Anxiety—College Boy Problems

Before I met with Peter, the 21-year old college boy with anxiety, I asked his parents if there was anything they were concerned about. He said, “Well, it would be great if he were a little more outgoing.” I hadn’t seen the boy in a couple of years and didn’t really know him well since he didn’t go to the doctor much. Was he shy?

An hour or so later, with them waiting patiently outside the exam room, I knew he had a full-blown anxiety disorder. Many people have some anxiety in certain situations, like public speaking. Some people have more focused anxiety about specific things, like spiders or heights. Some have anxiety about things that they themselves know intellectually to be fairly harmless to most other people, such as a fear of balloons. Some fears are so unusual that the person is able to talk about them freely, and knows that they are not an issue for everyone else they have ever met, but the fear is quite real to them. Perhaps a great thing about the internet is that it can give this last group of people the ability to connect with the 1 or 2 or 5 other people who share their unusual problem. By example, there is a community, of sorts, for those with a fear of buttons.

He lived at home with his parents. There’s nothing wrong with that, of course. His parents were nice people and nice to him. And they never threatened to kick him out. They probably never would. That’s a nice thing, too.

But he never indicated that there might be advantages to living away from his parents. More than that, he couldn’t fathom why anybody his age would want to move away from home. It wasn’t like he was so emotionally tied to his parents. I had spoken with them, though not about him. They went on vacation, sometimes camping. They went out to the movies sometimes. Most of the time, I learned from Peter, he never wanted to go. I could picture a dysfunctional relationship in which he didn’t want them to leave, but he never objected. He was most comfortable just staying at home. Alone.

He wasn’t psychotic about his anxiety. He didn’t believe (or say he believed) that if he rode the bus then the world would end by a volcano emerging under his suburban town just as a meteor hit the earth causing an rip in the space-time continuum which would provide an attack opportunity for the Monsters from the Id.

Still, I had a bad feeling about where this was heading. Unlike the College Girl I had seen just a day before, he was not tortured by his anxiety. He knew that others weren’t as concerned as he was about many things, but the way he thought was obvious. Every unusual fear was completely reasonable, and he was almost bemused about the mad foolishness he witnessed around him. To him, our riding in vehicles of all kinds appeared like those who walk tightropes over great gorges. He saw that people did it, that they could do it regularly, but you’d have to be positively nuts actually to try it.

This is also how he saw the pursuit of human relationships. This was another big difference with the College Girl. She didn’t have a boyfriend and wanted one. She absolutely did understand why her peers were in or wanted to be in a relationship. She also understood what was keeping her from achieving this goal. She perceived her anxiety as a handicap that she hated, a roadblock she was desperate to overcome and was so far unsuccessful at doing so.

Was he really forthcoming with me? Like every patient, he was entitled to his privacy and owed me no explanation. Some doctors, I know, think that if a patient isn’t open about something, or if a patient fabricates something, then they can’t or shouldn’t help them. It’s certainly an impediment to treatment when a person doesn’t seem to respond to medication that they say they are taking but aren’t. But mostly if patients want me to give them my best advice and they want advice based on some hypothetical situation, that’s what I and they will be stuck with.

Is this denial? Once I saw a child who had been in and out of emergency rooms at least 4 or 5 times over several months. Every time the family went in with him, he had trouble breathing. He was given breathing treatments and medication and sent home to follow up with his primary care physician. They didn’t give him the medication, didn’t make the follow up appointments. They needed a form filled out for school, and the doctor told them that the child had asthma and would benefit from better control of his symptoms. They changed doctors, and came to the practice where I used to work. I told them their child had asthma and would benefit from better control of his symptoms. He went to the ER again, then they asked for their records to be transferred to another practice.

Is it my job to puncture his denial, if it is? Is it my role to judge his life decisions as somehow inadequate, as incompatible with happiness? Is my definition of happiness and success as an adult a reasonable goal? There are societal norms, of course, and he was aware of these. Marriage, family, work, kids, and so on. Certainly here in one of the epicenters of alternative lifestyles, there aren’t a lot of choices that wouldn’t be tolerated. Besides, I lived in Utah for 3 years. In ways that I appreciate more from a distance—topographical, chronological, and metaphorical—some of those people were very much willing to do a lot to live outside of the mainstream. Whether in shallow swamps of consanguine genes or in isolated heavily-armed bunkers waiting for the race-war end-of-times, they were going to do it their way.

Let me be explicit about some of the ethical issues associated with this case.

1. If the patient doesn’t think it’s a problem, is it a problem? Before there were Wall Street executives who didn’t take any responsibility in their congressional testimony, there was a panel of Tobacco CEOs who swore under oath that they didn’t believe that smoking caused health problems. That seemed sleazy and dishonest. But if a patient says that they are just fine with what they are doing, does it matter if they are in denial or are out of touch with reality?  Does the doctor have an obligation to do more than educate, inform, and offer help?

