Nursing Voices

Tuesday, November 14, 2006

Take My Kid, Please!

Warning: This post is NOT politically correct. There are two types of kids that are admitted to psychiatric units, those with serious mental disorders who need professional help, and those who need a spanking. This post is about the latter. Before you send me hate mail, please hear me out.

There’s a new diagnosis making the rounds on psychiatric units. The diagnosis is Conduct Disorder, also known to many doctors and nurses as Brat Disease. I’ve never been able to understand how this disorder develops. Let me give you an example of what I routinely see on my unit. Two highly intelligent parents bring their little darling to the hospital because he or she won’t mind their manners. The kid dresses like a thug, uses drugs, assaults his or her parents, and refuses to go to school. The parents are dismayed by what is happening. They stand in front of the nursing station, wring their hands, and say, “We don’t know why our baby is acting like this. We’re afraid of our child. Please, help us.” Meanwhile, the kid is making demands, and telling the parents to go to hell. The parents cower, and give in to the child's demands. That’s when I step in. I tell the kid that while that type of behavior is tolerated at home, it will not be tolerated at the hospital. I let them know whose boss, and the parents stare at me, slack jawed in disbelief. Yes, Mom and Dad, it’s called setting limits.

I feel sorry for the psychiatrist. The parents are paying big bucks to have their child hospitalized, and they expect results. The kid usually goes home within three days, and like clockwork, the parents are calling the unit the next day, complaining about the incompetent doctor. Of course, the parents are clueless that they are part of the problem, and nothing gets resolved. It’s a no win situation, and unfortunately it’s the kid who suffers the most. I’ve observed that children are cured of Conduct Disorder when they turn 18 years old. After they turn 18, their condition changes into Convict Disorder, and they go to jail.


Blogger Julie, RN said...

Hear, hear!
Our Adolescent unit is near the Gero unit, and we often get to compare stories. Usually the general consensus is the parents need as much help as the kids. Aaaaand, on our side, we see the offspring of our patients are slipping along the same slope as their ancestors. Ahh, good old-fashioned personality d/o. Congenital defect?

10:00 PM  
Blogger greensunflower said...

Isnt this the disorder that leads to psychopath (AKA: Antisocial personality disorder) where they could give two shits about anybody but themselves, no matter the pain they cause.

I am sure it is often used to misdiagnose children who have something else going on, but from what I understand, there isnt really much you can do about someone who has no empathy whatsoever.

10:07 PM  
Blogger Mother Jones RN said...

A lot of kids that have a budding antisocial personality are diagnosed with impulse disorder. However, their behavior isn’t impulsive. They are very calculating when they inflict pain on others. And you're right, they only care about themselves.

10:18 PM  
Blogger Michael Clifford, L. Ac. said...

Entirely too true. That old saying of "Spare the Rod and Spoil the Child" applies. There are absolutely times you have to set some serious limits. I use the concept of choices & consequences. "If you choose to act that way the consequence is you are going to get your but whipped. Any questins?"
It may seem harsh, but it works...

10:36 PM  
Anonymous Mr. Code Brown said...

My kids are still "little curtain jerkers", I mean "ankle biters", I mean, you know what I mean. They're 2 and 4 and both boys. I'm instilling the fear of consequences in them early. You have to lay the ground rules. Once laid, you have to follow them. When I discipline them, I always explain why. This way they understand that I love them and that there are reasons we don't behave badly. If you do, you pay the consequences, PERIOD!

11:48 PM  
Blogger The Muser said...

The number one reason why I don't do pediatric clinical work for a living (I chose the research route instead) is because of parents. I'm afraid that if I DID do clinical work for a living, I wouldn't be able to control the urge to smack each and every parent (most of them, unfortunately) who came to me expecting to "fix" their child without displaying some accountability for their own contributions to their child's behavior. The parents I worked with back when I was doing my clinical training obviously didn't like me very much. Man, the stories I could tell. Unbelievable.

1:38 AM  
Blogger SQT said...

Oh man, in this world of Dr. Phil, a parent is scared to death to spank their child for fear of being reported to CPS.

I honestly have gotten to the point where I discipline my kids at home because of the looks you get if you dare threaten to spank your child.

I do believe there is a definite difference between a spanking and a beating. My kids know there are boundaries and not to cross them. But I don't disclose the fact that I might smack them on the butt from time to time to just anyone. People get really judgemental about it.

I have a really rambunctious almost-3-year-old and I have to watch his tendency to hit. You'd think my kid was a pariah the way some parents act if he so much as plays roughly with their little Johnnie. I mean, tag has been banned in some schools for crying out loud because it's been decided it's too rough. Are they serious? You can't play tag or dodge-ball anymore?!

Parents have decided to wrap their kids in cotton and raise a generation of kids who are too delicate to be touched.

