Behavior and diagnostics

The Pediatric Insider

© 2010 Roy Benaroch, MD

Children have always been challenging. Jacob took advantage of his hairy and slightly-older twin brother Esau by purchasing his birthright for some lentil stew; he also tricked his father into blessing the arrangement by hiding under a wig. But children like Jacob weren’t diagnosed with Oppositional Defiant Disorder, or even Expensive Soup Selling Disorder. They were just … children, each with their own skills, shortcomings, and challenges.

Now, there seems to be a quiet change taking place among those who care for children, towards more labeling and identifying of specific “problems.” I’m not so sure that’s always a good idea.

I’ve been thinking about this while trying to answer a question submitted a few months ago, by MKM:

“Would you please explain sensory integration and a ’spirted’ child? Is there a ‘checklist’ of signs/symptoms to look for? My 3 1/2 year old daughter is a very high energy child and not shy at all child who seems to be progressing as she should be. My concern is her ‘heightened’ anxiety (not sure if right word) in situations–completely clams up in new/somewhat familiar situations to the point of clinging to me and not participating, cries if startled, does not like being around men, can be somewhat sensitive. Many situations ‘change’ her personality. Is sensory integration similar to a ’spirited child’? Thanks for any information to help.”

It does sound like this girl can be a challenge. She’s clingy at times, can be sensitive, and doesn’t like men. But does that mean that she has a specific diagnosis that can be labeled, like “Sensory Integration Disorder,” or is she a “Spirited Child”?

The idea that problems should be diagnosed goes back to Hippocrates, or maybe further. In medical tradition, the patient presents with a symptom– “Why did you come to the doctor?”. The physician examines the patient, and then determines the “diagnosis.” From knowledge of the diagnosis comes the therapy. You’ve got pneumonia? Here’s the antibiotics. Your appendix is about to burst? Off to surgery you go. Know the diagnosis, then you know the therapy.

That way of thinking works quite well for medical problems. But I’m not so sure it’s a good fit for children with everyday behavioral challenges. After all, once you’ve settled on a diagnosis– let’s say, Attention Deficit Disorder– then therapy is going to be one of a few choices that work best for ADD. But children and their behaviors are far more complex than this one-to-one system of diagnosis and therapy. Different children even with the same “diagnosis”, like ADD, may have different challenges, strengths, and weaknesses. Worse, once you diagnose something like “ADD” it tends to mold the way you think about the child: all of the behavior problems are considered part of that one diagnosis, and if therapy doesn’t help, well, you’re stuck. In other words, specific diagnoses oversimplify children and their issues, and work against reformulating and refining treatment strategies. It’s like thinking along a “rut” in the road– the more times you diagnose the same problem and use the same therapy, the more “stuck” you’ll be in that rut, and pretty soon that’s the way you’re going to diagnose and treat all sorts of problems.

MKM mentioned two “diagnoses” that I don’t think are very useful for most families. “Sensory Integration Disorder” is a vague, poorly-defined entity that seems to encompass all sorts of behavior issues, and is treated with open-ended occupational therapy. Children who are to me completely normal– those that don’t like the sound of toilets flushing, or don’t like the feel of tags in their clothes– are labeled with this “illness,” whether or not the “symptoms” are actually causing any harm at all. Now, some kids do have intense tactile defensiveness, and have a hard time doing ordinary things. These kids do need OT, as well as family therapy to work through what can be debilitating symptoms. But simply crying when startled doesn’t make a child in any way abnormal.

Several books have been written about raising “spirited” or “high energy” children, and often do contain useful tidbits of advice. But no book could possibly identify the specific problem areas of any one specific child any more than one diagnosis could encompass all of the behavior issues that a family faces. Kids are just too complex to label in a meaningful way.

So for MKM’s daughter, I recommend staying away from the specific behavioral labels like “spirited child” and “Sensory Integration Disorder”. A more useful approach would be to make a list of specific behavioral challenges that prevent her and her family from doing normal things. The list might look like this:

1. Clingy in new situations

2. Cries if startled

3. Doesn’t like being around men

Now, put that list in order, putting the most problematic item first– let’s say in this case the clinginess. Then come up with a behavioral solution for the top problem, and continue to address issues one by one.

1. For clinginess- practice new situations more gradually, with warnings and “dry runs.” As these improve, back off on the extra support. Can also bring lovies or family photos to some of the most challenging new occasions to help them go easier.

Anticipate new challenges and problems– they will occur, and “The List” will need to be revised and reordered. Some therapies will work, and some won’t, so be prepared to learn and adapt.

In contrast to the one-diagnosis, one-therapy system implied by the medical model, my system is more individualized. It’s designed to identify unique characteristics and challenges for each child, rather than to pigeon-hole children into preexisting categories of problems and fixed solutions. I think it’s better, and I think Hippocrates and Isaac would agree.

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4 Comments on “Behavior and diagnostics”

  1. Mindy Says:

    Our daughter had the clinginess around strangers issue when she was 2 or 3. Around new people visiting our house she would attach herself to me, bury her face into my chest and not let go for at least an hour (or fall asleep). She also didn’t like men (or at least preferred women over men). After an hour or so she’d warm up around the new people and be fine.

    Here’s how we solved the problem:
    We did….. (drum roll please)….. nothing

    Now she’s a very outgoing, friendly 10 year old. I figured this was normal behavior for a toddler and she quickly outgrew it.


  2. kcspecialed Says:

    What results might be seen with child taking a fish oil supplement?


  3. Dr. Roy Says:

    Kcspecialed, probably nothing at all.

    There had been a lot of enthusiasm for treating children with fish oil or other omega-3 supplements, not only to help with behavioral and cognitive problems but also with allergic disease, cystic fibrosis, and certain metabolic disorders. Unfortunately, good clinical studies looking for actual effects of fish oil on behavior have not shown robust or consistent effects.

    One open (that is, unblinded) study in dyslexia showed improvements in some scores:
    (Lack of comparator group or any blinding makes this study very preliminary.)

    A study of fish oil supplementation for autism showed no effect:

    Once studies introduce placebo groups, effects are modest or not seen at all. I could only find one study of this quality of an omega-3 supplement, in this case for bipolar disorder: No significant effects were seen in the clinical endpoints.

    Fish oil itself is quite safe for most children, so perhaps it’s worth a try. But it doesn’t look like it’s going to turn out to be the miracle cure that was expected.


  4. Allison Says:

    Dr. Roy,

    Check out the effects of fish oil on children who have apraxia. My son’s speech therapist was astounded at the improvement in clarity and motor planning when I started him on it at age 2 (and she knew when I got lazy and didn’t give it to him!). So much so that she recommended all her clients go on it, and all saw improvement.

    Haven’t really heard it really have such obvious effects on any other area of the sped community. But definitely for kids with apraxia!!


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