June 19, 2009

The Dark Places

Everybody has dark places that they just don't want to go. Sometimes these places are physical locations that we can't avoid.

Evelyn is 9 and has asthma. Controlling her symptoms has been challenging, not because her asthma is so severe, but because her family is very disorganized. As with most chronic conditions, steady routines of preventive care can help to avoid serious episodes. On one Sunday, she was having particular difficulty, so I went to her home to check on her. She turned out basically to be OK and she and her family just needed some hands-on coaching to remind them when and how to use which medication.

A house call is a powerful tool, neither taught nor mentioned in medical training. I have learned a lot from them, and the information from experiencing a child's home is much more substantial than can be inferred from a brief history provided in an office visit. This is particularly true for chronic disease.

Evelyn was eager to show me her room. Her bed was completely hidden under an army of stuffed animals that covered it entirely. There were many clothes on the floor, some clean and some not. There was no door on her closet. She had a desk, which was cluttered with piles of books. Dust was thick everywhere. It looked like nobody in the family was a good housekeeper. I asked her, hinting at the stuffed animals, where her bed was. She pointed to the bed and added, “But I don't sleep there.”

She slept nearly every night on the sofa in the equally dusty living room. I asked, of course, why.

She was afraid of spiders, she explained, as if I were somehow inexplicably dense and couldn't see the obvious.

Evelyn knew there were cobwebs in the corners of her room, and her fear of spiders prevented her from turning off the light when she was in the room. The usual age for the start of specific phobias was about 7, and she said she'd been very afraid of them for a couple of years. She denied any specific traumatic experience, though.

Fear of spiders is one of the most common phobias, and it seems that this affects girls more frequently than boys. But phobias are very common, and we often are embarrassed by them and don't talk about them—we just plan our activities to avoid confronting them. So often when I diagnose an anxiety disorder, I find that the child has specific phobias they never told anyone about. They know that these phobic feelings are not shared by their friends, and sometimes they aren't even comfortable sharing with their parents. Even if the phobias aren't something that restricts their daily life, the child can feel deeply ashamed of what they know is an abnormal perception. So when I am talking to a child who I think might have an anxiety disorder, I always ask about phobias. And when a parent mentions to me that their child has not one but several phobias, I always will consider anxiety.

The key to her asthma control was getting her a low-dust place to sleep, so I offered to come and clean her room with her. She liked this idea and so did her mom. I told them to buy plastic storage bins big enough for clothes and toys, and asked her mother to sew a curtain-rod-to-floor washable curtain to use instead of a closet door. When I returned about a week later, all but one stuffed animal was in a bin. She was welcome to take all of them out whenever she liked, but she could only sleep with one. All the books went in a bin. The clothes went either into a laundry bag in the now-closed closet, or into a bin if clean. Evelyn herself was to take a damp sweeper/mop and dust her bare floor every day. I had a hidden purpose when I proposed this. Sure, it kept the dust level low in her room, which I hoped would help her asthma control. But it gave her control of the corners of her room. By cleaning them herself every day (they shouldn't get too dirty in just a day), she would be reminded that they are really clean, really empty, with no webs or spiders to lurk in the dark.

There was a lot of sneezing while we were cleaning the little room, but we ended up with a lot of dustable smooth surfaces (the floor, the desk, the lids on the bins) that could be kept clean with minimal effort. Within a few weeks, her asthma was much less of a problem. She was still afraid of spiders, but since she herself (with me there helping and protecting her) had cleaned out those dark corners, she could rest much easier in her own bed. I slept better too.

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