2. Is Peter hurting anyone else by his inattention to his anxiety disorder? Sure, his parents had dreams for him that might be difficult to achieve. But who among us has parents who have always thought that we would be exactly who we are now? I am, to be blunt, worried that what appears typical enough at the moment—a college kid living at home while attending a decent and popular local institution—could become more cumbersome as the years go by. Do his parents deserve a life of their own, without their kids? Do their kids owe them the freedom gained by moving the heck out of the house at some point? And the parents aren’t my patient, so should I care what they need?

3. I want to repeat that last part. The parents aren’t my patient. This is an easy issue for some of the patients I see. I have a patient who’s nearly 30 now, severely developmentally delayed. I have autistic kids who are technically autistic adults. It’s an easy issue for them because they have legal guardians and decision-makers. Not Peter—he’s warm and smart and going to college. But in some ways, obviously from these essays, I think of him as having a handicap. It’s not politically-correct, I know, to use that term at all. But there’s something about him, that is with him in every setting, that often interferes with his achievement of some of his own goals. It interferes, in my professional opinion, with his ability to meet some criteria of independent—if not happy, perhaps—adulthood. The Americans with Disabilities Act of 1990 says a covered disability is a physical or mental impairment that substantially limits a major life activity. What, if anything, should I tell his parents? That their kid is sick and needs to have medication spiked into his orange juice? I want to tell them everything. They are his best advocates, they know something isn’t right. He gets along well with them. Shouldn’t they be there to encourage him to seek the help I think he needs? A lot of parents read this, and would probably agree. But what about when you were 20—would you have wanted your doctor calling your parents?

Dancing and Friendship

 

George’s father brought him to me because he was worried. He remembered middle school, and the close friends he made and kept through most of high school. Though both he and his friends moved on and in different directions, he knew how essential they were as catalysts for him to become independent of his parents.

George, 13, didn’t have a best friend. He didn’t have a group of friends that his father knew about. He was smart, courteous, respectful of people and things. He usually had a book with him. His father was also concerned that George might inevitably become known as a nerd.

I admit that I have not seen genetic research investigating whether nerdiness can be inherited. I predict that at some point, there will be a nature vs. nurture debate about it among academic intelligentsia. Among nerds. The issue of nerdism is not the topic of this post, but I would politely point out that George’s father just happened to be the only computer engineer in his working class family.

George’s father was also concerned that his child might have an autistic-spectrum disorder, and wanted a professional opinion.

When I spoke to George, I asked questions I usually ask of teenagers. I asked about depression, suicidality, substance use. There were no surprises in the answers to my usual screening questions. He was a happy, thoughtful kid without any worrisome activities. He agreed that he really didn’t have any friends. The claimed this didn’t bother him. He didn’t say that people didn’t like him, he didn’t complain about having no one to play with. He said he was content the way things were.

How do you get your 2-year old to taste new foods, when she doesn’t want anything that isn’t the right shade of white even on her plate? As far as she is concerned, there isn’t a problem growing to retirement age on milk, macaroni and cheese (made one very specific way only), plain white rice, and cookies. Some years ago, I read a research study that asked how many times you have to put a new food in front of a 2-year-old before she will spontaneously try it. On average, 30. That’s just an average, of course. Some were more adventurous and some took a lot longer than 30 times. One single, lonely, french-cut string bean every night. Seven nights a week for a month. And then she takes a reluctant nibble. And then she says she doesn’t like it.

Be the parent. You know what your child does not know. Maybe George is satisfied with his friendships as they are. Maybe he’s not depressed about it, lonely, isolated. Maybe he’s not suffering from a personality disorder or autistic-spectrum disorder. Maybe he just doesn’t know how helpful and rewarding a good friendship can be. He doesn’t know that it can be crucial to have somebody who completely agrees that the history teacher mumbles and that parents can be unbearably unreasonable. He doesn’t know that eventually his classmates will notice that he carries a book around.

Social skills are an old-fashioned dance. A few of our children need no coaching. They will ask somebody to dance and get out there in front of everyone making a perfect fool of themselves. The rest of us look on critically about the way they look or move, and secretly envious that they are willing to do it. We feel helpless and alone. We want this skill, but feel humiliated to admit we lack it. We don’t even know where to go to learn it. We do not believe it can be learned, and feel like it is a deep personality flaw. Because we believe it can’t be learned, any attempt appears to us as doomed to failure. So we don’t try. We hang out with a group of our pals and make fun of the kids actually having fun.

You now know that this isn’t a flawless oracle predicting our futures. After all, somewhere along the way you became a parent. Professionally speaking, that usually requires help. (Though we have the technology….)

