The pediatric developmental and behavioral clinic nurse’s communication challenge
The pediatric developmental and behavioral clinic operates at the intersection of neuroscience, psychology, and the families’ accumulated intuitions about their children. The diagnoses made here — autism spectrum disorder, ADHD, intellectual disability, specific learning disorders — produce treatments that are not medications for visible illness but interventions for how the brain processes and regulates information. The treatments recommended — intensive behavioral therapy, stimulant medication, medical workup before behavioral labeling — consistently violate the family’s prior framework in ways that require mechanistic explanation to resolve.
The Spanish-speaking parent in a pediatric developmental and behavioral clinic arrives with a framework built from what they have observed and what they have heard: autism means not speaking; stimulants are drugs that create addiction; if a child has behavioral problems the solution is behavioral therapy. Each of these statements is true in some contexts and wrong in the specific clinical context the nurse is navigating. The child who speaks sixty words can have autism spectrum disorder. The medication that shares a mechanism with cocaine cannot produce addiction at the doses and absorption rates used therapeutically. The child whose behavioral changes are driven by an undiagnosed thyroid problem will not respond to behavioral therapy until the thyroid is treated.
Three conversations from a pediatric developmental and behavioral clinic:
Scenario 1: Valentina García-Mendoza — 2.5 years old, Houston, Texas
Valentina García-Mendoza had been referred to the developmental and behavioral clinic at Texas Children’s by her pediatrician after the 24-month visit. The pediatrician had noted concerns about joint attention during the office visit — Valentina had not pointed to a picture in the exam room to share it with her mother, had not looked at her mother’s face when the pediatrician’s stethoscope touched her chest, and had turned away from the pediatrician’s animated greeting rather than orienting toward it. The developmental screening score on the M-CHAT-R had been in the range requiring referral.
Valentina’s mother Rosa was an early childhood education teacher who ran a bilingual Head Start classroom three blocks from their home. She worked with typically developing two- and three-year-olds every day. She had been the parent the other parents asked for developmental guidance. The referral had blindsided her.
“Valentina dice aproximadamente sesenta palabras,” Rosa said to pediatric developmental clinic nurse Ana Torres-Domínguez, before the evaluation had formally begun. They were in the intake room, Valentina on the floor with a bin of toys, arranging small plastic animals in a precise line along the baseboard with the focused absorption of a child who does not notice the two adults watching. “Nos conoce a todos. Me da bésos cuando se lo pido. Cuando la llevo al parque, corre hacia el columpio. ¿Cómo puede tener autismo?” (Valentina says approximately sixty words. She knows all of us. She gives me kisses when I ask. When I take her to the park, she runs toward the swing. How can she have autism?)
“Exactamente esas son las preguntas que quiero responder con usted antes de que empiece la evaluación,” Ana said, sitting down on the floor mat to be at the same level as Rosa, who was watching Valentina. “Tiene usted razón en todo lo que describe — Valentina habla, reconoce a su familia, tiene cariño. Lo que quiero explicarle es por qué el diagnóstico del autismo no depende de esas cosas, sino de otras. ¿Puedo explicarle cómo se evalúa el autismo, para que cuando el equipo le explique los resultados, usted pueda entender de qué están hablando?” (Those are exactly the questions I want to answer with you before the evaluation begins. You are right about everything you describe — Valentina speaks, recognizes her family, is affectionate. What I want to explain is why the autism diagnosis does not depend on those things, but on other things. Can I explain how autism is evaluated, so that when the team explains the results, you can understand what they are talking about?)
Rosa nodded. Valentina had finished her line of animals and was now examining each one’s feet individually, turning them over with the methodical patience of a researcher cataloguing specimens.
“El autismo se diagnostica en dos áreas. La primera es la comunicación social. No el número de palabras — sino cómo las usa para compartir experiencias con otras personas. Hay un comportamiento específico que se llama atención conjunta — es cuando un niño mira algo interesante, y después mira a mamá para compartir ese interés. Es como decir, con los ojos: ‘¿ves eso tú también? ¿Qué piensas?’ Los niños típicos hacen esto constantemente desde los nueve o doce meses. Otro comportamiento es la referencia social — cuando algo nuevo o desconocido pasa, el niño mira la cara de mamá para leer cómo reaccionar. Un perro aparece: el niño mira al perro, después mira a mamá. Si mamá sonríe, el niño se acerca. Si mamá parece preocupada, el niño se aleja. Eso es referencia social.” (Autism is diagnosed in two areas. The first is social communication. Not the number of words — but how they are used to share experiences with other people. There is a specific behavior called joint attention — it is when a child looks at something interesting, and then looks at mom to share that interest. It is like saying, with the eyes: 'Do you see that too? What do you think?' Typical children do this constantly from nine or twelve months. Another behavior is social referencing — when something new or unfamiliar happens, the child looks at mom's face to read how to react. A dog appears: the child looks at the dog, then looks at mom. If mom smiles, the child approaches. If mom looks concerned, the child moves away. That is social referencing.)
