January 19, 2010

Hurting Mommy

I’m a worrier.  I worry about the patients I see and their families.  It comes with the job, I guess.  After all, part or much of a doctor’s job is to see people when they are sick or otherwise out of sorts, and try and make it better.  Make them better.  Maybe fix something that’s broken.  So I suppose it’s natural enough to worry about the things I can’t or don’t know how to fix.

Almost a year ago, I wrote about a toddler who couldn’t stop hitting mommy.  I could frame the situation in a logical way, since a new baby had just joined the family.  I thought that helping the mother see my interpretation of what was going on would relieve her of her feeling of failure as a parent, and it would give us a logical path for intervention.  It did on both counts.  I suggested that she spend extra time with the older sibling, on a rigidly scheduled basis so that the child could come to depend on the attention, rather than feel she had to fight for it.  It was insightful and helpful, and it worked.

I reviewed that post before starting this one.  At the bottom, in a smaller font, I provided a hedge against anybody thinking that I claimed having a magic formula to child behavior that works with everybody.  I’m glad to say that despite being one of the go-to people around here for difficult kids, I’ve only seen a very few who really seemed to like being difficult.

Albert came to the office today with his mother, to say goodbye.  He’s 30-months now, and he’s big for his age.  A year ago, when his mother first brought him, she cried easily.  She asked me how to manage him without hitting him.  I listened carefully to the situation she described.  Having recently moved here from out of state, she was isolated without friends or relatives.  She joined various parent/child groups.  Everyone was very nice, she said, but her little boy was so aggressive with the other children that the other parents didn’t want to get together with her.  She was alone with him all day, every day.  His father worked long hours at the new job, and came home late.  He had grown up in another country, in another culture, and didn’t think there was a problem.  Whenever he played with Albert, the child was always happy and active.  He told his wife explicitly that if there were a problem, it must be her, since Albert was just fine when he was with his dad.  Today, at 2 ½, I’m not really sure how much dad has been with him alone.  I have never met the man.

(OK, there’s obviously more than a child behavior issue here.  One of the many advantages of the conventional method of providing medical services (like at my own doctor:  6 minutes after 50 minutes of waiting; I get to ask maybe one question before the guy is out the door heading for the next patient; nothing is explained; often no exam of any kind takes place; I’m not sure he knows my name) is that the doctor can remain completely unconnected to the patient.  Time, or the lack of it, is a great insulator between people.  I spent hours with this mother and child over the last year.  She did better, she felt better.  I just couldn’t fix the structural issues of her life.  But I worried about her.)

My exam rooms have toys in them.  I have heard about—no, I have also seen—pediatric offices that don’t have toys in the rooms.  While it’s certainly less to keep clean, it seems to send a message.  Albert was getting bored quickly as his mom and I talked.  For just such occasions, I have a small inventory of double-secret toys, which often will engage even a finicky kid’s interest.  As any good magician will tell you, the patter is more important than it appears.  I make a show of reluctantly taking out my special and treasured toys.  Today it was a battery-driven hamster in a plastic ball.  Nicely designed, the ball’s relationship with the driving wheels of the hamster were asymmetric enough to redirect the device if it ran in to an obstacle.  In this way, it would keep going unpredictably until the batteries ran out (yes, I use rechargeables).

Another stroke of Dr. Wolffe magic!  Albert was completely enthralled for...maybe a couple of minutes.
When kids his age get bored, they ask for something, they whine about stuff, they interrupt.  Albert picked up the little gizmo and threw it to the floor as hard as he could.  The plastic sphere, which is designed to come apart in order to turn the hamster on and off, came apart.  I picked up the separated (not broken) sphere to put it back together for him.  Angrily, he tried to pull it out of my hands.  Hold on, I said, I’m trying to put it together.  He looked really mad and then, as hard as he could, hit his mother. 

This was new, even to me.  “Don’t hit your mother!” I said in my most serious voice.  He kept trying to strike her, but she deflected his blows.  He smoothly moved his head to her leg and started to bite her.  “NO!”  I said and physically lifted him to the other side of the small room and placed him on the floor.  He looked at me coldly, nearly expressionless.  He turned to his mother and started crying, sort of.  He needs your comfort, I told her, and she went to pick him up.  He started hitting her again.  “You can’t allow him to hit you.  Or hit anybody,” I said.  We started to talk about hitting.  He went to the little container of stuffed animals and one by one took them out and threw them at his mother’s head.

