Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary developmental science can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Tuesday, June 29, 2010

When a "Problem" Child Hides A Troubled Marriage

A piece in today's New York Times "Seeking to Pre-empt Marital Strife" states that only 19% of married couples take part in marital counselling. The article quotes Brian D. Doss, an assistant psychology professor at the University of Miami, “There’s a strong disincentive to think about your relationship as being in trouble — that’s almost admitting failure by admitting that something isn’t right.”

This article got me thinking about a six year boy named Mark. When he came to see me in my pediatric practice, his mother Dana’s face was tense and angry as she sat perched on the edge on the couch. Her son came easily into my office and was friendly and well related. He immediately settled in to play. I sat on the floor with him while I spoke with Dana. She had come to see me because he “never listens”. She said, her tone harsh and exasperated, “Tell me what to do so that I can make him listen.”

At the first visit when Dana came alone, she had given me a very detailed history of Mark’s difficulties and described frequent explosive scenes at home around such daily tasks as getting dressed. She had been to several pediatricians and specialists, none of whom had been able to help significantly with Mark’s behavior.

In reviewing his medical chart and all the previous evaluations, I noticed that Mark’s father had never been present. There was practically no mention of him. When I inquired, she said he traveled frequently and that yes, he had the same troubles dealing with Mark, perhaps even worse than her, as he tended to get angry more easily. When I scheduled our next appointment, I was sure to make it at a time when he could come. But she showed up without him, saying he had unexpectedly been called away on business.

This is often a warning sign to me. It may be easier to focus on one’s child’s behavior than to begin to acknowledge other large and seemingly unsolvable problems in a marriage. While Mark played quietly with the trains, Dana described his refusal that morning to come down for breakfast. Despite my best efforts to listen from a neutral place, I found myself feeling protective of Mark. There was so much aggression directed at him. I said to her, “It seems that this interaction was very upsetting to you.” “Oh no,” she replied, defensively backing away, “but I’m glad his father wasn’t home, because he really would have been furious.” I asked her to tell me more about this.

Perhaps it was the quiet room on the second floor, nestled in the trees. A brief respite from the constant challenge of Mark, who, for the moment, was content. But this small question unleashed a flood. I learned that much of the anger I felt in the room that day was actually directed towards her absent husband. She described years of conflict between them. He could fly into an explosive rage at the littlest provocation. She attributed her husband's behavior to his abusive father and his lack of a positive role model for managing anger. She revealed her suspicion that Mark was only reflecting in his behavior the rage that he experienced at home.

Now Dana could clearly see what needed to be done. With my encouragement, the next time she came with Mark’s father, Peter. The trust Dana had developed with me seemed to carry over to him. He spoke openly about his own abusive father. He became tearful as he described his difficulties controlling his feelings of anger. Once Dana and Peter acknowledged these problems, motivated by their desire to protect their son, they were able to get help for their troubled relationship.

In my experience, parents are often willing to locate a problem in their child rather than face the possibility of problems in their marriage. Perhaps this is because a spouse is, in a way, a primary attachment figure. A spouse is the person an adult most relies on for a sense of security and well being. Parents fill this role of primary attachment figure for a child. An adult may bring qualities from those original attachment relationships, some of which may have been less than healthy, to their relationship with their spouse.

Certainly marriage counselling takes time, money and a qualified therapist, three things that may be hard to come by. But perhaps the fear of loss of the person who provides a sense of safety and security may be an equal, if not larger, obstacle.

It is important for clinicians who evaluate children for "behavior problems" to recognize that couples are very reluctant to acknowledge difficulties in a marriage. Yet as was so clearly demonstrated with Mark, it is unfair to a child to locate the "problem" in a child when in fact it is in the marriage. We owe it to these children to support their parents efforts both to acknowledge marital conflict and to seek appropriate help.

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