Rosa was still. She was watching Valentina, who had aligned the animals and was now starting to rearrange them by some principle Rosa could not identify. “¿Valentina no hace eso?” (Does Valentina not do that?)
“Eso es lo que el equipo va a evaluar hoy en la sala de observación. Yo no puedo decirle el resultado antes de la evaluación. Lo que puedo decirle es que el pediatra refirió a Valentina porque observó esas conductas específicas en la visita — que Valentina no señaló para compartir, que no miró la cara de usted cuando el estetoscopio la tocó. Eso es lo que se está evaluando más en profundidad hoy.” (That is what the team is going to evaluate today in the observation room. I cannot tell you the result before the evaluation. What I can tell you is that the pediatrician referred Valentina because she observed those specific behaviors in the visit — that Valentina did not point to share, that she did not look at your face when the stethoscope touched her. That is what is being evaluated in more depth today.)
“¿Y las palabras que tiene — eso no importa?” Rosa asked. (And the words she has — doesn't that matter?)
“Las palabras sí importan, y sesenta palabras a los treinta meses es una fortaleza. El lenguaje de Valentina es algo que el equipo va a tomar en cuenta en el plan de apoyo. Pero las palabras y la comunicación social son dos sistemas cerebrales que se desarrollan de manera paralela — no uno depende del otro. Un niño puede tener doscientas palabras y tener el patrón de atención conjunta y referencia social que corresponde al autismo. Otro niño puede no hablar y tener un perfil social típico. El lenguaje es el sistema que produce las palabras. La comunicación social es el sistema que nos lleva a querer compartir esas palabras con otra persona. Es esa diferencia la que el equipo evalúa.” (The words do matter, and sixty words at thirty months is a strength. Valentina's language is something the team will take into account in the support plan. But words and social communication are two brain systems that develop in parallel — one does not depend on the other. A child can have two hundred words and have the joint attention and social referencing pattern that corresponds to autism. Another child may not speak and have a typical social profile. Language is the system that produces the words. Social communication is the system that leads us to want to share those words with another person. It is that difference that the team evaluates.)
Rosa looked at Valentina, who was now examining one plastic giraffe very closely, turning it in the light. She had not looked up at Rosa in the seven minutes they had been in the room. Rosa, who had worked with four hundred toddlers over her teaching career, understood suddenly what the pediatrician had seen.
“¿Y si el diagnóstico se confirma — qué viene después?” she asked. (And if the diagnosis is confirmed — what comes next?)
“El diagnóstico abre el acceso a los servicios de intervención temprana de Texas — el programa ECI. Terapia del habla, terapia ocupacional, y trabajo conductual en casa y en la clínica, hasta veinte o veinticinco horas por semana. Lo importante es empezar lo antes posible — el cerebro de Valentina está ahora en el período de mayor flexibilidad para aprender las habilidades de comunicación social. Los niños que empiezan a los dos años llegan a la escuela con habilidades significativamente mejores que los que empiezan a los cinco. No porque después de los cinco no mejoren — sino porque el cerebro responde más rápido ahora. Si el diagnóstico se confirma hoy, hacemos el referido a ECI esta tarde.” (The diagnosis opens access to Texas Early Childhood Intervention services — the ECI program. Speech therapy, occupational therapy, and behavioral work at home and in the clinic, up to twenty or twenty-five hours per week. What matters is starting as soon as possible — Valentina's brain is now in the period of maximum flexibility for learning social communication skills. Children who start at two arrive at school with significantly better skills than those who start at five. Not because they don't improve after five — but because the brain responds faster now. If the diagnosis is confirmed today, we make the ECI referral this afternoon.)
Valentina had finished with the giraffe and was beginning another arrangement, her profile intent and private. Rosa watched her with the specific grief of a mother who does not yet know what she is about to learn. “Haga la evaluación,” she said quietly. (Do the evaluation.)
