Being on vacation has led to a sparsity of blog posts, and now its full speed ahead with the book. I decided once again to borrow from fellow bloggers and post a few links. The first is to a parenting blog by child psychoanalyst Kerry Kelly Novick. This particular post, Wise parents a welcome sight on road trip offers an excellent demonstration of a parent holding a child's mind in mind.
Another is Reading the Baby's Mind by developmental psychologist Charles Fernyhough. Along with Elizabeth Meins, he is doing research that demonstrates the importance of parents thinking about their baby's mind in facilitating healthy emotional development.
A third, Small Steps by psychoanalyst Paul C. Hollinger offers an example of supporting a parent's efforts to reflect on the meaning of her child's behavior.
Friday, August 27, 2010
Tuesday, August 17, 2010
The Mess of ADHD Evaluation and Treatment
Two events today cause me to crash head-on into the terrible state of affairs that define ADHD diagnosis and treatment in our country. First, in my AAP SmartBrief, the daily listing I receive via email of important news stories related to pediatrics, I read this item Youngest in Class Get ADHD Label in USA today. The article states
A few hours after reading this article, I received a phone call from the office manager from the pediatric practice I recently left. As I have written about in my blog, I changed practices to focus on working with young children and their parents in the setting of a community health center. This was in part because I was struggling with the expectation, in keeping with the standard of care in pediatric treatment of ADHD, that I fill many,many prescriptions without any opportunity to understand the complex life experience of these children.
I was sure to refer every child I had been seeing to an appropriate provider. Many of them would be followed, in keeping with the standard of care in pediatrics, by the other primary care clinicians in the practice. Some, who I felt needed more intensive help, I referred to an excellent child psychiatrist in my community. Just before I left, I learned that she had a new policy that she would only see patients for medication evaluation if they were engaged in psychotherapy. I thought this policy was very wise.
One patient, the office manager called to tell me, was very unhappy with this plan. (details,as always, have been changed to protect privacy) "He's never been in therapy before," his irate mother apparently told the office manager. I had a vivid flashback. Mother and father at opposite ends of the room, tense and angry. A small, thin 9 year old boy slumped into the corner of the exam table nervously chewing his nails. As his parents argued about his "laziness" he seemed to want to disappear into the wall. At our last visit together, however, his parents agreed that things were perhaps more complex than simply inattentive ADHD. They accepted my referral to the psychiatrist.
But apparently they had a change of heart. Just getting the prescription filled by their pediatrician was their preference. "He doesn't need any therapy." his mother said. Perhaps he doesn't. But I can be sure of what he does need. He needs someone to listen to him.
I am sad for these many children whose voices are not heard. It made me agitated to think about the state of affairs in children's mental health care that has led to a situation where countless children are mislabeled, their complex life experience tucked into vastly oversimplified categories.
Now I'm going to take a deep breath and go back to working on my book. In this task I immerse myself in describing a model of child development that acknowledges the importance of understanding children's feelings from the moment they are born. By letting children's voices be heard and recognizing the meaning of their behavior, we can facilitate their healthy emotional development. I can already feel my blood pressure going down!
Kids who are the youngest in their grades are 60% more likely to be diagnosed with ADHD than the oldest children, according to a study out today from Michigan State University, given exclusively to USA TODAY. A second study, by researchers at North Carolina State University and elsewhere, came to similar conclusions. Both are scheduled for publication in the Journal of Health Economics.In my previous job,when the majority of my work consisted of seeing children who had been referred for "evaluation of ADHD" I commonly encountered children who were having their first structured school experienced. Many were among the youngest in their class. They were described as "impulsive." They found difficult to sit at circle time, and unfathomable to sit at a desk to do a written assignment. Yet parents would frequently tell me that the teacher had confided that while she wasn't supposed to make diagnoses, she was sure this child must have ADHD. The findings reported in this article confirm my suspicion that for many of these "ADHD evaluations" referred to me, it was the environment that didn't fit the child, rather than that the child had a "problem."
A few hours after reading this article, I received a phone call from the office manager from the pediatric practice I recently left. As I have written about in my blog, I changed practices to focus on working with young children and their parents in the setting of a community health center. This was in part because I was struggling with the expectation, in keeping with the standard of care in pediatric treatment of ADHD, that I fill many,many prescriptions without any opportunity to understand the complex life experience of these children.
