Two recent experiences have gotten me thinking about the concept of "containment." It is the third component of keeping your child in mind, an approach to supporting healthy emotional development that I describe in my book, Keeping Your Child in Mind. In its most concrete form it refers to the importance of setting limits on your child's behavior. For example, by giving a "time out" every time your child hits, you show him that this behavior will not be tolerated. In doing so, you protect him from the intensity of his feelings by making sure that things do not get out of control. When young children are so consumed with anger and frustration that they hit, they feel out of control, and clear limits help them learn to regulate and manage these difficult emotions. (Combining limits with empathy, as I describe in my previous post, is essential.)
The first experience was a radio interview I had last week on the program Radio 2 Women on WBCR in the Berkshires. My interviewer, Serene Mastrianni, was among the best I've encountered. She had read the book twice, the first time going right to the section corresponding to her own child's age, and then again from the beginning. She had given it some careful thought. She had begun to actively use the book, not only in her own family, but to support friends. She told me the following story.
One such friend, the mother of a 12-year-old boy, had called her in tears. Her son had just had an explosive tantrum and at its height, he screamed at her, " I know you hate me, but I didn't know Dad hates me too!" Her friend was devastated. Serene's response to her hysterical friend was (after, "you've go to to read this book") "sit with him find out what this is all about." So her friend, rather than reacting in anger or hurt, did just that. And with time, the story unfolded that he had been bullied at school. He was a very successful student, president of his class, and he had never had this experience. He was furious with his parents for having failed to protect him, even though in reality they knew nothing about it.
This story combined with the second experience, attending the Zero to Three conference,"the premier conference for professionals dedicated to promoting the health and well-being of infants and toddlers," this past week in Washinton, DC, led me to consider the deeper meaning of the term 'containment." At a lecture I attending on teaching therapists to work with parent-infant pairs, the speaker described containment as "tolerating and sitting with feelings until the meaning unfolds." This is exactly what Serene's friend had done.
Tolerating your child's feelings in this way can be very difficult for a parent, as your child's behavior, particularly when it involves either physical or verbal assault, may provoke intense reactions. But the rewards, as this story shows, are great. Containment requires that, for the moment, you put your own distress aside (the fourth component of keeping a child in mind.) The beauty of Serene's story is that she was able to help her friend with this challenging task. It points out that for parents to be able to keep their child in mind in this way, there must be someone keeping them in mind. That person could be a friend, spouse, family member, pediatrician, or therapist.
"What about positive feelings?" Serene asked. I love this question. Much attention is given in the parenting literature to negative feelings, such as anger, frustration and sadness. But meeting a child’s experience of excitement and joy is in many ways equally important in promoting healthy development. Failure recognize and contain joy may slip under parents' radar as the behavior that follows may not be disruptive. But a child brimming with excitement over an experience with a friend or teacher who is met by a distracted parent may feel unrecognized, as the above child would have been if rather than being listened to he were sent to his room for "talking back." A parent who is depressed may have particular difficulty meeting a child's joy. This is one of many reasons why it is critical for parents who are struggling with depression to get help.
Serene told of a time when her daughter came home in just such an excited state, and she busy with something and did not respond. Later that day, however, Serene recognized what had happened and said to her daughter, "you were really happy when you came home and I wasn't listening. I'm sorry. Come here now and tell me all about it."
In the everyday stress of life, there are many times when a parent will not be available to contain a child's feelings, whether positive or negative, in the way I have described. But this very process of recognizing such a moment of disruption, and subsequently repairing it, is, in itself, essential for promoting healthy emotional development.
Senin, 12 Desember 2011
Selasa, 06 Desember 2011
Why "Defiant" Behavior Pushes Parents' Buttons
Recently NPR had a story about temper tantrums, describing a new study showing that the sounds children make during a tantrum indicate that they are primarily sad rather than angry. The written version of the story opens with description of tantrums as " the cause of profound helplessness among parents."
I thought this was an interesting choice of words, as I have always thought of tantrums as representing a sense of helplessness in children. In fact, in my over 20 years of practicing pediatrics I have told parents that, for the most part, tantrums are a normal healthy phenomenon. They occur when young children emerge for a stage of omnipotence in the first year to recognize that they are relatively powerless. An excerpt from my book describes the phenomenon.
The word"defiant" is a perfect example of this negative language. That word(as well as "tantrums") is actually in the title of my book Keeping Your Child in Mind: Overcoming Defiance, Tantrums and other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes. The first part of the title was my doing, as it comes from an important concept in contemporary developmental science. The subtitle was my publisher's doing, but I understand why it was chosen, as this is a common language. Perhaps, however, it is time to rethink that language.
Recently I was asked to do an email interview for a parenting blog about defiance. The interviewer also used the word "impudence," another highly negative word. I suggested that this word projects intentions onto the child that are likely not there. In fact, "defiant" behavior almost always has its origins in a feeling of being out of control. From the child's perspective, his experience is not being recognized or understood. In a way he is not "seen."