1:50 AM  
Blogger I am a Milliner's Dream, a woman of many "hats"... said...

We heard about this (Conduct Disorder) in lecture and it was surprising and sad.

I had the most awesome mental health rotation this quarter...and I said (respectfully) that when a schizophrenic patient had a meltdown it LOOKED like a child's temper tandrum. Staff agreed.

It's interesting and perhaps naive, but I wonder how much of mental illness is nature and nurture blended to induce it, because of these kinds of behavior "disorders."


6:09 AM  
Blogger Juliette said...

I entirely agree. I've been an au pair this summer, and I reached a point where it was impossible for me to work, because anytime the children misbehaved and I punished them (though no by spanking, I would have been fired right away), they ran to their parents, cried a little, and got their way (anywhere from ice-cream to staying up until midnight for the fifth time in a row).
Then, when they misbehaved again, the parents made me understand they thought I wasn't doing my job properly, because the kids kept misbehaving.
At what point can you tell your employers that they are just terrible parents?

8:09 AM  
Blogger Oestre-Bunny said...

When we were growing up my mum and dad laid down the boundaries from an early stage and we knew better than to cross them. The odd clip round the ear did us no harm.

It is a firm belief of mine that kids today are not disciplined properly. They know no limits and don't care about the trouble they cause. They have trumped up ideas about 'their rights' but not about the rights of others.

This was an issue that was particularly highlighted in my school. In the years I attended the disciplinary system slowly broke down until the teachers were actually powerless to do anything, even punishment exercises and detention were banned.

11:13 AM  
Blogger The Curmudgeon said...

Juliette asked, "At what point can you tell your employers that they are just terrible parents?"

A. In the exit interview. After you get your reference letter. Or the job in another field.
MJ -- Never heard of the disorder, but I've sure seen it. Long Suffering Spouse is a grammar school teacher; she sees it every single day.

All kids are manipulative. I remember yelling once at Older Daughter and sending her to her room. She must have been about 4 then.

She gets halfway up the stairs and pauses... looks down at us... lip trembling... and says, "But I still love you."

If I'd had a heart, it might have melted... but I didn't, and she went to her room.

Eventually, though, the kids learn: If Mom say no, don't bother asking Dad. Because I have two questions: Have you asked your mother? And what did she say?

So the kids learn, if taught. Now who teaches the parents?

I've got an idea: We tell the yuppie parents that the only cure for Brat Disease, uh, Conduct Disorder is family counseling. What do you think?

11:23 AM  
Blogger Forty_Two said...

You do realize that admitting the existence of parental incompetence is politically incorrect.

11:49 AM  
Blogger Jean-Luc Picard said...

It's hard to put a psychopath on the naughty chair.

1:32 PM  
Blogger Shrinked Immaculate said...

Reminds me of my practice

3:10 PM  
Blogger Impetua said...

I have worked in residential mental health for years, not with kids though, but the bottom line was that we could not force them to do anything for themselves, i.e. clean room, shower, etc. Right down to taking medications. Of course the consequences for this was that EVENTUALLY you went back to the hospital because you spun completely out of control, but try to get your other clients to do anything they don't want to do during the WEEKS and sometimes MONTHS that it took for the system to decide that the uncooperative client was sufficiently dangerous to self or others to put back in the hospital.

I work only a little on-call in residential MH now and am on my way to becoming a nurse. I don't expect to escape the bullshit that goes along with human nature in so many individuals, but I have certainly had my fill of mental health.

Oh, and my child? She's 2 1/2 and she is given a choice when she is uncooperative. So far she has been able to deal with that appropriately. I don't intend to spank her but I'm not saying Never, just I Hope Not.

5:13 PM  
Blogger MadMike said...

Most crime in the United States is committed by young men between the ages of 18-24. I view "conduct disorder" as yet another label. Once a child is labeled they often act out what they consider to be the expectations of the labelers. So if they suffer from conduct disorder their conduct will likely be disorderly. I hate labels. Then again, I'm not certain I can often a viable alternative.

6:17 PM  
Blogger poody said...

Hey I got my ass whipped plenty of times and I turned into a respectable citizen! In school if you got a lick with the paddle then when you got home you best believe you were gonna get a whipping there too!I think the reason God makes babies so cute is so you don't kill them when they're teenagers!

7:06 PM  
Anonymous Anonymous said...

They definetly need to revise some of the discipline laws in effect now. If a parent even looks at a child funny it's called 'child abuse' and many children are very quick to take advantage of a law which was originally meant to help children who actually WERE being abused. We've gone overboard on interpreting this law.

9:07 PM  
Blogger Kris said...

For freakin' real! What kids need nowadays is some dang discipline! I am sometimes just beside myself at the total lack of respect for authority and the sense of entitlement these little monsters have. As you read from my election day meltdown, I am not afraid to threaten my child. She's been spanked maybe a grand total of 4 single-swat times in her 5 years, but you'd better believe that her memory of them tends to keep her in line.

