Sam burst into the office, a two year old wild bundle of energy. Squealing with delight--or was it distress; it was hard to tell--he ran from toy to toy not looking at me or his mother, Jane. He was unable to engage with anything. Jane had brought him to see me in my pediatric practice because, “he hits me, has explosive tantrums, and I can’t take him anywhere.” She sank into the couch. I sat on the floor, wanting to listen to Jane, but also to include Sam in the visit. At first, I focused my attention on her story, while Sam continued his frantic exploration of the room.
Jane described a scene at the playground. The other mothers had been engaged in easy conversation, but she was on edge. She knew Sam was “inflexible” and at any moment could go from happy play to a full-blown tantrum. Sure enough, as she tried to join in the group, she saw him getting upset because his toy car was stuck. She rushed over to calm him, but his crying escalated. As the other kids and moms turned to look, she quickly went from embarrassment to rage. She yelled at Sam to cut it out. This only made him scream more. Finally, she grabbed him, her bag and his toys and ran to her car, where she collapsed in tears of helplessness.
Things had not been easy for Jane. Sam’s father had abused her and was in prison. She was afraid when she felt Sam’s anger that he would turn out like his father. Of her own mother she said, “She was never there for me.” Jane was frustrated and bewildered by the fact that Sam could relate to other people, yet reserved all his difficult behavior for her.
At the beginning of the visit, Jane made several awkward attempts to interact with Sam, but without success. She was anxious and her body language felt intrusive, which seemed to cause Sam to withdraw. As she opened up and shared more of her painful feelings with me, however, an interesting transformation occurred. Sam began to engage in more focused play. Mom and I talked about what Sam was doing, observing together how he was calming down. At first he talked to me, bringing me toys and naming them and describing what he was doing. But then he spontaneously ran over and gave his mother a hug. Her whole body relaxed, she leaned forward on the couch toward him, her pleasure and relief palpable in the room. Sam began to engage her in his play, and to communicate with her. Jane told me that she had been reluctant to come for the appointment, but was glad she had.
Being a parent of such a child is a hard job. Raising a child alone, without support from extended family or a spouse, is even harder. In our culture of advice and quick fixes, in seeking help for her problems with him, Sam’s mother would find many who would offer “expert” advice about how to manage her child’s behavior. An increasing number would recommend some type of medication to control his “hyperactivity.” Helping her to be fully emotionally present with her child--supporting her in the challenges she faced as a mother--is not a common approach.
Yet current research at the interface of developmental psychology, neuroscience and behavioral genetics is showing that it is just this type of intervention that will help children like Sam to manage strong emotions and relate to other people. A child’s mind grows and develops when the people who are most important to the child are able to think about and understand a child’s experience from the child’s perspective, without being overwhelmed or shutting down. A parent’s capacity to “hold the child in mind” leads to a child’s increased cognitive resourcefulness, greater social skills, and better capacity to regulate emotions. If we, pediatricians, grandparents, spouses, neighbors--can help a mother like Sam’s to join her child, to accept his “low frustration tolerance” as part of him, not a reflection of her own failure as a parent, then she can help him regulate his frustration. He can then learn to manage his feelings on his own. Most important, if she can do this, she may actually change the way his brain handles stress and strong emotions.
Minggu, 31 Januari 2010
Jumat, 29 Januari 2010
The Aggressive Child and the Elephant in the Room
In the Tony award winning play God of Carnage two couples meet in an elegant living room for an ostensibly civilized conversation about the aggressive act of one couple’s child against the other’s. The meeting soon degenerates to reveal the underbelly of conflict in the two marriages. Husband and wife hurl insults, precious items and even themselves with escalating rage. We see, as they attempt in vain to focus on the children’s behavior, the proverbial “elephant in the room.”
It brought to mind another depiction of the nature of the elephant, presented by the pharmaceutical industry. A recent issue of The Journal of Developmental and Behavioral Pediatrics features prominently a two page ad from Shire, makers of drugs commonly used for treatment of Attention Deficit Hyperactivity Disorder (ADHD). A mother and her son sit at the desk of a doctor in a white coat. Behind them is a large elephant draped in a red blanket on which is printed the words, “resentful, defiant, angry.” The ad recommends that these symptoms, in addition to the more common symptoms of inattention and hyperactivity, should be addressed. This is the message: doctors should be treating these symptoms with medication.