I was sure to refer every child I had been seeing to an appropriate provider. Many of them would be followed, in keeping with the standard of care in pediatrics, by the other primary care clinicians in the practice. Some, who I felt needed more intensive help, I referred to an excellent child psychiatrist in my community. Just before I left, I learned that she had a new policy that she would only see patients for medication evaluation if they were engaged in psychotherapy. I thought this policy was very wise.
One patient, the office manager called to tell me, was very unhappy with this plan. (details,as always, have been changed to protect privacy) "He's never been in therapy before," his irate mother apparently told the office manager. I had a vivid flashback. Mother and father at opposite ends of the room, tense and angry. A small, thin 9 year old boy slumped into the corner of the exam table nervously chewing his nails. As his parents argued about his "laziness" he seemed to want to disappear into the wall. At our last visit together, however, his parents agreed that things were perhaps more complex than simply inattentive ADHD. They accepted my referral to the psychiatrist.
But apparently they had a change of heart. Just getting the prescription filled by their pediatrician was their preference. "He doesn't need any therapy." his mother said. Perhaps he doesn't. But I can be sure of what he does need. He needs someone to listen to him.
I am sad for these many children whose voices are not heard. It made me agitated to think about the state of affairs in children's mental health care that has led to a situation where countless children are mislabeled, their complex life experience tucked into vastly oversimplified categories.
Now I'm going to take a deep breath and go back to working on my book. In this task I immerse myself in describing a model of child development that acknowledges the importance of understanding children's feelings from the moment they are born. By letting children's voices be heard and recognizing the meaning of their behavior, we can facilitate their healthy emotional development. I can already feel my blood pressure going down!
Thursday, August 12, 2010
Comment on MA Enforcement of 8 Week Maternity Leave
It is not until about eight weeks of age that an infant has a fully developed capacity for mutual gaze. Then a baby looks directly into his mother’s eyes, while she, in turn, reflects back this loving gaze, cooing softly in response to her baby’s earliest communication. When a mother looks at a baby in a way that communicates with him, not with words but with feelings, “I understand you,” he begins to recognize himself, both physically and psychologically. He begins to be able to regulate his feelings. This mutual gaze, literally and figuratively being “seen,” actually facilitates the development of the baby’s brain.
The Massachusetts Supreme Judicial Court now has proposed to interrupt this newly emerging dance of co-regulation by ruling this week that woman workers are entitled to only eight weeks of maternity leave. This ruling applies only to women whose maternity falls under state law, and differs from the wiser federal Family and Medical Leave Act of 1993 which provides up to 12 weeks of unpaid leave and job protection.
Research at the interface of neuroscience and infant development is offering great insight into how mutual gaze actually grows the brain. Our knowledge about early brain development is derived from a combination of detailed video observations of mother-infant interaction and studies of the brain known as functional MRI. These imaging studies can actually see which parts of the brain are responsible for what behaviors. This research has shown that healthy wiring of the brain is contingent on attuned responses of caregivers. This attunement is not only in gaze but in touch, sound of voice and facial expressiveness.
When baby is born, the amygdala, the lower center of the brain that responds to fear and stress, is fully formed. The amygdala connects directly to the hypothalamus, which in turn connects directly with the parts of the body, like the adrenals, responsible for the release of hormones that lead us to experience the physical sensations of stress.
At about 2 months of age, another part of the brain known as the medial prefrontal cortex(MPC) begins to develop. It serves to regulate and control the smoke alarm. When a mother engages in this dance of co-regulation with her baby, she is wiring his brain, helping the fibers of the MPC to grow. The MPC continues to develop well into a person’s twenties. An infant’s brain, however, doubles in weight in the first year of life. A lot of wiring goes on in the third month.
When these connections are not well developed, intense emotions are not regulated. In the face of difficult feelings a person may be flooded with stress hormones. He may become overwhelmed by feelings of rage, anxiety or sadness.
