The Last Normal Child

The Last Normal Child article by Dr. Sam Goldstein

I awoke one morning this past week with a vivid memory of a dream I had during the previous night. A family came to see me to have their ten-year old son evaluated. Nothing out of the ordinary for me as I evaluate nearly 200 children each year in my Center. Most are children with complex medical and developmental problems. I sometimes refer to these children as Biblical Jobs as they present with a myriad of problems any one of which can be overwhelming. I have also commented that the “address” of my Center is 3333. That is, to find their way to my office parent’s typically have a child who has exhibited: at least three problems, over three years, in three settings with three different adults!

However, this family and child were different. The parents in my dream came seeking a diagnosis for their child because he was “average” and they just knew there must be some condition or problem that afflicted him, holding him back from greatness. In real life I would have sent them away with some reassuring words. However, irrationality typically guides our dreams. So, I agreed to complete a thorough neuropsychological evaluation. In my dream I spent many hours administering a battery of neuropsychological, intellectual, academic, motor and emotional tests. This pleasant young man dutifully completed all the tests I administered. As time means nothing to the unreality of dreams, in a flash I found myself sitting in front of his parents and a large crowd of people.

“What’s our son’s diagnosis”? Does he have ADHD, ASD, ODD, or CD? Is his just average performance in school a consequence of Depression or Anxiety?” they asked.

I shook my head and from my mouth came the words: “He doesn’t have any diagnosis, disability or disorder. He’s just an average, normal child. The last normal child.”

Fortunately for me at that moment I awoke. Is this the destiny of our youth? In twenty or thirty years will everyone “have a diagnosis” to explain the idiosyncrasies of human development or the consequences of a stressful world? Am I equally to blame as I promote a Center to evaluate and treat the many complex problems of childhood?

The Data is Alarming

In a survey of 47,090 adolescents completed pre-Pandemic between 2005 to 2018, published in 2020 in the Journal of the American Medical Association, a greater proportion of adolescents in more recent years received care for internalizing problems, such as depressive symptoms or suicidal ideations, whereas a smaller proportion received care for externalizing and relationship problems. Care in inpatient and outpatient mental health settings increased, and care in school counseling services modestly decreased. Outpatient mental health visits (e.g., private mental health clinicians), rose from 7.2 in 2005-2006 to 9.0 in 2017-2018 and overnight stays in inpatient mental health settings from 4.0 nights in 2005-2006 to 5.4 nights in 2017-2018 per thousand youth.

According to another survey published in February 2021 by the National Institute for Health Care Management, mental illness is increasingly common in young people and may persist throughout their lifetime, as 75% of all lifetime mental illness develops by age 24. Rates of mental illness are rising faster among 18- to 25-year-olds than the rest of the adult population, which is largely driving the overall increase in rates of mental illness in the United States. Mental illness is also underdiagnosed and undertreated, particularly among young people. Less than 50% of 12- to 25-year-olds who reported a major depressive episode within the previous year received treatment, as compared to 70% for people over the age of 26. Mental illness is also a risk factor for suicide, which increased among all young people between the ages of 10 and 24 years between 2000 and 2017. Suicide is now the second leading cause of death in this age group. Every generation over the past seven have had a higher incidence of mental health problems. Keep in mind this is pre-Pandemic. As I have written in previous articles (view here), mental health challenges among our youth are increasing at an alarming rate during the current Pandemic. If this trend continues the idea of the “last normal child” may become a reality by the middle of this century.

The Deficit Model Hits Critical Mass

Charles Dickens wrote to start his epic novel the Tale of Two Cities: “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair.” Most certainly the world we have created to raise our children and prepare them for adulthood is more stressful than we had hoped. But have we made it harder for them by pathologizing, demonizing or moralizing every difference in childhood? Have we created a Matrix of Stepford Wives in which any and all differences are viewed through a lens of liability? Have we been too quick to look for what’s wrong rather than what’s right with children, in our mistaken belief that fixing “what’s wrong” with a child clears a path to a happy adulthood? However, an increasing body of longitudinal research confirms the error of this belief.

As Dr. Bob Brooks and I have summarized in many of our books, the greater a child’s “ocean of problems” the more important an “island of competence” becomes in charting a course for resilience. When children transition into adulthood no one asks about their diagnoses or whether they made their beds. It doesn’t matter. What matters is what they can do moving forward. As we have written, resilience is about harnessing strengths and assets to successfully negotiate adversity.

I was fortunate in my training to be taught that no matter a child’s developmental challenges, we do not fix them, rather we manage their challenges and make sure for every weakness we identify two strengths. We must never put the diagnosis before the child as in, the Autistic child. Instead, we must say the child with Autism. This difference is not subtle. In nearly every outcome study of transition from childhood to adulthood, appropriate treatment carries its’ weight in symptom relief but predicts little in adult outcome. Strengths, it has been demonstrated, are much better contributors to positive, long-term outcome, especially in vulnerable children.

A Final Word

As I write this message a new, but less potent variant of the COVID 19 virus is spreading quickly throughout the world prompting measures to prevent spread of the illness but again at the expense of many other factors including our children’s mental health. Every month more youth are in need of mental health care. A tertiary care model, one that waits until a child is in the throes of one or more mental health disorders has reached its’ functional limits and now is clearly failing. In the coming year we need to find mental health resources to help those in need. There are thousands of well-trained school psychologists, social workers and counselors ready to help if given the opportunity. This but one of many available resources.

However, the eventual end of the Pandemic is not likely to stem the tide of this problem. As I pointed out, the steady, insidious rise in mental health challenges began long before the Pandemic. If we want to change the future, we must begin by changing the present. We look for what is wrong with our children because we wait until they are struggling. We do little to prevent mental health challenges in all children and even less for children at risk. Managed care will compensate a pediatrician or dentist for a yearly “well care” physical check-up, but not a parallel check-up for mental health. Children beginning school for the first time must only show proof that they have received a physical examination and immunizations before they start school.

So, my message is simple – start by asking what is right with your children – before looking for what is wrong. Appreciate that strengths and assets are the best predictors of good life outcome for every child and even more important for children at risk. Start by making a list of your child’s strengths and when challenges arise, begin with that list as you seek help. Sometimes parents are surprised when they come to see me that my first question asked of them is open ended – tell me about your child. There is a very large difference between a parent responding to that question with – he’s a great kid, as one parent told me last week, and a parent beginning with a list of grievances.

In our new book, Tenacity in Children, Bob and I concluded that we are cautiously optimistic that as our understanding of ourselves and our place in the Universe grows, we will find the means to prepare the next generation to lead us into a promising, though not likely, perfect future. The strength of our conviction is drawn not just from our knowledge, but from the thousands of children and families from whom we have learned time and time again about the tenacity, resiliency, self-discipline, and creativity of the human mind and spirit. We must begin this new year with an appreciation and a commitment that every child is normal no matter their challenges. I wish you all good health and the strength needed to nurture resilience in your children and yourselves. ◆