They may not want it. They may not know they need it. But you need to know better. Discipline. Boundaries. The foundation of knowing how to navigate through society. You may not think that this applies to children with mental illness. However, structure is paramount for children, including those struggling with issues such as Obsessive Compulsive Disorder (OCD), Attention Deficit Hyperactivity Disorder, Oppositional Behaviors, Mood Disorders... the list goes on.

"Doctor, my daughter cannot go to sleep unless my wife and I are awake. She needs to be able to ask her questions, check the light ten times in a row, and the door needs to be open a certain exact amount. My wife and I do not get enough sleep. We are awake until 2 a.m."

“Doctor, my 11-year-old daughter needs to hold our newborn son constantly. It is the only thing that calms her down. But she won't let go. My wife has a difficult time getting the baby back to change and feed her. Sometimes the baby cries for hours. But if my wife takes the baby, my daughter hits us and cries. She cannot tolerate the anxiety if she does not hold the baby. I cannot hurt her like that."

“My son pinches and hits my wife and tries to push me if I do not buy him what he wants in the store. He also attacks his siblings and they have bruises. We are walking on eggshells, but I do not want to admit him into the hospital. He will learn bad behaviors there, meet crazy kids, and what will people think of our family if I call Hatzalah?"

Although one may think these extreme, all the above constitute real scenarios with which parents struggle on a daily basis. Many have seen several therapists throughout the years to no avail. Medications can be the easy part of the answer, and will likely help. However, they are not the whole remedy. Often, there is a learned component to these behaviors, and the child gets some benefit from continuing them. It takes time, effort, and most of all, willpower and consistency on the part of both the child and the parent, to slowly eradicate the behaviors.

I am often asked how to distinguish between mental illness, and the volitional component of behaviors. How to discipline without punishing what the child has no control over. My answer is two-fold. Firstly, safety for everyone must be paramount, no matter what the cause. The newborn child in the scenario above needs to be cared for, siblings should not live in fear, and parents should not tolerate bruises and pain. Secondly, the child can gain control of his behaviors with the proper support, structure, and medications if needed.

Implementation is not easy. Parents may experience tears and fears. Many times it hurts the parents more than it hurts the child to enforce rules. When safety becomes a concern, as in the scenario above, the newborn must be taken out of the older child's arms. Aggression must be prevented physically if need be. At times, 911 should be called, and the child taken to the hospital for an emergency evaluation.  The main therapeutic modality for OCD is response prevention. The child must use willpower to mitigate the compulsion for obsessive behaviors. By giving the child external motivation and proper structure, the child is aided in overcoming his/her illness. Guidance is available from mental health professionals. At times parents may need to seek their own treatment. By providing structure and boundaries, the parents can show the pure love they feel for their children.

Pamela P. Siller, MD is a Board Certified Child, Adolescent and Adult Psychiatrist who provides medication management, as well as individual and family therapy, to children and adults.She maintains a private practice in Great Neck, New York. Dr. Siller is also the Director of Child and Adolescent Psychiatry at the Interborough Developmental and Consultation Center in Brooklyn. She is an assistant Professor of Psychiatry at New York Medical College. Dr. Siller can be reached at 917-841-0663.