Scenario 2: Marco Salazar-Ríos — 7 years old, San Antonio, Texas
Marco Salazar-Ríos had been referred to the developmental and behavioral clinic by his school counselor and pediatrician in October of first grade. His teacher had documented six months of consistent observations: Marco could not remain in his seat for more than three or four minutes without getting up; he called out answers before questions were finished; he lost his pencil, his folder, and his homework multiple times per week; he could not sustain attention on any academic task for more than five minutes without redirection; he had been removed from the classroom line three times for impulsive physical contact with classmates that was not aggressive in intent but had resulted in tears and a bruised arm. At home, his parents reported the same pattern: no sustained independent play, constant interrupting, inability to wait for his turn at dinner, homework sessions that required one parent to sit beside him for the entire duration.
The evaluation at the developmental clinic had confirmed ADHD combined type by DSM-5 criteria — six of nine inattentive symptoms and six of nine hyperactive-impulsive symptoms, present across home and school settings for more than six months, with documented functional impairment. The developmental pediatrician had recommended extended-release methylphenidate, starting at 18 mg once daily in the morning.
Marco’s father Luis had driven both Marco and Marco’s grandmother to the feedback appointment. He was an electrician, second-generation Mexican-American, and he had listened carefully to the evaluation results. When the developmental pediatrician had finished, he had a question he had been holding since before the appointment.
“Le di la vuelta a esto dos semanas,” Luis said to nurse Carlos Herrera-Muñoz, when the pediatrician had stepped out to pull the prescription. “Soy el primero en decir que Marco necesita ayuda — en el colegio, en la casa. Yo mismo fui así de niño, nunca me diagnosticaron. Pero hay un programa en la radio que escucho a las seis de la mañana donde un doctor habla de que los estimulantes para niños son básicamente cocaína controlada para chicos. Que los mismos estudios que muestran que la cocaína es adictiva aplican al Ritalin. Y mi hijo de siete años.” (I've been going back and forth on this for two weeks. I'm the first to say Marco needs help — at school, at home. I was the same way as a child, they never diagnosed me. But there's a program on the radio I listen to at six in the morning where a doctor talks about how stimulants for children are basically controlled cocaine for kids. That the same studies showing cocaine is addictive apply to Ritalin. And my seven-year-old son.)
Carlos Herrera-Muñoz sat down across from Luis. Marco had gone with his grandmother to the waiting area with a tablet. “La preocupación que tiene es legítima, y el doctor en la radio está describiendo algo real — la cocaína y el metilfenidato comparten un mecanismo. Yo quiero explicarle en detalle por qué ese mecanismo compartido no lleva al mismo resultado. Porque la respuesta tiene que ver con algo específico de cómo funciona la adicción en el cerebro.” (The concern you have is legitimate, and the doctor on the radio is describing something real — cocaine and methylphenidate share a mechanism. I want to explain to you in detail why that shared mechanism does not lead to the same outcome. Because the answer has to do with something specific about how addiction works in the brain.)
Luis nodded. He had the posture of a man who had come prepared to listen carefully.
“El TDAH existe porque en el cerebro de Marco — específicamente en la corteza prefrontal, la parte del cerebro que maneja la atención, el control del impulso, y la memoria de trabajo — los mensajeros químicos que regulan esas funciones, que son la dopamina y la norepinefrina, se eliminan demasiado rápido de las sinapsis. Hay unas proteínas llamadas transportadores de dopamina que recogen la dopamina que fue liberada en la sinapsis y la devuelven a la célula. En el cerebro de Marco, eso ocurre más rápido de lo que ocurre en el cerebro de otros niños, lo que significa que la dopamina y la norepinefrina que la corteza prefrontal necesita para sostenerse funcionando durante una tarea están disponibles por menos tiempo. El metilfenidato bloquea temporalmente esos transportadores de dopamina — los mismos que devuelven la dopamina demasiado rápido. Con el transportador bloqueado, la dopamina permanece en la sinapsis más tiempo. La corteza prefrontal de Marco recibe la señal que necesita para sostener la atención, inhibir el impulso de levantarse, retener la información de trabajo. Eso es el metilfenidato.” (ADHD exists because in Marco's brain — specifically in the prefrontal cortex, the part of the brain that manages attention, impulse control, and working memory — the chemical messengers that regulate those functions, which are dopamine and norepinephrine, are eliminated too quickly from the synapses. There are proteins called dopamine transporters that pick up the dopamine that was released in the synapse and return it to the cell. In Marco's brain, that happens faster than in other children's brains, which means that the dopamine and norepinephrine that the prefrontal cortex needs to sustain functioning during a task are available for less time. Methylphenidate temporarily blocks those dopamine transporters — the same ones that return the dopamine too quickly. With the transporter blocked, the dopamine remains in the synapse longer. Marco's prefrontal cortex receives the signal it needs to sustain attention, inhibit the impulse to get up, retain working memory information. That is methylphenidate.)