From my vantage point of over 20 years of practicing pediatrics, where I sit on the floor, not in a white coat, and play with children, I believe that the play’s depiction of the nature of the elephant is much more accurate and meaningful than that of the pharmaceutical industry. In the play the elephant is the environment of rage and conflict in which the aggression occurs, while in the ad the elephant is the child’s symptom. Consider these two stories from my pediatric practice (with details changed to protect privacy.)
Everything was a battle with six year old Mark. Though I asked both parents to come to the visit, Mom came alone. She was furious.”Tell me what to do to make him listen.” We had a full hour visit, and as she began to relax, she shared a story of constant vicious fighting between herself and her husband. Mark, who had been playing calmly and quietly, took a marker and slowly and deliberately made a black smudge on the yellow wall. His mother was too distracted by her own distress to stop him. I said, “You cannot draw on the wall, but maybe you are upset about what we are talking about.” He came and sat on his mother’s lap. She reluctantly revealed her suspicion that his angry behavior was a reflection of the rage he experienced at home. She agreed to get help for her marriage, and Mark’s behavior gradually began to improve.
Jane’s parents became alarmed when her aggressive behavior began to spill over into school. Her third grade teacher told them that not only was she distracted and fidgety, but she seemed increasingly angry. At our second visit, Dad became tearful as he described his cruel and abusive father. He acknowledged being overwhelmed with rage at Jane when she didn’t listen. He yelled at her and threatened her. He longed for a positive role model to learn how to discipline her in a different way. He realized he needed help to address the traumas of his own childhood in order to be a more effective parent for Jane.
If the elephant in the room is the child’s symptoms, as the drug companies would have us believe, then medication may be the solution. Children taking medication for ADHD often tell me that it makes them feel calm. The full responsibility for the problem then falls squarely on the child’s shoulders.
For Mark and Jane, and countless children like them, the elephant in the room, however, is not the child’s symptoms. It is the environment of conflict in which the symptoms occur. If the family environment is the elephant, the treatment of the problem is not as simple as prescribing a pill. Families must acknowledge and address seemingly overwhelming problems. The parents’ relationship with each other, and each parent’s relationship with his or her own family of origin, often contributes significantly to this environment.
In the supportive setting of my office, Mark and Jane’s parents were freed to think about their child’s perspective and experience. Rather than focusing on “what to do” they understood what their children might be feeling growing up in an environment of conflict and rage. This ability for parents to think about their child’s feelings has been shown, in extensive research at the intersection of developmental psychology, genetics and neuroscience, to facilitate a child’s development of the capacity to manage strong emotions and adapt in social situations.
In another interesting link between this ad and God of Carnage, one of the fathers is an attorney representing a drug company. He speaks loudly on his cell phone, seemingly oblivious to the effect of his behavior on the other people in the room. His conversation reveals the profit motive of the drug company taking precedence over the well being of the patient.
God of Carnage was written by Yasmina Reza, a French playwright. While the play itself is hugely entertaining as a witty farce about family life, an important message was in a brief scene at the very end. The telephone rings. The mother answers. It is her daughter, all upset about the loss of her pet hamster, which the father had “set free” one night because he was annoyed by the animal’s habits. Suddenly the mood of the play, which was lively with scintillating dialogue throughout, becomes serene as the mother speaks lovingly to her distraught daughter. Perhaps most of the audience was barely aware of the sudden mood change. Yet it lifted this delightful play into universal significance. Freeing herself from the preceding chaos, she calmly gives her full attention to her daughter’s experience.
The popularity of the play gives me hope that people are hungry for a different way to think about children and families than that offered by the pharmaceutical industry, which, with the money to place an attention getting ad, has a very loud voice. It is joined by the equally loud voice of the private health insurance industry, which supports the quick fix of medication over more time intensive interventions. In contrast, Mark, with his black smudge on my yellow wall, has a very small voice. His voice says “Please think about my feelings, not just my behavior.”