10:53 PM  
Blogger Mother Jones RN said...

Hi everyone, thank you for your comments.

When I see kids abusing their parents on the unit, I'll give the parents feedback about what I'm seeing at that moment. I'll say something like, "It seems to me that the tail is waging the dog." That's a nice way of telling the parents they are being manipulated.

At least I have job security thanks to clueless parents.

6:30 PM  
Anonymous Anonymous said...

It's amazing, really. I'm 21 and I've always been embarressed by the way some of my friends act towards their parents. I was brought up that when mother said no, mother meant no. My parents were not saints at all, I think I could have been hit in the face a little less. But, when you're parents both work in an inpatient Adolescent rehab center...their toleration's lower than others when they get home.

Number one threat as a child" "If you don't straighten up, you're going to Peninsula (the rehab center) for the week!

9:44 PM  
Blogger Bohemian Road Nurse... said...

Thank you! Oh man, you just hit the nail on the head. I agree with you wholeheartedly. The other day I was talking to a sales rep for medical equipment--and she told me she quit her former job as a teacher because of remarks like this: "I did my little Jimmy's homework last night and I think he deserves an 'A' instead of that stupid 'C' you gave him." Aaargghh!!!

10:04 PM  
Blogger JustCallMeJo said...

There are two types of kids that are admitted to psychiatric units, those with serious mental disorders who need professional help, and those who need a spanking.

Coffee > nose > keyboard

Let's have an AAAA-MEN!

6:19 AM  
Blogger Forty_Two said...


If only parents brutalized their children more often they'd be more disciplined.


9:26 AM  
Blogger Gerbil said...

I find it interesting that there is no single recommended treatment modality for conduct disorder... but there is one which is universally contraindicated: group therapy.

I don't believe in empirically validated treatments as the be-all and end-all of mental health treatment, but I'm glad someone out there realized that putting a bunch of delinquents in a therapy group tends not to produce better kids, but rather better delinquents.

(BTW to greensunflower: conduct disorder can only be diagnosed in children and adolescents, and antisocial PD can only be diagnosed in adults. "Happy 18th birthday, Bad Seed! You're no longer a child with CD--now you are an adult with Antisocial Personality Disorder! Go buy a pack of cigarettes, register to vote, and take advantage of some defenseless folks.")

3:31 PM  
Blogger Cyndy said...

I vote for more consistency in parenting, and less over-indulgent, guilt-ridden "I-want-to-be-your-friend" parenting.. please, please, please

4:21 PM  
Anonymous Anonymous said...

The brats usually have never had any limits set on their behavior, so they have a skewed view of how they'll be allowed to function once the parents are no longer shielding them.

No limits means very poor development of a sense of reality. Once the kid grows up, he gets taught painful lessons by the rest of society, including the criminal courts.

8:27 PM  
Blogger Mom of Three said...

Well, I just had a Brownie troop meeting today, as co-leader, and I am about ready to quit because of 3 of the 13 girls. It was unbelievable. And, of course, we can't discipline them. The rest of the ones who knew how to behave were drained of attention by the three who were constantly running, jumping, screaming, crawling under furniture. These are 8 year olds! When I was 8 I was just three years away from babysitting other people's kids!

I think it's laziness. Easier to let them run amok, give them to other people as often as possible, then scratch thier heads (in between TV shows) when all isn't running smoothly.

11:53 PM  
Blogger Spirit of 1976 said...

Is inpatient care really that available for child and adolescent mental health services in the US?

Here in the UK, mental health services will try to avoid at all costs putting kids into inpatient in care. All the focus is on outpatient and home treatment services.

There are currently TWO adolescent inpatient units for the whole principality of Wales (population: 3 million) of which one shuts at weekends.

Only deeply mentally ill kids get into inpatient care here. When they do, they usually wind up copying self-harming and eating disorder behaviours off each other. Which is why the psychs do their best to keep them at home.

4:36 PM  
Anonymous Anonymous said...

Spirit - I think the kids being referred to are the ones who's mummies and daddies are willing/able to pay for private care, because they won't believe that junior is not mentally ill and is actually just an intolerable spoilt brat.

The units you were referring to are NHS units which due to funding limits are obviously few and far between. Maybe you'd find some wealthy teenagers with conduct disorder in the Priory.

S x

2:50 PM  
Blogger Kim said...

Oh good lord, if I even looked at my father cross-eyed, I did not sit for a week.

Conduct disorder startes waaaay before they ever hit an adolescent unit. I see it as young as 2 1/2.

My favorite line? The one I used over and over in pediatric advice:

Answer, sheepishly: "I am".

