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 research in child development 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.

Sunday, July 29, 2012

Sibling conflict: untangling the complexities

A number of years ago I was asked to see six-year old Sam for a second opinion after a local "ADHD expert" had diagnosed that disorder and written a prescription for Ritalin based on one visit with Sam and his mother.   My first visit had been with Sam, his four-year-old brother Jake, and their mother. At that time I learned that Sam's "behavior problems" occurred mostly in the form of conflict with his younger brother. Sam was "impossible," always provoking Jake, who had to follow along when family activities were disrupted by Sam's "difficult" behavior.

I was immediately struck, when I met with his parents together, at Sam's father's close physical resemblance.  Like Sam, he had a full head of curly red hair. He was silent and sullen for the first part of the visit while his wife unleashed a torrent of complaints about Sam. Interestingly, she looked like Jake, who was a handsome blond boy.

As I shifted my focus to Dad, and expressed interest in his experience of Sam's behavior, it immediately became clear that he was an unwilling partner in this evaluation. He had no concerns about Sam. "I was just like him as a kid" he said. Then things began to get complicated. I learned that Sam's father was temperamentally not only very much like Sam, but also shared many qualities with the maternal grandfather, with whom Sam's mother had a difficult relationship. The sibling conflict was actually a symptom of difficulties in the marriage, which were in turn related to relationships from the parent's past.

In almost every child I see for behavior problems, there is a similarly complex story in the background. Lest I feel tangled in an impossible web of multigenerational conflict, it is important to step back and focus on the task at hand, namely to evaluate this child, Sam.

My aim is simple. It is to help these parents to recognize Sam's "true self," to quote D. W. Winnicott. My task is to, in a sense, clear the brush of this complex tangle of relationships to enable parents to see Sam for who he is.

When qualities are placed in a child that actually belong to some other relationship, it is often out of parent's awareness, or to use the psychoanalytic term, "unconscious." When I participated in at a Parenting conference at Austen Riggs last weekend, I learned that most of the adult patients there, who struggle with serious mental illness, feel that they were born to play a role, in a sense robbing them of their own unique identity. It occurred to me at the conference, where I spoke about the Newborn Behavioral Observation system as a way to bring out a baby's unique characteristics at birth, that this intervention might offer a tool to prevent such a dynamic from being played out.

The beauty of working with young children is that it is possible set things in a better direction by clearing conflicts belonging to other relationships off the child.  Parents need to be given the space and time to tell their story to a nonjudgmental listener. This process may allow unspoken and even unconscious feelings to be brought to light. Once his caregivers recognize a child's true self,  he is free to develop in a healthy way.

In the case of Sam and Jake, once the conflict was put in its proper place, Sam's "difficult" behavior decreased. Interestingly, when his parents were less stressed by his behavior, tension in the marriage lessened, setting in place a positive cascade of change. Sam was, to use another therapy term, the "identified patient" in a larger family dynamic. If he had been medicated for his behavior symptoms, however, the full story might never have been brought to light.







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