Interesting research by Dr. Hilary Blumberg at Yale offers food for thought. Using MRI, she has found that adolescents with bipolar disorder have structural abnormalities in the amygdala and underdeveloped prefrontal cortex. She points to hopeful research using medication to rewire the brain to treat the emotional dysregulation characteristic of the disorder.
This is not to say that stressed early relationships inevitably lead to psychopathology. But doesn’t it make sense to do all that we can to insure that brains are wired well in the first place?
Important changes happen not only in an infant’s brain but also in a mother’s brain in her baby’s third month of life. When a mother sees her loving gaze reflected back at her from her baby, she develops a sense of competence. This trust in herself is critical in helping her face the many challenges ahead in her role as parent.
Certainly a mother who works full time is well able to facilitate her child’s healthy development if she is receiving appropriate support. But even under the best of circumstances, returning to work means that a mother will be stressed. Offering her the option for a full three months of what D.W. Winnicott, pediatrician turned psychoanalyst, referred to as “primary maternal preoccupation” seems an important and wise investment in the next generation.
The Massachusetts Supreme Judicial Court now has proposed to interrupt this newly emerging dance of co-regulation by ruling this week that woman workers are entitled to only eight weeks of maternity leave. This ruling applies only to women whose maternity falls under state law, and differs from the wiser federal Family and Medical Leave Act of 1993 which provides up to 12 weeks of unpaid leave and job protection.
Research at the interface of neuroscience and infant development is offering great insight into how mutual gaze actually grows the brain. Our knowledge about early brain development is derived from a combination of detailed video observations of mother-infant interaction and studies of the brain known as functional MRI. These imaging studies can actually see which parts of the brain are responsible for what behaviors. This research has shown that healthy wiring of the brain is contingent on attuned responses of caregivers. This attunement is not only in gaze but in touch, sound of voice and facial expressiveness.
When baby is born, the amygdala, the lower center of the brain that responds to fear and stress, is fully formed. The amygdala connects directly to the hypothalamus, which in turn connects directly with the parts of the body, like the adrenals, responsible for the release of hormones that lead us to experience the physical sensations of stress.
At about 2 months of age, another part of the brain known as the medial prefrontal cortex(MPC) begins to develop. It serves to regulate and control the smoke alarm. When a mother engages in this dance of co-regulation with her baby, she is wiring his brain, helping the fibers of the MPC to grow. The MPC continues to develop well into a person’s twenties. An infant’s brain, however, doubles in weight in the first year of life. A lot of wiring goes on in the third month.
When these connections are not well developed, intense emotions are not regulated. In the face of difficult feelings a person may be flooded with stress hormones. He may become overwhelmed by feelings of rage, anxiety or sadness.
Interesting research by Dr. Hilary Blumberg at Yale offers food for thought. Using MRI, she has found that adolescents with bipolar disorder have structural abnormalities in the amygdala and underdeveloped prefrontal cortex. She points to hopeful research using medication to rewire the brain to treat the emotional dysregulation characteristic of the disorder.
This is not to say that stressed early relationships inevitably lead to psychopathology. But doesn’t it make sense to do all that we can to insure that brains are wired well in the first place?
Important changes happen not only in an infant’s brain but also in a mother’s brain in her baby’s third month of life. When a mother sees her loving gaze reflected back at her from her baby, she develops a sense of competence. This trust in herself is critical in helping her face the many challenges ahead in her role as parent.
Certainly a mother who works full time is well able to facilitate her child’s healthy development if she is receiving appropriate support. But even under the best of circumstances, returning to work means that a mother will be stressed. Offering her the option for a full three months of what D.W. Winnicott, pediatrician turned psychoanalyst, referred to as “primary maternal preoccupation” seems an important and wise investment in the next generation.
Thursday, August 5, 2010
How to Grow a Child's Brain
Last week I took an amazing course at the Cape Cod Institute. The course, taught by Francine Lapides, was entitled "Keeping the Brain in Mind." Over the week, extensive evidence was offered to show how a parent's attunement with her child's emotional experience, or her ability to, as I have referred to elsewhere in this blog as "holding her child's mind in mind," leads to a capacity for emotional regulation and healthy emotional development at the level of structure and biochemistry of the brain.