Luis was following carefully. “Y la cocaína hace lo mismo.” (And cocaine does the same.)
“Bloquea el mismo transportador. La diferencia — y es una diferencia que cambia todo — es la velocidad. La cocaína, cuando se inhala o se inyecta, llega al cerebro en segundos. El nivel de dopamina en el cerebro sube de manera instantánea y masiva. El núcleo accumbens — la parte del cerebro que procesa la recompensa y crea la adicción — responde a la velocidad del cambio de dopamina, no a la cantidad en sí misma. Una subida rápida y grande produce una euforia intensa que refuerza compulsivamente el comportamiento de buscar la droga. Eso es el ciclo de la adicción: euforia intensa, luego baño rápido, luego compulsión a repetir. El metilfenidato de liberación prolongada que le vamos a dar a Marco se absorbe durante ocho a diez horas. El nivel de dopamina en el cerebro de Marco va subiendo lentamente durante la mañana. No hay una subida rápida y grande. No hay euforia. El núcleo accumbens no registra un evento de recompensa que valga la pena repetir compulsivamente. Es farmacológicamente imposible producir adicción con esa velocidad de absorción.” (It blocks the same transporter. The difference — and it is a difference that changes everything — is the speed. Cocaine, when snorted or injected, reaches the brain in seconds. The dopamine level in the brain rises instantaneously and massively. The nucleus accumbens — the part of the brain that processes reward and creates addiction — responds to the rate of change in dopamine, not the quantity itself. A fast and large rise produces an intense euphoria that compulsively reinforces the drug-seeking behavior. That is the addiction cycle: intense euphoria, then rapid drop, then compulsion to repeat. The extended-release methylphenidate we are going to give Marco is absorbed over eight to ten hours. The dopamine level in Marco's brain rises slowly through the morning. There is no fast and large rise. There is no euphoria. The nucleus accumbens does not register a reward event worth repeating compulsively. It is pharmacologically impossible to produce addiction with that absorption rate.)
Luis had his arms uncrossed. He was leaning forward slightly. “¿Y los niños que toman el medicamento de adultos tienen más problemas con las drogas?” (And children who take the medication as adults have more problems with drugs?)
“Es exactamente lo que los estudios analizan. La respuesta es lo contrario de lo que el doctor de la radio afirmó. Los niños con TDAH que recibieron tratamiento farmacológico tienen las mismas tasas o menores de trastornos por uso de sustancias en la adolescencia y la adultez que la población general. Los niños con TDAH que no fueron tratados tienen tasas más altas. El TDAH no tratado — la impulsividad, el fracaso escolar, el rechazo de los compañeros, la baja tolerancia a la frustración — es lo que predice los problemas con sustancias. El medicamento que reduce esos problemas reduce también ese riesgo.” (That is exactly what the studies analyze. The answer is the opposite of what the radio doctor stated. Children with ADHD who received pharmacological treatment have the same or lower rates of substance use disorders in adolescence and adulthood as the general population. Children with ADHD who were not treated have higher rates. Untreated ADHD — the impulsivity, the academic failure, peer rejection, low frustration tolerance — is what predicts substance use problems. The medication that reduces those problems also reduces that risk.)
Luis was quiet for a long moment. He thought about himself at seven, unable to sit still in school in Monterrey, his father telling his teacher he would grow out of it. He thought about the years he had grown out of it, and the years he had not. “El doctor de la radio no mentionó eso.” (The radio doctor didn't mention that.)
“El mecanismo compartido con la cocaína es llamativo y hace un programa de radio memorable,” Carlos said. “La diferencia farmacinética que determina si ese mecanismo produce adicción o tratamiento — eso es lo que el programa no explicó.” (The shared mechanism with cocaine is striking and makes for a memorable radio program. The pharmacokinetic difference that determines whether that mechanism produces addiction or treatment — that is what the program did not explain.)
Luis nodded slowly. “Empieza el lunes,” he said. (It starts Monday.)