Herein lies the explanation of why defiance pushes our buttons. In a sense a parent is having exactly the same experience as the child. He or she is not being "seen" or recognized as an adult deserving of respect. A parent might have had other experiences of not being "seen,” perhaps by a spouse, co-worker or by her own parents, that makes her particularly vulnerable to getting upset about not being “seen” by her child.
In almost every instance of “defiant" behavior, if one digs a bit below the surface, there is a way the child is also not being seen, or a way in which her experience is not recognized. For a particularly dramatic example, a six-year-old was brought to my practice with a chief complaint of “defiant behavior”. Further history revealed significant trauma in the child’s life. An alcoholic father who had abandoned the child as a toddler had recently been making visits, at which time he was often drunk and very loud. Yet her feelings about visits had not been discussed until they came to see me for “defiant” behavior,” which was worse around bedtime.
This child began sleeping all night in her bed after a couple of visits with me. We discussed this experience, recognizing her need for her mother's company at bedtime for stories, comfort and reassurance. Once a child feels that he is being seen, that his experience is recognized and understood, the "difficult" behavior often evaporates.
In general, if there is increasing “defiance” it is important to take a step back and try to understand what feels out of control for the child. It might be that he is very sensitive to loud noises or taste, and battles around "making a scene” at a family outing or being “picky eater” are related to these sensory sensitivities. It might be that there is a new baby and everyone is chronically sleep deprived. Or there may be financial stress or marital conflict. Simply recognizing that these things are difficult for a child and acknowledging his experience, even if the stressors are still there, goes a long way in having a child feel understood, and in turn decreasing “defiant” behavior.
Limits on behavior are essential, and my book goes on to say that the above toddler must be taught that hitting is never OK. But understanding, empathy and managing our own distress are all equally important. Reframing "difficult" behavior as "stressed" behavior is an important first step.
I thought this was an interesting choice of words, as I have always thought of tantrums as representing a sense of helplessness in children. In fact, in my over 20 years of practicing pediatrics I have told parents that, for the most part, tantrums are a normal healthy phenomenon. They occur when young children emerge for a stage of omnipotence in the first year to recognize that they are relatively powerless. An excerpt from my book describes the phenomenon.
Imagine that your toddler sets his sight on your glasses and declares proudly, “mine.” In an appropriate way, you might calmly say, “No, those are Mommy’s. I need them to see.” Suddenly he is confronted with the fact of his relative smallness and powerlessness. If he happens to be in a particularly vulnerable state, such as before lunch or naptime, he might become enraged that you, his beloved mother, have burst the bubble of his omnipotence. Unable to contain his intense feelings, he might lash out and hit you.The NPR piece got me thinking that we often describe children's behavior in negative terms, which immediately sets up a relationship of antagonism and confrontation. A colleague of mine, Suzanne Zeedyk, wisely has suggested that we reframe "challenging" behavior as "stressed" behavior. Then the language itself puts us in a position to empathize with the child's perspective.
The word"defiant" is a perfect example of this negative language. That word(as well as "tantrums") is actually in the title of my book Keeping Your Child in Mind: Overcoming Defiance, Tantrums and other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes. The first part of the title was my doing, as it comes from an important concept in contemporary developmental science. The subtitle was my publisher's doing, but I understand why it was chosen, as this is a common language. Perhaps, however, it is time to rethink that language.
Recently I was asked to do an email interview for a parenting blog about defiance. The interviewer also used the word "impudence," another highly negative word. I suggested that this word projects intentions onto the child that are likely not there. In fact, "defiant" behavior almost always has its origins in a feeling of being out of control. From the child's perspective, his experience is not being recognized or understood. In a way he is not "seen."
Herein lies the explanation of why defiance pushes our buttons. In a sense a parent is having exactly the same experience as the child. He or she is not being "seen" or recognized as an adult deserving of respect. A parent might have had other experiences of not being "seen,” perhaps by a spouse, co-worker or by her own parents, that makes her particularly vulnerable to getting upset about not being “seen” by her child.
In almost every instance of “defiant" behavior, if one digs a bit below the surface, there is a way the child is also not being seen, or a way in which her experience is not recognized. For a particularly dramatic example, a six-year-old was brought to my practice with a chief complaint of “defiant behavior”. Further history revealed significant trauma in the child’s life. An alcoholic father who had abandoned the child as a toddler had recently been making visits, at which time he was often drunk and very loud. Yet her feelings about visits had not been discussed until they came to see me for “defiant” behavior,” which was worse around bedtime.
This child began sleeping all night in her bed after a couple of visits with me. We discussed this experience, recognizing her need for her mother's company at bedtime for stories, comfort and reassurance. Once a child feels that he is being seen, that his experience is recognized and understood, the "difficult" behavior often evaporates.
In general, if there is increasing “defiance” it is important to take a step back and try to understand what feels out of control for the child. It might be that he is very sensitive to loud noises or taste, and battles around "making a scene” at a family outing or being “picky eater” are related to these sensory sensitivities. It might be that there is a new baby and everyone is chronically sleep deprived. Or there may be financial stress or marital conflict. Simply recognizing that these things are difficult for a child and acknowledging his experience, even if the stressors are still there, goes a long way in having a child feel understood, and in turn decreasing “defiant” behavior.