At the end of the course, I rewrote a clinical vignette from an earlier blog post, Holding a Child in Mind, incorporating the language from the course. A very brief discussion of the structures of the brain responsible for regulating emotions will be necessary to make sense of the new piece, which follows below.
The medial prefrontal cortex(MPC), which is made up of the orbitofrontal cortex and anterior cingulate gyrus, is primarily responsible for emotional regulation. When a person has a well developed MPC he experiences a sense of emotional balance. He can feel things strongly without being thrown into a state of chaos.
The amygdala, the structure referred to by trauma researcher Bessel van der Kolk as the “smoke alarm of the brain,”, connects directly to the hypothalamus, which in turn connects directly with the parts of the body, like the adrenals, responsible for the release of these stress hormones, the hormones that lead us to experience the physical sensations of stress. Lapides describes how the medial prefrontal cortex, by virtue of its location, wrapped around the amygdala, literally hugs the amygdala. It serves to regulate and control the smoke alarm.
When these connections are not well developed, intense emotions are not regulated. In the face of difficult feelings a person may be flooded with stress hormones. He may become completely overwhelmed and unable to function. Thus in the face of fear, for example, with a well developed MPC, a person will experience the feeling, but his hormonal response will be turned down by the MPC so that he is not overwhelmed or paralyzed.
If, on the other hand, he does not have a well developed MPC, the amygdala will go off and he will be flooded with fear that he cannot manage. When the amygdala acts unopposed in this way, it impairs a person’s ability to make use of the higher cortical centers of the brain, meaning that he cannot think clearly in the face of overwhelming distress. In fact, the amygdala is overactive in PTSD and all anxiety disorders.
When a parent gazes into her baby’s eyes, she literally promotes the growth of her baby’s brain, helping it to be wired for a secure sense of self. The MPC has been referred to as the “observing brain.” It is where our sense of self lies. When a mother looks at a baby in a way that communicates with him, not with words but with feelings, “I understand you,” he begins to recognize himself, both physically and psychologically. This mutual gaze, literally and figuratively being “seen,” actually facilitates the development of the baby’s brain. As the MPC matures in this kind of secure loving relationship, the brain is wired in a way that will serve him well for the rest of his life. He will be able to think clearly and to regulate feelings in the face of stressful experiences.
The story of Sam and Jane illustrates the way in which supporting a parent’s efforts to hold her child in mind may actually promote the healthy development and growth of her child's brain.
Sam burst into the office, a two year old wild little 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, and seemingly unable to engage with anything. His mother had brought him to see me in my pediatric practice because “he hits me, has explosive tantrums and I can’t take him anywhere.”
Jane sank into the couch in a way that suggested she was feeling discouraged and dejected in her role as mother. She needed to be heard. 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. Things had not been easy for her. Sam’s father had abused her and was no longer involved in thier lives. Jane 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, but seemed to reserve 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. However, as she opened up and shared more of these difficult, painful feelings with me, an interesting transformation occurred. Jane’s whole body relaxed and she leaned forward on the couch toward Sam. Sam, in turn, began to engage in more focused play. Jane 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 pleasure and relief were palpable in the room.
Sam began to engage her in his play, and to communicate with her. It seemed as if the very act of being held in mind by his mother served to calm him down. He could feel her thinking about him. She looked directly into his face, speaking with him in a soft intimate way. They were engaged in a private dance. As I observed this scene, I literally felt as if I was watching Jane growing Sam’s brain. By holding him in a loving way that reflected her recognition of him, I thought that I could see the projections forming from the MPC and reaching down to hug his amygdala.
At the end of the course, I rewrote a clinical vignette from an earlier blog post, Holding a Child in Mind, incorporating the language from the course. A very brief discussion of the structures of the brain responsible for regulating emotions will be necessary to make sense of the new piece, which follows below.
The medial prefrontal cortex(MPC), which is made up of the orbitofrontal cortex and anterior cingulate gyrus, is primarily responsible for emotional regulation. When a person has a well developed MPC he experiences a sense of emotional balance. He can feel things strongly without being thrown into a state of chaos.