Scenario 3: Sofía Reyes-Vega — 8 years old, Dallas, Texas
Sofía Reyes-Vega had Down syndrome — trisomy 21, diagnosed prenatally — and mild-to-moderate intellectual disability, had been in early intervention services since eighteen months, and had made steady progress through special education programs in an inclusive first-grade classroom. Her teacher had known Sofía for two years. The referral to the developmental and behavioral clinic had come in November with a teacher report that something had changed in October: Sofía was hitting more, throwing classroom materials, refusing to cooperate with transitions that she had managed without difficulty the previous year. Her academic work had declined noticeably — she had lost the ability to name colors she had known since age four. She was hyperactive in a way that was new. She had been crying at drop-off, which had not happened since kindergarten.
Sofía’s mother Elena had been doing everything right. She had a private behavioral therapist come to the home twice a week. She had consulted Sofía’s special education case manager. She had attended a parent workshop on behavior management for children with Down syndrome. She had a behavioral chart on the refrigerator and a token economy system that had worked for two years. None of it was working now.
At the developmental clinic visit, nurse María Villanueva-López reviewed the history and asked carefully about the timeline. The behavioral change had started in early October, six weeks ago. It had worsened progressively since then. Sofía was sleeping later in the mornings and harder to wake, which was new. Elena had not connected these observations.
“Le voy a explicar por qué antes de hablar sobre la terapia conductual o de cambiar el plan de manejo, necesitamos hacer dos análisis que el pediatra no siempre pide cuando el comportamiento cambia,” María said, after Elena had finished describing the past six weeks. (I am going to explain why, before talking about behavioral therapy or changing the management plan, we need to do two tests that the pediatrician does not always order when behavior changes.)
Elena had her notebook out. “¿Pero el cambio de comportamiento no es part del síndrome de Down — que a veces empeora?” (But isn't the behavioral change part of Down syndrome — that it sometimes worsens?)
“Es una pregunta muy importante,” María said. “Y la respuesta es: el síndrome de Down no produce empeoramiento conductual progresivo a los ocho años en un niño que ha tenido tres años de progreso estable. Un cambio conductual abrupto en un niño con el síndrome de Down que estaba bien es una alerta médica hasta que se demuestre lo contrario. Y hay dos razones específicas para eso.” (That is a very important question. And the answer is: Down syndrome does not produce progressive behavioral worsening at age eight in a child who has had three years of stable progress. An abrupt behavioral change in a child with Down syndrome who was doing well is a medical alert until proven otherwise. And there are two specific reasons for that.)
Elena had her pen ready. “Explique,” she said. (Explain.)
“La primera: el síndrome de Down viene con un riesgo elevado de que la tiroides empiece a funcionar lentamente. No en todos los niños, pero entre el 15 y el 30 por ciento de los niños con Down desarrollan hipotiroidismo en algún momento de la niñez. La tiroides produce una hormona que regula el metabolismo de todo el cuerpo, incluyendo el cerebro. Cuando la tiroides funciona lento, el cerebro recibe menos de esa hormona. Y lo que produce eso en los niños — especialmente en niños con discapacidad intelectual que no pueden decir que se sienten lentos o cansados — es exactamente lo que la maestra de Sofía está describiendo: irritabilidad, agresividad, pérdida de habilidades que ya tenía, sueño excesivo, dificultad para despertarse. Todo eso. Sin análisis de sangre, ese perfil parece un empeoramiento conductual primario. Con el análisis de sangre — si la TSH está alta — sabemos que la causa es la tiroides. Y el tratamiento es una pastilla de levotiroxina que repone la hormona tiroidea. En cuatro a ocho semanas, el comportamiento mejora por sí solo. Sin cambiar la terapia conductual. Sin añadir intervenciones. La causa médica se trata y el comportamiento se resuelve.” (The first: Down syndrome comes with an elevated risk that the thyroid starts working slowly. Not in all children, but between 15 and 30 percent of children with Down develop hypothyroidism at some point in childhood. The thyroid produces a hormone that regulates the metabolism of the entire body, including the brain. When the thyroid functions slowly, the brain receives less of that hormone. And what that produces in children — especially children with intellectual disability who cannot say they feel slow or tired — is exactly what Sofía's teacher is describing: irritability, aggressiveness, loss of skills she already had, excessive sleep, difficulty waking up. All of that. Without blood tests, that profile looks like a primary behavioral worsening. With the blood test — if the TSH is high — we know the cause is the thyroid. And the treatment is a levothyroxine pill that replenishes the thyroid hormone. In four to eight weeks, the behavior improves on its own. Without changing the behavioral therapy. Without adding interventions. The medical cause is treated and the behavior resolves.)