His voice is particularly critical now, as our country strives to create social policy and a health care system that values prevention and primary care. Parents, if they are supported and nurtured, know what is best for their children. We as a culture must demonstrate that we respect both the difficulty and the critical importance of being an effective parent. In this way we will be able to help children, not only by treating their symptoms, but giving an opportunity for deeply rewarding changes in the important relationships in their lives.
It brought to mind another depiction of the nature of the elephant, presented by the pharmaceutical industry. A recent issue of The Journal of Developmental and Behavioral Pediatrics features prominently a two page ad from Shire, makers of drugs commonly used for treatment of Attention Deficit Hyperactivity Disorder (ADHD). A mother and her son sit at the desk of a doctor in a white coat. Behind them is a large elephant draped in a red blanket on which is printed the words, “resentful, defiant, angry.” The ad recommends that these symptoms, in addition to the more common symptoms of inattention and hyperactivity, should be addressed. This is the message: doctors should be treating these symptoms with medication.
From my vantage point of over 20 years of practicing pediatrics, where I sit on the floor, not in a white coat, and play with children, I believe that the play’s depiction of the nature of the elephant is much more accurate and meaningful than that of the pharmaceutical industry. In the play the elephant is the environment of rage and conflict in which the aggression occurs, while in the ad the elephant is the child’s symptom. Consider these two stories from my pediatric practice (with details changed to protect privacy.)
Everything was a battle with six year old Mark. Though I asked both parents to come to the visit, Mom came alone. She was furious.”Tell me what to do to make him listen.” We had a full hour visit, and as she began to relax, she shared a story of constant vicious fighting between herself and her husband. Mark, who had been playing calmly and quietly, took a marker and slowly and deliberately made a black smudge on the yellow wall. His mother was too distracted by her own distress to stop him. I said, “You cannot draw on the wall, but maybe you are upset about what we are talking about.” He came and sat on his mother’s lap. She reluctantly revealed her suspicion that his angry behavior was a reflection of the rage he experienced at home. She agreed to get help for her marriage, and Mark’s behavior gradually began to improve.
Jane’s parents became alarmed when her aggressive behavior began to spill over into school. Her third grade teacher told them that not only was she distracted and fidgety, but she seemed increasingly angry. At our second visit, Dad became tearful as he described his cruel and abusive father. He acknowledged being overwhelmed with rage at Jane when she didn’t listen. He yelled at her and threatened her. He longed for a positive role model to learn how to discipline her in a different way. He realized he needed help to address the traumas of his own childhood in order to be a more effective parent for Jane.
If the elephant in the room is the child’s symptoms, as the drug companies would have us believe, then medication may be the solution. Children taking medication for ADHD often tell me that it makes them feel calm. The full responsibility for the problem then falls squarely on the child’s shoulders.
For Mark and Jane, and countless children like them, the elephant in the room, however, is not the child’s symptoms. It is the environment of conflict in which the symptoms occur. If the family environment is the elephant, the treatment of the problem is not as simple as prescribing a pill. Families must acknowledge and address seemingly overwhelming problems. The parents’ relationship with each other, and each parent’s relationship with his or her own family of origin, often contributes significantly to this environment.
In the supportive setting of my office, Mark and Jane’s parents were freed to think about their child’s perspective and experience. Rather than focusing on “what to do” they understood what their children might be feeling growing up in an environment of conflict and rage. This ability for parents to think about their child’s feelings has been shown, in extensive research at the intersection of developmental psychology, genetics and neuroscience, to facilitate a child’s development of the capacity to manage strong emotions and adapt in social situations.
In another interesting link between this ad and God of Carnage, one of the fathers is an attorney representing a drug company. He speaks loudly on his cell phone, seemingly oblivious to the effect of his behavior on the other people in the room. His conversation reveals the profit motive of the drug company taking precedence over the well being of the patient.