The amygdala, the structure referred to by trauma researcher Bessel van der Kolk as the “smoke alarm of the brain,”, connects directly to the hypothalamus, which in turn connects directly with the parts of the body, like the adrenals, responsible for the release of these stress hormones, the hormones that lead us to experience the physical sensations of stress. Lapides describes how the medial prefrontal cortex, by virtue of its location, wrapped around the amygdala, literally hugs the amygdala. It serves to regulate and control the smoke alarm.
When these connections are not well developed, intense emotions are not regulated. In the face of difficult feelings a person may be flooded with stress hormones. He may become completely overwhelmed and unable to function. Thus in the face of fear, for example, with a well developed MPC, a person will experience the feeling, but his hormonal response will be turned down by the MPC so that he is not overwhelmed or paralyzed.
If, on the other hand, he does not have a well developed MPC, the amygdala will go off and he will be flooded with fear that he cannot manage. When the amygdala acts unopposed in this way, it impairs a person’s ability to make use of the higher cortical centers of the brain, meaning that he cannot think clearly in the face of overwhelming distress. In fact, the amygdala is overactive in PTSD and all anxiety disorders.
When a parent gazes into her baby’s eyes, she literally promotes the growth of her baby’s brain, helping it to be wired for a secure sense of self. The MPC has been referred to as the “observing brain.” It is where our sense of self lies. When a mother looks at a baby in a way that communicates with him, not with words but with feelings, “I understand you,” he begins to recognize himself, both physically and psychologically. This mutual gaze, literally and figuratively being “seen,” actually facilitates the development of the baby’s brain. As the MPC matures in this kind of secure loving relationship, the brain is wired in a way that will serve him well for the rest of his life. He will be able to think clearly and to regulate feelings in the face of stressful experiences.
The story of Sam and Jane illustrates the way in which supporting a parent’s efforts to hold her child in mind may actually promote the healthy development and growth of her child's brain.
Sam burst into the office, a two year old wild little 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, and seemingly unable to engage with anything. His mother had brought him to see me in my pediatric practice because “he hits me, has explosive tantrums and I can’t take him anywhere.”
Jane sank into the couch in a way that suggested she was feeling discouraged and dejected in her role as mother. She needed to be heard. 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. Things had not been easy for her. Sam’s father had abused her and was no longer involved in thier lives. Jane 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, but seemed to reserve 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. However, as she opened up and shared more of these difficult, painful feelings with me, an interesting transformation occurred. Jane’s whole body relaxed and she leaned forward on the couch toward Sam. Sam, in turn, began to engage in more focused play. Jane 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 pleasure and relief were palpable in the room.
Sam began to engage her in his play, and to communicate with her. It seemed as if the very act of being held in mind by his mother served to calm him down. He could feel her thinking about him. She looked directly into his face, speaking with him in a soft intimate way. They were engaged in a private dance. As I observed this scene, I literally felt as if I was watching Jane growing Sam’s brain. By holding him in a loving way that reflected her recognition of him, I thought that I could see the projections forming from the MPC and reaching down to hug his amygdala.
Thursday, July 29, 2010
Drugging Children to Sleep
A recent study published in the journal Sleep Medicine revealed that most child psychiatrists prescribe medication for sleep at least once a month, despite the fact that no sleep medications are approved for use in children. The study was funded by Sanofi-Aventis, makers of Ambien.
Managing sleep is one of the greatest challenges of being a parent. It represents the first major separation and can be fraught with complex ambivalent feelings. As children get older, battles for control often play out around sleep. Most significant behavior problems are associated with major emotional dysregulation. Calming down sufficiently to fall asleep may be very difficult. Sleep deprivation, in turn, exacerbates emotional dysregulation. Children learn to regulate emotions in relationships with the people who care for them. Efforts to help children regulate emotions must focus on supporting these relationships.
The trend towards medicating away these complex sleep problems, rather than getting at the root cause, is, in my opinion, quite disturbing.
Consider the following story. I first saw Charles when he was three. His mother, Anne, described terribly disrupted sleep (details, as always, have been changed to protect privacy.) He would wake multiple times at night and scream for his mother who was, in fact sleeping right next to him. Even as she held him he would continue to thrash and cry out. His behavior was so wild and out of control that his parents feared he was having a seizure. To reassure both them and myself, I sent him to a neurologist, who after an exam and EEG, declared that there was "nothing wrong." He prescribed a tricyclic anti-depressant.
