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.

Child Behavior: Spanking

Don't hit your kids. I was actually asked about spanking this past week, and thought it was worth committing some of these concepts to whatever this medium is. The issues with spanking, of course, overlap with most other discipline issues. The question was posed to me as a philosophical one. I was asked how I feel about it. This post is only a little bit about my feelings and a lot about statistics.

A group of researchers at Phoenix Children's Hospital compiled a Report on Physical Punishment in the United States. I learned a lot.

Spanking is not a philosophical question. True enough, I don't like the idea of anybody hurting anybody. I'm not alone—29% of Americans are against physical punishment by parents and 77% think that school personnel shouldn't either. Wait, I did the math too. I was surprised to learn that 71% think it's OK for parents to hit their kids, and 23% think it's OK for somebody at school to hit their kids. Though I was surprised to learn I was in the philosophical minority about parents hitting their kids, I didn't have more than a philosophical set of objections. I found statistics.

I wondered why a school would find it necessary to physically hurt a child. Curiously, African-American students were 2.5 times more likely to get physical punishments than white students, and boys 3.4 times more likely than girls. So even if no one was consciously selecting who to hit, there was definitely some selection going on. That didn't sound fair to me.

Parents are more likely to hit their kids if:

• They believe that it works.
• They were hit when they were kids.
• They are under stress.
• They are frequently frustrated with their kids.
• They are under 30.
• The child is a preschooler (age 2-5).
• They think their religion approves of it.

It's reasonable to think that the more aggressive and oppositional the child is, the more frustrating it would be to manage these behaviors. Sure enough, the active and aggressive kids get hit more. But what if it was the physical discipline that was contributing or even causing the aggressive behavior? A study was done in which new types of parenting interventions were taught to parents. Within a short time, the problem behaviors decreased. Studies of all kinds have showed that decreasing the amount of physical discipline caused a decrease in the child's problem behaviors. So it doesn't work to control the very behaviors it's aimed at—it makes them worse.

Increasing amounts of physical punishment are associated with increasing substance use problems and increasing mental health problems. These problems persist into adulthood. So you're hurting your kids for years to come.

It also won't help your children to feel close to you. Of those physically punished, children themselves, and adolescents looking back, say explicitly that they feel less warm and open toward their parents. That doesn't sound helpful.

Here's my take on this, from a parenting point of view.

1. Spanking often was used for aggressive behavior. But the aggressive behavior of the parent actually provides unintended positive feedback that supports the child's problem behavior. It confirms the idea that hurting someone is an effective way of getting what you want from them. It's confusing at best, and counterproductive at worst.
2. It teaches that the reason for good behavior, or not doing an unwanted behavior, is to avoid punishment. All of us are capable of being conditioned, like Pavlov's Dog. With severe enough rewards and punishments, we will find a path of least resistance. So I think it's possible that punishment will indeed get the kid to do what's desired. But they won't learn anything that could apply to a new situation. Maybe if we take away the threat, the kid won't have any reason to behave well.
3. It's a good way to get children to be afraid of their parents. How will they model loving relationships? Is love tied to violence?

Don't hit the kids. Or anybody else's kids, either. In fact, it's probably a good idea to keep your hands to yourself.



The photo above is not from my collection. It is from Vanity Fair magazine, 1903. Under the title 'Bifurcated Girls,' it was risqué not for the scene, but for the fact that the women were wearing pants.