Elena had stopped writing. “¿Cuatro a ocho semanas?” she asked. (Four to eight weeks?)
“Con el tratamiento adecuado, sí. Ahora la segunda razón.” María continued. “Los niños con síndrome de Down tienen la musculatura de la garganta más relajada que otros niños, y la lengua es proporcionalmente más grande en relación al tamaño de la boca. Durante el sueño, cuando los músculos se relajan aún más, eso puede causar que la garganta se cierre parcialmente o completamente por momentos — lo que llamamos apnea obstructiva del sueño. Y cuando eso pasa, el cerebro manda una alerta para despertar al cuerpo lo suficiente para abrir la garganta — sin que la persona se dé cuenta completamente de que se despertó. Esto puede pasar docenas de veces por hora. El resultado es que Sofía llega a las siete de la mañana habiendo pasado ocho horas en la cama pero con un cerebro que no descansó. Y lo que produce un niño con el cerebro sin descanso — especialmente un niño que ya tiene un control de impulso limitado por la discapacidad intelectual — es exactamente lo que la maestra está viendo: impulsividad, agresividad, hiperactividad, dificultad para manejar transiciones, regresiones cognitivas. Eso no es un problema de comportamiento. Es un problema de sueño que se expresa como un problema de comportamiento.” (With the right treatment, yes. Now the second reason. Children with Down syndrome have more relaxed throat musculature than other children, and the tongue is proportionally larger relative to the mouth size. During sleep, when the muscles relax even more, that can cause the throat to partially or completely close momentarily — what we call obstructive sleep apnea. And when that happens, the brain sends an alert to wake the body enough to open the throat — without the person being fully aware they woke up. This can happen dozens of times per hour. The result is that Sofía arrives at seven in the morning having spent eight hours in bed but with a brain that did not rest. And what a child with an unrested brain produces — especially a child who already has limited impulse control from intellectual disability — is exactly what the teacher is seeing: impulsivity, aggressiveness, hyperactivity, difficulty managing transitions, cognitive regressions. That is not a behavioral problem. It is a sleep problem expressing itself as a behavioral problem.)
Elena set her pen down. “Sofía se ha estado durmiendo más desde octubre y me cuesta más trabajo despertarla,” she said. (Sofía has been sleeping more since October and it's harder to wake her.)
“Eso puede ser tanto hipotiroidismo como apnea del sueño — ambas producen eso. Hoy pedimos los análisis de sangre. Si la tiroides está bien, coordinamos el estudio del sueño. Si encontramos alguna de las dos cosas, la tratamos. Si la tiroides está bien y la apnea está bien, entonces sí miramos el manejo conductual más de cerca. Pero en un niño con síndrome de Down que cambió el comportamiento de manera abrupta, estas causas médicas tienen que estar descartadas primero — porque si están presentes y no se tratan, ninguna terapia conductual funciona bien.” (That can be either hypothyroidism or sleep apnea — both produce that. Today we order the blood tests. If the thyroid is fine, we coordinate the sleep study. If we find either thing, we treat it. If the thyroid is fine and the sleep apnea is fine, then we look more closely at behavioral management. But in a child with Down syndrome who had an abrupt behavioral change, these medical causes must be ruled out first — because if they are present and untreated, no behavioral therapy works well.)
Elena had been carrying the weight of six weeks of escalating behavior, two behavioral therapists who were equally puzzled, a teacher who was running out of strategies, and her own growing doubt that she was doing something wrong. The possibility that there was a medical explanation — something treatable, something fixable — landed in the silence of the examination room like something she had needed to hear. “Entonces la terapia conductual no era la solución para esto.” (So behavioral therapy was not the solution for this.)
“No era la solución para la causa que hay que buscar primero,” María said. “Cuando esa causa esté tratada, la terapia que tiene Sofía va a funcionar mucho mejor. El sistema conductual que tiene en casa — el que estuvo funcionando dos años — no desapareció. Si hay un problema médico, cuando se trate, ese sistema va a volver a funcionar. Porque el comportamiento de Sofía no cambió porque la terapia falló. Cambió porque algo en su cuerpo está diferente desde octubre.” (It was not the solution for the cause that must be searched first. When that cause is treated, the therapy Sofía has will work much better. The behavioral system she has at home — the one that worked for two years — did not disappear. If there is a medical problem, when it is treated, that system will work again. Because Sofía's behavior did not change because the therapy failed. It changed because something in her body has been different since October.)