His mother threw the pamphlet about the drug in the garbage and arrived at my office horrified, yet ready to do the difficult work addressing this problem in a meaningful way entailed.
Charles had been a dysregulated baby since birth. In addition, as we came to understand in or time together, Anne had been abandoned by her own mother, who had severe mental illness. Not only had she been left alone in her crib as an infant, but as she grew up, her mother had not been emotionally available to her, though she had provided physical care. Anne recognized that in order to be emotionally available to Charles in the way he needed, she would have to address her own trauma.
With time and lots of hard work, Anne came to understand that Charles' neediness at bedtime was so disturbing to her that in a sense she was not there emotionally, though physically she was present. Once she felt supported and understood, she was able to be emotionally present with Charles at bedtime as well as other times that were difficult for him. Gradually the sleep disruption subsided. By the time Charles was in Kindergarten he was sleeping well and thriving in school.
There may well be a role for short term use of sleep medication for children in situations where families are spiralling dangerously out of control. But routine use, without careful thought, as was the case when the neurologist prescribed a tricyclic for Charles, represents a risky oversimplification of often very complex problems.
Managing sleep is one of the greatest challenges of being a parent. It represents the first major separation and can be fraught with complex ambivalent feelings. As children get older, battles for control often play out around sleep. Most significant behavior problems are associated with major emotional dysregulation. Calming down sufficiently to fall asleep may be very difficult. Sleep deprivation, in turn, exacerbates emotional dysregulation. Children learn to regulate emotions in relationships with the people who care for them. Efforts to help children regulate emotions must focus on supporting these relationships.
The trend towards medicating away these complex sleep problems, rather than getting at the root cause, is, in my opinion, quite disturbing.
Consider the following story. I first saw Charles when he was three. His mother, Anne, described terribly disrupted sleep (details, as always, have been changed to protect privacy.) He would wake multiple times at night and scream for his mother who was, in fact sleeping right next to him. Even as she held him he would continue to thrash and cry out. His behavior was so wild and out of control that his parents feared he was having a seizure. To reassure both them and myself, I sent him to a neurologist, who after an exam and EEG, declared that there was "nothing wrong." He prescribed a tricyclic anti-depressant.
His mother threw the pamphlet about the drug in the garbage and arrived at my office horrified, yet ready to do the difficult work addressing this problem in a meaningful way entailed.
Charles had been a dysregulated baby since birth. In addition, as we came to understand in or time together, Anne had been abandoned by her own mother, who had severe mental illness. Not only had she been left alone in her crib as an infant, but as she grew up, her mother had not been emotionally available to her, though she had provided physical care. Anne recognized that in order to be emotionally available to Charles in the way he needed, she would have to address her own trauma.
With time and lots of hard work, Anne came to understand that Charles' neediness at bedtime was so disturbing to her that in a sense she was not there emotionally, though physically she was present. Once she felt supported and understood, she was able to be emotionally present with Charles at bedtime as well as other times that were difficult for him. Gradually the sleep disruption subsided. By the time Charles was in Kindergarten he was sleeping well and thriving in school.
There may well be a role for short term use of sleep medication for children in situations where families are spiralling dangerously out of control. But routine use, without careful thought, as was the case when the neurologist prescribed a tricyclic for Charles, represents a risky oversimplification of often very complex problems.
Tuesday, July 27, 2010
Toddlerhood, Teenagers and Winnicott's Wisdom
Psychoanalyst Peter Blos describes the "second individuation process of adolescence," referring to the way in which adolescence shares many qualities with toddlerhood in terms of developmental tasks. Sometimes when I listen to parents describe their struggles with their teenage children, I have an image of trying to contain a person, often bigger than themselves, with advanced thinking skills. The tantrums of adolescence involve not thrashing arms and legs, but rather words, often cruel and vicious words.
