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.

My Child Hates Me

Hitting Mommy

"You will not be punished for your anger, you will be punished by your anger.” --Hindu Prince Gautama Siddhartha, the founder of Buddhism, 563-483 B.C.

A sensitive and intelligent mother started the visit by saying that her 3-year-old said, "I hate you." There had to be a lot more to the story, of course, so I said, "that must be very hard for you." Mom started to cry.

"She hits me," she said, very seriously as if confessing.

"How long has this been going on?" I asked. She said that her daughter has been hitting her and only her for about 6 months. Though she hasn't been hurting anyone else, she's been more difficult in preschool and quicker to fight over toys and play turns. She said that the child hits as hard as she can, with obvious intention to hurt.

It wasn't always like this, mom said as I started to examine her 6-month old baby. There used to be times of cuddling and laughing, and now it seems that the toddler is angry all the time. With gentle questioning, this mother admitted that her daughter still has happy times with dad, who is working long hours but is a big help when he's home. She admitted worrying about the future of her daughter, worrying if she will be violent as a teenager or adult. This made her very sad.

I felt sad for her, too. I told her the quote above, to help share my perspective--as on most child behavior issues--through an empathic view of the child. Siddhartha could easily have had preschoolers in mind. They don't want to be angry! It may seem like the child spent a lot of energy on her anger, but it wasn't a fun place to be for her. So I knew that she wasn't enjoying feeling or expressing this aggression, especially against her mother. And toddlers don't do things they don't enjoy for reasons of principle.

It should be obvious that the child's aggressive behavior towards mom started soon after the baby was born. When I pointed this out to the mother, however, she was surprised. She tried to retrace the calendar in her mind as a way of proving that it had nothing to do with the new baby. She failed, and realized it had everything to do with the baby.

This is not an unusual story, and many kids (as well as many dogs and cats) can get pretty resentful of the new baby.

Mom was surprised, however, because she said she had followed my advice from before the baby was born: make time to be one-on-one with the older child, so they know you are still interested in them and their priorities. She said she did this as much as possible. Depending on what time her husband came home, and the baby's nap schedule and feeding schedule (which varied every day), this could be a couple of hours or none. Sometimes the dad came home after bedtime, and he wouldn't see his daughter at all that day.

Now all the pieces fell into place. This 3-year-old had VPS, and a bad case of it. Vanishing Parent Syndrome, a problem that often arises as a complication of Concrete Thinking. (NB to the reader with OCD: Concrete Thinking is real, look it up. I just made up VPS.)

First, the problem arose because the parent has made a subtle but serious error in empathy. Mom was trying as hard as she could, and made as much time for the child as possible, but the kid is only 3 and cannot appreciate her mother’s sacrifice. It is perfectly understandable and natural for the loving parent to make the assumptions she did. But it's an error. Would you take your 3-year-old jogging? No, she wouldn't be able to keep up. Would you take her to a college lecture? No, because it wouldn't be reasonable to expect her to pay quiet attention for so long. Concrete thinking means that the child has a limited capacity to imagine herself in somebody else's shoes. Her ability to think abstractly in the future, which is to say imagine herself doing something tomorrow or next week, is absent.

So let me apply empathic analysis, a methodology I came up with to help work through challenging child behavior issues. Maybe she can't put herself in my place, but I can put myself in hers.

From the 3-year-old's point of view, these one-on-one sessions with mommy and daddy are great. But because she can't plan tomorrow or the next day, she is trapped into reacting to whatever is happening right now. She doesn't remember the hours spent with her yesterday--they might as well have been ancient history. Even if you remind her, she can't grasp the feeling it gave her yesterday when you were with her. Thus, it doesn't soothe her or relieve her need any more than the drink of water you had last week can relieve your thirst right now. In the same way, your promise of spending time with her tomorrow is of no value to her today. In this case, there wasn't even that promise. Maybe there would be time tomorrow, maybe not.

For the child living in the moment, as would be developmentally normal for a child this age, these times with her parents seem arbitrary and unpredictable. Though nice when they happen, they start and end for inconceivable reasons. The child has no confidence that these times will ever happen again.