I need to stop this story, since I know his mom will read it and I don’t want to hurt her feelings.  She’s a smart, warm person who is not incompetent as a parent.  I respect her and like her.  My extensive experience with difficult children reinforces my reluctance to walk a day in her shoes.

Does it tell you something that the child hit mom when he was frustrated with me?  Most kids, even at this age, are socialized enough to keep their most egregious behavior out of the view of strangers.  I don’t believe he could think that hitting his mother was acceptable, and certainly not in front of me.  That he felt completely at ease about it is kind of chilling.  This was not about attention, not about having to share a parent with a new baby sibling.  He had certainly come to take mom for granted, since he knew she was going to be there with him no matter what he did.  But it bothers me that he kept pushing the envelope in this difficult, aggressive direction.  I worry that it’s not a typical instinct.

For his mother, I think there are guidelines that generally apply:
  • Be the grown-up.
  • If you let your child hurt you, you are permitting him to hurt others.
  • Is this what you want your kid to be?  (The nonsense that pop psychology projected onto bullies for decades was that they suffered as much as the victims, and had low self-esteem.  That is and has always been crap.  In fact, the latest research on bullies confirms what I thought when I was in elementary school (and medical school)—they are happy, and have high self-esteem. ) 

At Albert’s age, the key to extinguishing a problem behavior is immediate disengagement and feedback.  Don’t punish him—he won’t remember the transgression and will simply interpret your punishment as arbitrary and mean on your part.  This can lead to an escalating problem.  A dramatic NO! or brief sentence will do.  No hitting! or No kicking!  Then remove the child from the activity.  If they do it again, remove again with the same brief message.  Don’t interact with the child or engage in conversation, don’t lecture the kid.  It’s not supposed to be fun.  But as soon as the tide turns, you need to be there, as ever, with open arms.  Every child can learn to get mom’s attention in a better way.

Ironically enough, I think that part of parenthood is loving our children despite the many little ways they hurt us, whether intentionally or not. 

Albert and his family are moving away, close to his mom’s family.  I really hope that she will get a lot more support and help.  But I’m a worrier, and I will worry about her.  I hope she stays in touch.


  1. I have a kid that used to bite me when she was stressed. It was a problem that lasted until she was well over 2. At one point my arm looked like it had leopard spots because it was so bruised. I had no way to understand how to deal with it. I was a first time parent... When she was really little I just thought that if she was stressed and this helped then it a small price to pay for her being comforted. But eventually, as she got bigger, it really hurt and it was a situation that was really hard to figure out how to get out of. It was a situation that was out of control but that I had neither the experience nor the perspective to think my way out of. I got some "old wives tale" kind of advice and actually bit my 2 year old back. I'm still mortified.
    Second kid comes along and she only bit once. The first time it happened I called you! You gave me exactly the same advice as in this post and for whatever reason it worked! One of the many reasons we love you as a doctor.

  2. Yes, unfortunately, I've heard reports of many children like this. And I truly feel for this mother. Isolated from support, lacking a husband who comprehends the issue and validates her concerns. It's a recipe for depression. I'm glad to hear she is moving closer to her family.

    Given what I've learned about neurogenetic conditions, I can't help but wonder if the boy shares some challenging neurobehavioral traits with his father. If that is the case, the father might be modeling bad behavior as well, thus reinforcing the patterns and the disregard for the mother's feelings.

    Low empathy, oppositional-defiance disorder/conduct disorder, irritability combined with impulsivity.....these are not uncommon brain-related issues, unfortunately.

    If your empathic gestures could not reach this child, perhaps this child has neurobiological issues that simply are not dependent on how he is treated or approached. I wonder how a pediatrician approaches that, without having full knowledge of the family situation. Sounds tricky!

    I've been reading a discussion at Dr. Charles Parker's blog on a medication called Intuniv. It seems this new formulation of Tenex/Guanfacine can often address brain-based oppositional/anger issues. In parent AND child.


Please let me know what you think. Do you know a child or situation like this?