Once again D. W.Winnicott, pediatrician turned psychoanalyst, comes through with some words of wisdom that I believe can serve well to guide a parent through this challenging and often tumultuous period. He writes, in his book Playing and Reality
But then over some little thing, Pam couldn’t even remember what it was when she told me the story in my office, Eva had exploded with a burst of venomous rage. “You never think about my feelings,” she’d started with, calmly enough. But when Pam tried to get her to explain what she meant, Eva’s anger only increased. Vicious insults started flying at her. Caught off guard, Pam found herself becoming defensive.
Their discussion escalated into a shouting match as they quickly paid their bill and left the restaurant. Pam, in an effort to get home without being in an accident, stopped talking to Eva, who, she felt, was becoming increasingly irrational in her verbal assault on her mother. Pam’s silence only further enraged Eva and she screamed at her mother, who held tight to the wheel, hands shaking.
They made it home and immediately went their separate ways. Pam called her husband. As he was not the recipient of the full intensity of Eva’s distress he was able to support his wife and help her to calm down. Eva closed the door to her room and called her boyfriend. Several hours later Eva emerged from her room. “I’m sorry, Mom, she said. I’ve been feeling so much stress trying to balance work and friends and Chris.” “I understand that this is a very difficult time for you,” Pam had replied. “But," she went on to say, "it is not acceptable for you to speak to me the way you did.”
Pam was feeling beaten down by these repeated interactions with her daughter. She had experienced what she described as a highly traumatic transition to adolescence. When she was 16, her parents divorced. She recalled seeking comfort from her mother, who was so bereft about her own circumstances that she was totally unavailable for any meaningful emotional support. Pam had descended into a serious depression and only many years of therapy had gotten her to a place where she could have her own family.
While she had been able to negotiate the prior stages of development with Eva, the intensity of feelings directed at her from her teenage daughter sometimes was too much to bear. I told Pam that she was doing just what she needed to do, namely withstand the full intensity of her daughters feelings , both the negative and positive ones, yet set limits on her behavior. Pam needed to show Eva that she loved and supported her daughter, but would not allow her destroy her mother.
Winnicott offers a hopeful look at the future if a parent has withstood the “long tussle”of adolescence. He writes, also in Playing and Reality
Once again D. W.Winnicott, pediatrician turned psychoanalyst, comes through with some words of wisdom that I believe can serve well to guide a parent through this challenging and often tumultuous period. He writes, in his book Playing and Reality
If you do all you can to promote personal growth in your offspring, you will need to be able to deal with startling results. If your children find themselves at all they will not be contented to find anything but the whole of themselves, and that will include the aggression and destructive elements in themselves as well as the elements that can be labeled loving. There will be this long tussle which you will need to survive.This idea resonated with Pam, mother of 16 year old Eva, who had come to see me for a consultation. She described the following scene. Pam and Eva had planned to have a nice lunch together. Eva was busy at school and had developed an increasingly serious relationship with her boyfriend, Chris. Eva and Pam had always been close and both eagerly anticipated this opportunity to spend a bit of time together. Things started off well enough. Eva excitedly told her mother about the latest social happenings at school and about a paper she was working on.
But then over some little thing, Pam couldn’t even remember what it was when she told me the story in my office, Eva had exploded with a burst of venomous rage. “You never think about my feelings,” she’d started with, calmly enough. But when Pam tried to get her to explain what she meant, Eva’s anger only increased. Vicious insults started flying at her. Caught off guard, Pam found herself becoming defensive.
Their discussion escalated into a shouting match as they quickly paid their bill and left the restaurant. Pam, in an effort to get home without being in an accident, stopped talking to Eva, who, she felt, was becoming increasingly irrational in her verbal assault on her mother. Pam’s silence only further enraged Eva and she screamed at her mother, who held tight to the wheel, hands shaking.
They made it home and immediately went their separate ways. Pam called her husband. As he was not the recipient of the full intensity of Eva’s distress he was able to support his wife and help her to calm down. Eva closed the door to her room and called her boyfriend. Several hours later Eva emerged from her room. “I’m sorry, Mom, she said. I’ve been feeling so much stress trying to balance work and friends and Chris.” “I understand that this is a very difficult time for you,” Pam had replied. “But," she went on to say, "it is not acceptable for you to speak to me the way you did.”