Limits on behavior are essential, and my book goes on to say that the above toddler must be taught that hitting is never OK. But understanding, empathy and managing our own distress are all equally important. Reframing "difficult" behavior as "stressed" behavior is an important first step.
Jumat, 02 Desember 2011
When Time and Space is the Treatment
In my pediatric practice, it is not uncommon for a parent, given the space and time, to reveal a critical and unexpected piece of information. Consider these two stories, with details changed to protect privacy. Jennifer’s Mom was desperate for a change in her ADHD medication. A previous doctor had diagnosed her and now she was increasingly distracted in school. In telling me Jennifer’s story, Mom focused on all the different medications she had been on and how they had controlled her symptoms. Towards the very end of the 50 minute visit Mom almost casually dropped this information. “She’s wary of therapists because of what happened with DCF (Department of Children and Families.)” I asked why. Recently, Jennifer had told a therapist about her stepfather’s behavior and it had been reported as possible abuse.
Five year old Kevin’s Mom was distraught about his constant fighting with his younger sister. He always had to have everything first, his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family had never mourned this loss. That trauma came flooding back now that she had two children of her own.
“If you ask questions you get answers-and hardly anything else.” This well know aphorism in medicine comes from a book, The Doctor, HIs Patient and the Illness by Hungarian psychiatrist Michael Balint. In this book he documents his experience running groups for primary care doctors. He writes of the “doctor as drug,” describing how doctors use themselves and their relationship with their patients as an important part of the care they offer.
Time and space, then, is the treatment. It gives patients a chance to say what is really important, the things that won’t come out if doctors just ask questions. For parents who feel stressed and alone, an opportunity to sit in a quiet room with respected and attentive listener for 50 minutes is invaluable. It gives them an opportunity to think about their child, rather than simply get advice about what to do. In both of these cases, telling their story was essential for effective treatment. For Jennifer, she needed an acknowledgement of the trauma of that experience with DCF, which now got in the way of her asking for help. Kevin’s mother recognized how her own unresolved loss interfered with her ability to respond effectively to her children. In a brief visit structured by questions, parents are unlikely to develop the comfort required to open up.
The world of business has its own saying: “Time is money.” For the private health insurance industry it is more profitable to cover a brief "medication check" than a 50 minute visit. Put this together with huge marketing efforts from the pharmaceutical industry and you have a big problem. Prescribing medication takes much less time than sitting with someone until they trust you enough to talk about what is important.
Primary care practices must have a large staff to manage the complexities of multiple different insurance plans. Office managers spend hours making calls and filling out forms to get insurance companies to give prior authorization for such things as MRIs and neuropsychological testing. In order for the practice to be viable and support this staff, the doctors are forced to see more patients in less time.
The interests of the private health insurance industry and the interests of children can stand in direct opposition to one another. As health care reform (I hope!) proceeds, the perspective of this non-voting population must be taken into account.
Five year old Kevin’s Mom was distraught about his constant fighting with his younger sister. He always had to have everything first, his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family had never mourned this loss. That trauma came flooding back now that she had two children of her own.
“If you ask questions you get answers-and hardly anything else.” This well know aphorism in medicine comes from a book, The Doctor, HIs Patient and the Illness by Hungarian psychiatrist Michael Balint. In this book he documents his experience running groups for primary care doctors. He writes of the “doctor as drug,” describing how doctors use themselves and their relationship with their patients as an important part of the care they offer.
Time and space, then, is the treatment. It gives patients a chance to say what is really important, the things that won’t come out if doctors just ask questions. For parents who feel stressed and alone, an opportunity to sit in a quiet room with respected and attentive listener for 50 minutes is invaluable. It gives them an opportunity to think about their child, rather than simply get advice about what to do. In both of these cases, telling their story was essential for effective treatment. For Jennifer, she needed an acknowledgement of the trauma of that experience with DCF, which now got in the way of her asking for help. Kevin’s mother recognized how her own unresolved loss interfered with her ability to respond effectively to her children. In a brief visit structured by questions, parents are unlikely to develop the comfort required to open up.
The world of business has its own saying: “Time is money.” For the private health insurance industry it is more profitable to cover a brief "medication check" than a 50 minute visit. Put this together with huge marketing efforts from the pharmaceutical industry and you have a big problem. Prescribing medication takes much less time than sitting with someone until they trust you enough to talk about what is important.
Primary care practices must have a large staff to manage the complexities of multiple different insurance plans. Office managers spend hours making calls and filling out forms to get insurance companies to give prior authorization for such things as MRIs and neuropsychological testing. In order for the practice to be viable and support this staff, the doctors are forced to see more patients in less time.
The interests of the private health insurance industry and the interests of children can stand in direct opposition to one another. As health care reform (I hope!) proceeds, the perspective of this non-voting population must be taken into account.
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