God of Carnage was written by Yasmina Reza, a French playwright. While the play itself is hugely entertaining as a witty farce about family life, an important message was in a brief scene at the very end. The telephone rings. The mother answers. It is her daughter, all upset about the loss of her pet hamster, which the father had “set free” one night because he was annoyed by the animal’s habits. Suddenly the mood of the play, which was lively with scintillating dialogue throughout, becomes serene as the mother speaks lovingly to her distraught daughter. Perhaps most of the audience was barely aware of the sudden mood change. Yet it lifted this delightful play into universal significance. Freeing herself from the preceding chaos, she calmly gives her full attention to her daughter’s experience.
The popularity of the play gives me hope that people are hungry for a different way to think about children and families than that offered by the pharmaceutical industry, which, with the money to place an attention getting ad, has a very loud voice. It is joined by the equally loud voice of the private health insurance industry, which supports the quick fix of medication over more time intensive interventions. In contrast, Mark, with his black smudge on my yellow wall, has a very small voice. His voice says “Please think about my feelings, not just my behavior.”
His voice is particularly critical now, as our country strives to create social policy and a health care system that values prevention and primary care. Parents, if they are supported and nurtured, know what is best for their children. We as a culture must demonstrate that we respect both the difficulty and the critical importance of being an effective parent. In this way we will be able to help children, not only by treating their symptoms, but giving an opportunity for deeply rewarding changes in the important relationships in their lives.
Kamis, 28 Januari 2010
Listening to a Mother
I first met Rachel about three years ago when she brought her four year old adopted son, Sam, to see me in my pediatric practice because of problem behavior(as always, details have been changed to protect privacy). A story of severe trauma in his early years emerged. He had lived on the streets with his mentally ill mother, then been shuttled between foster homes until he was adopted at the age of three. While he was a sweet and engaging child, Rachel told of explosive rage and defiance at home. She had raised four biological children and was feeling completely undone by this one.
I did not come close to solving Sam's "behavior problems." But I did help Rachel to understand the roots of his behavior. By gradually working with her to think about the effects of this early trauma on his development, I helped to free her from the debilitating self blame from which she had been suffering. She gathered her strength and began the long and difficult task of getting the help for Sam that he needed.
Last week, Rachel called me. We had not spoken for many months. She had a adopted two more children from another country. These children had not been traumatized like Sam, and things were going smoothly. But not for Sam. The intensive therapy Sam had been receiving was no longer covered by their insurance. The only option, one Mom did not feel was a long term solution, was to increase his dose of medication. Monthly visits to the psychiatrist were still covered.
We fell into easy familiar conversation. She shared her moments of despair, when she lost her cool and felt painfully inadequate. I shared my frustration with the insurance situation. At the end of our conversation she thanked me. But for what? I, too, was helpless to get Sam the services he needed. Perhaps what I had done was simply to listen to Rachel. I recognized her experience, and in doing so recharged her in her efforts to be emotionally present with Sam at these difficult moments. I can only hope that this will help to set Sam on a healthier path of development.
I did not come close to solving Sam's "behavior problems." But I did help Rachel to understand the roots of his behavior. By gradually working with her to think about the effects of this early trauma on his development, I helped to free her from the debilitating self blame from which she had been suffering. She gathered her strength and began the long and difficult task of getting the help for Sam that he needed.
Last week, Rachel called me. We had not spoken for many months. She had a adopted two more children from another country. These children had not been traumatized like Sam, and things were going smoothly. But not for Sam. The intensive therapy Sam had been receiving was no longer covered by their insurance. The only option, one Mom did not feel was a long term solution, was to increase his dose of medication. Monthly visits to the psychiatrist were still covered.
We fell into easy familiar conversation. She shared her moments of despair, when she lost her cool and felt painfully inadequate. I shared my frustration with the insurance situation. At the end of our conversation she thanked me. But for what? I, too, was helpless to get Sam the services he needed. Perhaps what I had done was simply to listen to Rachel. I recognized her experience, and in doing so recharged her in her efforts to be emotionally present with Sam at these difficult moments. I can only hope that this will help to set Sam on a healthier path of development.
Langganan:
Postingan (Atom)