Pam was feeling beaten down by these repeated interactions with her daughter. She had experienced what she described as a highly traumatic transition to adolescence. When she was 16, her parents divorced. She recalled seeking comfort from her mother, who was so bereft about her own circumstances that she was totally unavailable for any meaningful emotional support. Pam had descended into a serious depression and only many years of therapy had gotten her to a place where she could have her own family.
While she had been able to negotiate the prior stages of development with Eva, the intensity of feelings directed at her from her teenage daughter sometimes was too much to bear. I told Pam that she was doing just what she needed to do, namely withstand the full intensity of her daughters feelings , both the negative and positive ones, yet set limits on her behavior. Pam needed to show Eva that she loved and supported her daughter, but would not allow her destroy her mother.
Winnicott offers a hopeful look at the future if a parent has withstood the “long tussle”of adolescence. He writes, also in Playing and Reality
Your rewards come in the richness that may gradually appear in the personal potential of this or that boy or girl. And if you succeed you must be prepared to be jealous of your children who are getting better opportunities for personal development than you had yourselves. You will feel rewarded if one day your daughter asks you to do some baby-sitting for her, indicating thereby that she thinks you may be able to do this satisfactorily; or if your son wants to be like you in some way, or falls in love with a girl you would have liked yourself, if you had been younger. Rewards come indirectly. And of course you know you will not be thanked.
Monday, July 19, 2010
Thoughts on a Toddler's Declaration of "Mine"
As a child makes moves to assert his independence, he begins to test the limits of what he can and cannot do. Limit setting is not only about controlling your child’s behavior. It is about teaching the essential life skills of frustration tolerance, impulse control and emotional regulation. Setting limits helps children learn to manage healthy aggression.
“Mine” is favorite word of most toddlers. This word represents not greed, but rather joy in a newly emerging sense of self. Toddlers delight in their expanding language and motor skills and the power these skills give them in the world. Recently I was visiting a friend whose 20 month old son described everything he touched as "mine." Then he proclaimed happily, "Run!" as he toddled back and forth across the kitchen floor.
But 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 your child 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.
Feeling angry at such an assault is a natural reaction. Yet it is important to contain your own response and to recognize the two year old meaning of his behavior. What he needs from you at that moment is the assurance that you accept his feelings but that you will help him to contain and manage his rage. This might be in the form of a firm statement of “no hitting” or even a brief time out.
A toddler on a Youtube video who declares to his mother, “I love you but I don’t like you,” offers an example of the fact that intense but opposite feelings are a healthy part of any passionate relationship. John Bowlby has written extensively on this subject. His ideas are well summarized by Miriam Steele when she writes: ‘What distinguishes healthy individuals from unhealthy individuals is the extent to which the inevitable conflict between feelings of love and hate, often directed towards the same person, are controlled, regulated and so resolved. For children, Bowlby tells us this will develop naturally if young children have the loving company of their parents who put up with outbursts of hostility by showing that they are not afraid of hatred and conveying a belief that it can be contained and controlled.”
“Mine” is favorite word of most toddlers. This word represents not greed, but rather joy in a newly emerging sense of self. Toddlers delight in their expanding language and motor skills and the power these skills give them in the world. Recently I was visiting a friend whose 20 month old son described everything he touched as "mine." Then he proclaimed happily, "Run!" as he toddled back and forth across the kitchen floor.
But 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 your child 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.
Feeling angry at such an assault is a natural reaction. Yet it is important to contain your own response and to recognize the two year old meaning of his behavior. What he needs from you at that moment is the assurance that you accept his feelings but that you will help him to contain and manage his rage. This might be in the form of a firm statement of “no hitting” or even a brief time out.
A toddler on a Youtube video who declares to his mother, “I love you but I don’t like you,” offers an example of the fact that intense but opposite feelings are a healthy part of any passionate relationship. John Bowlby has written extensively on this subject. His ideas are well summarized by Miriam Steele when she writes: ‘What distinguishes healthy individuals from unhealthy individuals is the extent to which the inevitable conflict between feelings of love and hate, often directed towards the same person, are controlled, regulated and so resolved. For children, Bowlby tells us this will develop naturally if young children have the loving company of their parents who put up with outbursts of hostility by showing that they are not afraid of hatred and conveying a belief that it can be contained and controlled.”
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