Yes, I have said it. In the ER it's the four year old who refuses to let the parent take off their jacket and actually HITS the mother - I swoop in so damn fast that jacket is off before the kid even takes a breath.

And I've never had a complaint and the parent looks at me in amazement.

"Somebody needs to be the grown-up and if you don't act like it, the kid will".

Same with trying to give meds: "Johnny doesn't want it...."

Tough cookies.

"Do YOU want Johnny to have it?"

Then Johnny is held down and the medicine given.

Pardon my language but screw this "my child has needs that need to be respected" garbage.

The only thing your child needs at this point is a strong adult presence to model appropriate behavior and punish inappropriate behavior.

12:21 PM  
Anonymous Calli Arcale said...

I've totally seen this. Spoiled brat syndrome. It's tough to distinguish it from genuine mental disorder, but I'm willing to bet that the majority are spoiled brats rather than actually having something neurologically wrong.

I think what we need is a "Kid Whisperer", sort of like the "Dog Whisperer", Cesar Milan. He rehabilitates dogs and trains their owners. After all, as with spoiled brats, the number one cause of bad dogs is a lack of discipline. It doesn't have to involve brutal physical punishment; the punishment needs to be appropriate to the situation and to the individual being punished. For some kids, that'll mean a swat. For others, it'll mean sitting in the time-out chair. Probably the most important thing is not how you punish but that you do it swiftly and consistently.

Sadly, there is an element to our society now that thinks all punishment is cruel. But as Cesar Milan frequently points out, not punishing can be cruel too.

4:49 PM  
Anonymous Calli Arcale said...

Oh, and one more thing: the child most certainly does have needs which must be respected. The child has fears, dreams, wishes, etc.... And the child has a burning need to learn, not just about the world around them, but about human society. Too many parents disrespect one of the most fundamental needs their child has, and that's to learn how to function in society. If the kids grows up thinking he can get away with anything, that does him a tremendous disservice.

It's funny -- those most strongly advocating respect by removing discipline or adverse consequences are in many respects the people disrespecting children the most. They are disrespecting children by acting as if those children can't handle the real world.

4:52 PM  
Anonymous Anonymous said...

"the most important thing is not how you punish but that you do it swiftly and consistently"
Yup. I don't think that any of the physical punishment that I received as a child ever did me any good - it made me feel that there was a deep sense of injustice, mainly because when an adult hits a child it often has more to do with their emotional state (frazzled, bad day at work), than being in proportion to what the child has done. But the ill-disciplined litle blighters that I see need boundaries, need punishing when they go wrong. Too many people equate not smacking with letting kids do what they want, and that's not the point at all.

Round here, the NHS calls it 'Child and Family Psychiatry'. Sometimes they'll have appointments without the child to try and sort out the parents problems, so are very committed to that model.

9:45 AM  
Anonymous Deirdre said...

Part of the reason we see a lack of discipline is it's usually stated as either/or; beat the kid or spoil them. There are other options. Any decent parenting class can suggest a multitude of other methods.

One of the disturbing trends I see in medical school is the link between spank the kid and abuse the medical student. (Sarcasm warning!)It's for their own good isn't it.

2:50 PM  
Anonymous Anonymous said...

Conduct disorder was a frequent diagnosis when I was doing inpatient adolescent psych nursing in the 80s. That was before managed care when kids were hospitalized for months or years, depending on the limits of their insurance or parental ability to pay. (When kids exhausted coverage they were suddenly able to handle outpatient treatment) The diagnosis fell out of favor when insurance companies caught on that it wasn't a reason to hospitalize an unruly child and wouldn't pay. The docs began to use "oppositional defiant disorder" instead and it worked for a while. After that played out it was then changed to "Bipolar Disorder". Interesting that "Conduct Disorder" is coming back into vogue.

9:18 PM  
Blogger Opa said...

being the step-father of a 32 yr old daughter who still acts 25 is an issue all by itself - having read comments on spoiled brat it really hit home - having raised a child in a home which had her grandmother living with us didn't help but it is what it is - trying to buy her affection as a stepfather, her mother defending her to no end, and mom-mom giving her anything we didn't has produced a adult who see's life attaching her, stress levels above everyone else's, a mother who doesn't love her, she NEVER does anything to start an issue (it's someone else's doing things to her)- may be God can find it in his heart to forgive me -

6:55 AM  
Blogger Opa said...

being the step-father of a 32 yr old daughter who still acts 25 is an issue all by itself - having read comments on spoiled brat it really hit home - having raised a child in a home which had her grandmother living with us didn't help but it is what it is - trying to buy her affection as a stepfather, her mother defending her to no end, and mom-mom giving her anything we didn't has produced a adult who see's life attaching her, stress levels above everyone else's, a mother who doesn't love her, she NEVER does anything to start an issue (it's someone else's doing things to her)- may be God can find it in his heart to forgive me -

6:59 AM  

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