dealing with abnormal behavior.  A one-year internship in a mental institution or mental health clinic is required for the Ph.D.  There are psychologists who specialize in other areas of psychology (e.g., educational, counseling, and developmental psychology); one of these professionals may act as the primary therapist for the child.  This decision would depend on the nature of the disorder and, to some extent, on the availability of psychologists in a particular geographic area.  Regardless of the area of specialization, the psychologist should be licensed by the state licensing board or should be closely supervised by a licensed psychologist.  Psychologists do not have medical training; therefore, they may not prescribe medication.  However, psychologists have highly specialized skills, exclusive to the profession, that are often essential in the treatment of a psychological disorder.

Social workers are found in many mental health setting.  The social worker has generally completed a two-year course of study resulting in an M.S.W. degree.  Much of the social work curriculum parallels that of the psychologist, without the emphasis on testing and research.  The social worker usually establishes close personal relationships with clients (patients) and often works toward helping solve practical problems.  These may include problems with transportation, housing, and medical expenses.  Social workers should have extensive knowledge of the resources available in the community.  One of the main functions of the social worker is to serve as a link between the client and other human service agencies within the community.  Like the psychologist, in most states, the social worker should be licensed.  Social workers with a M.S.W. from a certified school are eligible to join the Academy of Certified Social Workers after two years of experience under the supervision of a certified social worker.

The psychiatric nurse holds the R.N. degree and usually has had specialized training in a mental health facility.  Psychiatric nurses work very closely with physicians and are often intensely involved with the patient (client).  Nurses may administer but not prescribe medical treatment.  Their recommendations are considered vital to effective treatment by other professionals.

Remember that physicians other than psychiatrists also play major roles in the treatment of psychological disorders of childhood.  The expertise of family practitioners, neurologists, ophthalmologists, pediatricians, internists, and other medical specialists is necessary in many instances.

Paraprofessional treatment is on the upswing.  Paraprofessionals do not have graduate training in a mental health field.  These people are primarily employed to increase human contact in inpatient (hospital) settings.  Paraprofessionals are especially useful to children who have been placed in residential treatment facilities.  Of particular value is the paraprofessional’s ability to discuss the child’s disorder with family members in lay terms.  Paraprofessionals also assist professionals in carrying out a treatment plan.

The ideal treatment setting is one that combines the expertise of all of the mental health professionals.  Multidisciplinary teams are available in many parts of the country.  In situations where teams are not in use, experts should recognize the strengths of other professions and refer to them without hesitation.

WHEN TO SEEK PROFESSIONAL HELP : GETTING HELP

There is considerable variability in children’s behavior, and it is often difficult to decide whether professional help with a problem is justified.  This decision is easy only when a child is showing a serious problem.  Frequently, the parent or teacher hesitates to refer a child when the problem appears less serious.  Facts to consider include the financial commitments, the time demands, the risk of stigma sometimes associated with treatment, and the prognosis for the effectiveness of treatment.  These concerns frequently prevent an afflicted child from entering therapy.  On the other hand, many parents and teachers inadvertently refer children who are experiencing normal “growing pains.”  Although this type of error is far less serious than failure to refer when warranted, knowledge of behaviors that require professional attention is essential to making appropriate referrals.  Finally, many parents use their children as an entrée into a professional’s office to deal with problems that actually concern the adult.  In order to avoid exploiting the child who does not require treatment, parents should investigate their motivations for seeking treatment.

It is important to note that all children experience significant problems en route to becoming adults.  Most of these adjustment problems are transient and insignificant.  Young children will usually demonstrate one or more of such traits as withdrawal, excessive worry, disobedience, excessive aggressiveness, shame, and nightmares.  Specific behavior problems may include temper tantrums, bedwetting, soiling, and thumbsucking.  Such behavior does not automatically mean that the child has a psychological disorder.  Children are quite resilient and adaptable, and these types of problems often improve without professional intervention.  Excessive parental concern may cause the behavior to persist.  On the other hand, the behavior problem that continues should not be lightly dismissed.  Parents must be alert to the balance between worry and complacency.

One of the keys to recognizing a disturbance is the persistence of the behavior.  For example, if a first-grade child is having difficulty discriminating among the letters of the alphabet during the first few weeks of school, a referral would be unwarranted.  However, if no progress is observed after three or four months, referral may be proper.  Stealing is a good example.  Most children will, at some point, take an item that does not belong to them.  A professional referral is unnecessary in response to the first or second occurrence of stealing.  However, if a pattern of stealing emerges, professional help is certainly indicated.

There are several general questions that should be asked prior to making a decision to refer a child for mental health related treatment.