When did this start? It's a mistake to think that the child has formed a conspiracy theory to explain it, with the newborn baby as the evil leader. Earlier, I said that I helped mom see that the problems started about the time when the baby arrived. But the baby didn’t do anything—it was the behavior of the parents that changed. The baby is an incidental artifact to the situation from the child’s point of view. It's the parents that this child depends upon, and it is their actions alone that she reacts to. So it's perfectly reasonable that a developmentally normal child will try one thing or another to regain the attention that she has inexplicably lost. Maybe it's refusing to go to sleep or eat. Maybe it's giving up the potty and going back to diapers. Maybe it's hitting mommy. She's creative, inventive, and needy. She has now learned that the hitting thing works, in a big way. Mom puts down the baby and talks directly to her--maybe not in the tone she hoped for, but at least, like a desperate salesman, she's got her foot in the door. The attention of her parents is the single most valuable thing in her world, yet her parents dole it out like worthless crumbs.

This mismatch between the priorities of the child and the priorities of the parent is a set up for relationship friction. Each party doesn’t understand why the other can’t see reality in the clear bright light of truth.

This sweet preschooler couldn’t jump up to her mother’s perspective, but maybe I could get mom to kneel down to hers. What I had to do was come up with a system that the child could rely upon, that the parents could live with, and that would still include the baby. I needed to work with the tools I had.

The child didn’t know numbers and couldn’t read, but did know colors. So I told the mother to get a big desk calendar at an office supply store. Every day had a plan. On weekends, daddy would go for a walk to the park and leave mom at home with the baby. Every weekend morning, even in a cold, drenching rain. This is crucial—the child thinks concretely, so she can’t abstractly imagine her own wet discomfort trying to play in the rain (and she might, in fact, enjoy it). So get over your petty adult comfort preferences and take her to the park, at the same time every weekend morning. If you go and she says she wants to go home, that’s OK, but that still means isolating dad and her from mom and baby and giving her one-on-one time with dad. These are orange days, and every weekend day must be colored orange. On green days, mom would do laundry when the baby was sleeping in the afternoon. And laundry was their special time to be alone together. The child was given special helping tasks and made to feel important and useful to mom. She knows a baby couldn’t do these things! By the time dad came home, mom would have specific things she could tell him about all the helpful things she did. On blue days mommy would go to the store with her and the baby. But before going to the store, she helped mommy make a list of things to buy. She helped take things off the shelves and put them in the cart. A baby couldn’t do that!

Every day, at bedtime, the child would put a dinosaur sticker in that day on the calendar. That was the end of that day. Goodnight, dinosaur!

Though the child had limited ability to picture the next day, this became a bedtime ritual. When the next day was green, she was reminded of the important job she had helping to sort light from dark wash, or adding the dryer sheets.

I can’t emphasize enough that for this plan to work, it needs to be cast in steel. It isn’t the tasks that change the toddler’s behavior, it’s the dependability. When she feels confident that she can count on the plan happening, she won’t feel the need to experiment with new and inventive attention-getting techniques. The plan is designed to build confidence, so it doesn’t matter if it’s only an hour a day of parent time. It matters a lot if the parent doesn’t follow through. That will erode the child’s confidence in the parents even more, with predictable increases in problems. So the key success factor here is the commitment of the parents to do what they contract to do.

Her parents told me that she’d sometimes ask to start the laundry first thing in the morning. When reminded that they have to wait for the baby to be asleep, she’d talk very quietly and sometimes sing softly to the baby to help initiate this process.

She stopped hitting mommy.

I need to add this caveat. There are kids this age who are aggressive, even hurtful. Not just with mom and dad, but with peers, strangers, grandparents. I’d guess that in the last 10 years, I’ve seen 1 child like this for sure, maybe a couple of other, less clear cases. This aggression and oppositionality can sometimes be perceived at a very early age. It’s not normal, and it obviously is going to have an impact on this child’s life. It seems to be caused by brain chemistry, not some external influence. The child should be carefully evaluated.