I told George’s dad that I thought he was on a spectrum, but it wasn’t the Autistic Spectrum. Some people, especially starting around middle school, are particularly self-conscious about the possibility of social failure and rejection. We might not be able to teach them to love to dance. We can, however, teach them some dance steps. We can also be there to catch them when they fall.

I made some specific suggestions. If George wasn’t into sports—he wasn’t—he should sign up for an after-school program. He should be given a list of choices. In this local area, there are many choices that aren’t too costly. In his case, there were library programs and science and computer classes. There were also programs in which students like George can tutor other students in certain subjects. This can be really helpful for good students who get their homework done before they get home, and spend the rest of the day and evening playing video games or on the computer. In some schools, there’s still a chess club or a debate team. I suggested finding a program requiring some cooperative activity, where participants have to work together to make something or learn something. The group is the way to find others of about the same age with a common interest.

The next suggestion was to host one or several group gatherings. Don’t miss this opportunity to show those kids where George lives, the stuff he has in his room, the video games he plays. Remember, they are all nervously making fun of the popular kids on the dance floor. They don’t have enough perspective to realize that none of them know how to dance. Be the parent. As everyone shows up, keep a little log book of names, addresses and phone numbers—George won’t think of this. Don’t supervise, disappear into the background. But only after the pizza arrives.

The photograph is from my collection and is by Keith Carter.  It's called Waltz.

Friends

I received the following message from the faceless internet: Are you the wolf nadoolman who went to p.s. 189 in manhattan?.I know you can't possibly remember me. My name is sonja and I sat behind you in mrs. Lowe's class. [First grade.] We were taking a test and you didn't have a no. 2 pencil. I had an extra one and you asked me what I wanted for it. I was fascinated with the word encyclopedia so the next day you brought me in volume 1 of your encyclopedia! I had it for years and have often told people this story!  Of course I remembered her.

My father, by all accounts, was naughty. He grew up in a relatively rural area, and his family didn’t have much. Among the stories he told--or, rather, confessed to--was the one in which he led and coaxed a nearby goat away from the neighbor’s field and into the school building, up the stairs, and onto the roof of the school. It turns out that goats are not that easy to move once their acrophobia makes them so terrified that they resist moving altogether. His mother, as he put it, let him have it. There were about 15 or so people in his high school graduating class.

He was a good student and a smart man. But he never talked about his grades or the tests he aced or failed (I have no idea which). He never spoke about the book report he didn’t hand in on time, never told stories about the textbook he had to skim because he didn’t get the reading done before the test.

He spoke about the goat. And the windows he broke: some accidentally, some not so accidentally.

These are the stories he told, and the ones he and his schoolmates laughed about at their 30^th, 40^th, and yes 50^th reunions. Oh, did I mention there was a 60^th reunion? By then, of course, some classmates had passed away. For his entire life, he continued to socialize with these friends and his friends from his military service.
What do you remember from elementary school? OK, maybe it wasn’t an entirely rosy picture. There was the bully, the humiliating bathroom accident in kindergarten, the time the teacher made you read aloud in class and you weren’t good at reading aloud. I will grant that you might still remember those events, which left some scars. But you probably don’t remember the map of the united States that took so much work, the pages and pages of vocabulary words and arithmetic problems. The paragraph you had to write about George Washington.

What about middle school? Do you remember the homework assignments, the final exams, the problem you got only partial credit for though you deserved full credit for and how unfair it felt? High school?

Homework is important. It’s how we learn. It’s how unfamiliar material becomes familiar, gets to sound right in our heads, becomes comfortable knowledge. We may use every day what we learned in those pages of arithmetic problems. But it’s not what we remember.

It’s the friends.

Friends are our pathfinders to the world outside of our families. Though we don’t plan to be, we are their pathfinders, too. To outsiders, especially in the school years, it looks like our friendships are very superficial relationships. Whether in cooperative sandbox play like digging a tunnel from both sides at one time or a swordfight using rolled newspaper as weapons, or co-hosting a tea party for dolls and stuffed bears, these are important social experiences. Some important learning skills are obvious. Learning to listen to the other person, to incorporate their ideas into our plan, and compromising are just a few aspects of social play that can be key factors for success or failure in adulthood.

Sometimes parents mistakenly equate social play with sports or other ultrastructured group activities. They aren’t the same. While physical activity is important, and organized sports or theater can be essential for some kids, I think learning to play with others is a lesson itself, not obviously reinforced automatically in the context of competition and trophies. I wonder about the influence of professional sports, in which players are teammates only as long as their contract term. Star players want to help their team win, but only if they get the exposure and opportunity to enhance the next round of negotiations, during which their team loyalty is explicitly for sale. Is it so different, by the way, for star ballet dancers or actresses?

It’s the friends. Are you still in touch with friends from these school years? Maybe from preschool? Even if you’re not in touch with them, I bet you remember them.