1.  Is the child behaving in a similar manner to children his or her age?  As stated, there are considerable individual differences in children’s abilities and in the appropriateness of their behavior.  However, if extreme differences between the child in question and other children the same age are observed, a disorder may be present.  If a three-year-old child cannot produce short sentences when its siblings were talkative at the same age, a professional referral would be in order.  Although occasional squabbles are common among most children, constant fighting should arouse suspicion.  There are general limits of acceptable behavior that are partially determined by the behavior of the child’s peers.  Sound judgment and common sense usually result in decisions that are best for the child.

2.  The child’s ability for self-control is another factor that should be considered in making a referral.  The term self-control is used in the broadest sense and generally refers to the child’s ability to direct his or her behavior.  Children who act on impulse and whose behavior never seems to result from internal cues may be experiencing one of several types of disorders.  Internal cues may include visual images, self-verbalization, relaxation responses, and other types of self-produced stimuli.  Distractability, running away, extreme aggressive behavior, daytime wetting or soiling past toilet training, and excessive selfishness may be considered characteristic of impulsive behavior.  It is important to arrange the consequences of this behavior in such a manner as to reduce the frequency of occurrence.  This task frequently requires the expertise of a mental health professional.

3.  How well does the child adjust to the home and school environment?  Adequate functioning within the home and school is imperative to the child’s general well-being.  These are the places where the child absorbs most of the experience required for independent adult living.  Children are expected to get along reasonably well with peers and siblings.  Excessive withdrawal, dependence, or aggression may indicate social ineptitude.  Some degree of social responsiveness is required for the child to learn many important lessons taught through play.  Children are also expected to grow and learn through experiences encountered at home and in school.  The child’s behavior may show that he or she is not benefiting from experience.  In such cases, a learning disability or phobia, mental retardation, or a behavior disorder may be present.  Poor adjustment within the home or school may be indicative of any number of problems that could demand professional attention.

4.  What is the quality of the child’s emotional responses?  Excessive crying, enduring nightmares, significant loss of appetite, sleeplessness, persistent irritability, temper tantrums, and phobias should evoke concern among parents and teachers.  Again, it is helpful to judge the level of a child’s emotional maturity in relation to others approximately the same age.  The kinds of problems mentioned above may inhibit normal development and create an atmosphere of apprehension and dissatisfaction.  Unnecessary stress is placed on all of the family members as well as on others who are responsible for the child’s well-being.

There are many physical indicators of emotional stress.  Adults must be aware of recurring physical complaints, the causes of which cannot be discovered by the family physician.  Headaches, dizziness, frequent stomach pains, nausea, and constipation are several physical symptoms that are often caused by stress.  These are usually caused by significant changes in the child’s environment.  Common examples include divorce or separation, a death in the family, bringing a newborn sibling home from the hospital, moving to another location, or merely transferring to a different school.  Sometimes the stresses that evoke physical symptoms are more subtle and become apparent only after careful study.  Each child responds uniquely to his or her environment, particularly in situations which produce stress.

5.  Are there any peculiarities in the child’s physical development?  Extreme variation in the size and shape of the body parts should be noted.  Specific areas of interest include head circumference and the size and shape of eyes, hands, and feet.  Irregularities in these areas may suggest some type of genetic disorder.  The child’s motor coordination should be compared to others approximately the same age.  Lack of coordination is often characteristic of mental retardation or a learning disability.  The family physician should be consulted concerning the child’s weight in relation to both age and height.  It is important to look for radical shifts in weight and eating patterns.  These data are extremely helpful to mental health professionals and may help to confirm a diagnosis of a psychological disorder.

6.  Has the child ever displayed a seizure or convulsion?  Seizure activity is an extremely serious neurological dysfunction.  However, seizures can generally be controlled with medication.  A seizure may take the form of violent spastic movements coupled with loss of consciousness and total lack of motor control.  On the other hand, a brief staring spell during which the child is unresponsive to external stimulation may represent seizure activity.  When these behaviors are observed, the child should be immediately taken to a physician.  The doctor may do an electroencephalogram (EEG) and/or a brain scan.  These are painless procedures and pose no risk to the child.

Other signs of possible neurological disorders include intense recurring headaches, lethargy, daytime wetting or soiling, periods of unresponsiveness, tremor activity, and memory lapses.  Although these problems are usually physiological, learning and emotional problems may exist concomitantly.

In summary, there is overlap in the general areas of behavior that may indicate a psychological disorder.  These categories are by no means exhaustive.  They are intended to help the responsible adult organize his or her approach to making a reliable assessment of the child.  The adult should focus on (1) significant differences in the child’s behavior relative to age, (2) degree of self-control, (3) learning and social behavior exhibited at home and in school, (4) emotional tone, (5) physical development, and (6) neurological indicators.  The parent, teacher, minister, or guidance counselor is reminded to look for enduring patterns of behavior rather than for transient situational reactions.  Given the above information, coupled with reasoning, sound judgment, and common sense, the adult will be able to make referrals confidently and sensibly.