We all remember these early friendships, and the ones we may have lost along the way. Why is that? The answer, I believe, is hidden in the way we keep and categorize our friends. Most of us keep our friends in organized containers. There’s the friends from glee club, friends from our mom’s group. Maybe the soldiers we trained with--and they might be in a different group from those we served with. The friends from church and friends from karate. The friends from tie-dye class and the friends from detention. The friends our parents seemed to like more than us and the friends they used to forbid us to see.

Friendships are not generic. Empathic parents see beyond the playdate and try to understand the importance of friends in the lives of their children.

The lives of infants are constrained by their physical needs. Food, shelter, and the need to induce sleep deprivation and emotional lability in those who love them. As they become more capable of exploring the world, they manage their curiosity through good-natured spelunking in the cabinet where you keep your cleaning products, and originate science experiments involving figuring out how to open grandma’s pills.
How do they get to see the world outside our family constraints? How did you? As we get to school age and older, our friends, from each of the compartments in which we keep them, show us what they know. They show us the places they discovered and the insights they have had. They show us paths we didn’t know were there.

Friends are important for your children, especially once they get to school age. Mess with this at your own risk!

The photograph is from my collection and is by Helen Levitt, 1942.

Teaching Empathy

I was flying last week. The rows are close together, but the flight was just an hour. There wasn't any room for my legs, however, because of a large suitcase jammed under the seat in front of mine. Very politely, I asked the person sitting in that seat to take the bag and put it under the seat in front of her seat. “I can't do that, she explained helpfully. Then there would be no room for my feet.”

Empathy is the currency of human relationships. Being able to walk in another person's shoes gives us the ability to understand where they're coming from and what they might be feeling. When you think about it, this is the skill behind all kinds of human interactions, including everyday courtesy, safe driving, and successful romantic relationships.

How do we learn this? Are we born with it?

Just like most other behavior, our parents model it for us. But my work with kids who have really difficult behaviors makes me suspect that there's more to it than that. How come some kids are so sensitive to the needs of others, while a sibling not so much—even though they grew up with the same parents? I believe there's a component of brain chemistry involved also.

But whatever the kids are born with, can we make a difference? As it turns out, we can. There are many different aspects to good parenting, but this just hasn't made it into parenting books. As regular readers, and my patients know, I think it's essential.

In one study, children were given a task to do with their mom and a friend. The interaction was observed at 3 and 4 years old. The scientists scored the interaction for conflict vs. cooperation. They found that the most influential factor was the actual words the mother used when talking to the child. Mothers who explained to their 3-year-olds how others might be feeling had, on average, more cooperative 4-year-olds a year later. This is supported by research in which mothers were observed with their children, and what they said was recorded. Children whose mothers often reminded them about what others might be feeling didn't remember the words but did remember the concepts. They showed more understanding of what others were feeling. Maybe these research results aren't surprising. I am impressed, however, by how much these young children can absorb from the little things said my their mothers. Lots of other studies support these findings.

Let's take a step back. Children can, in fact, learn how to appreciate the feelings of others, and this skill could improve their social understanding and relationships. They seem to gain this understanding by listening to the remarks and explanations of their parents. In my mind, this brings up some interesting questions. I didn't find any research on this, but I wonder if they also pick up the negative things we say. That SUV cutting us off on the freeway might deserve an out-loud expression of our analysis of the driver's motives and intelligence, but if our kid is in the back seat, even at a very young age, won't they remember that, too? What about the opinions we voice about our bosses or ex-spouses (or current spouses)? The research is so strong about positive influences that I suspect we may inadvertently provide some examples of insensitivity as well.

If there is a sunny side of the street that we're all supposed to walk on, I haven't found it. Parenting isn't just about only sharing your positive experiences with your children, and hiding the negative ones. How will they learn how to handle interactions that don't go as well as you hope? So a perceptive parent, an empathic parent, will find and use the teachable moments of everyday life, even with the youngest children.

When you see a child crying in the park, ask your child why. If they don't know, help them make up a reasonable explanation. This is an exercise in imaginative story-telling that can be as long or as short as your child likes. But it exercises their empathy muscles, both in trying to imagine why that child is crying, and by the fact that you are interested in why and are interested in why your child thinks the child is crying. As with any behavior, if your children think it's important to you, it will be important to them. It almost doesn't matter what, exactly, your child's scenario is. Maybe the kid fell down. Maybe they had to wait their turn on the slide. Or maybe they couldn't have the pink cookie shaped like a strawberry that probably tasted really really good that their mommy didn't buy for them when they were shopping in the supermarket to buy macaroni and cheese and milk and then get home right away because daddy would be home soon.

Parents translate the world for their children. When we talk to them about the feelings and motivations that make others act as they do, we equip them to manage successfully their lives with others.