Mortality and Kids

A robust literature exists on how children understand mortality, and rightly so. Adults struggle greatly with understanding the meaning of life - the meaning of death.  The matter cuts to a critical essence of who we are and our most basic questions of existence.  I couldn't help but notice that recently I've seen a couple of kids, one with autism and one without, who've confronted mortality.  In this, as with all posts, materiel changes in client descriptions are made for reasons of confidentiality.

Harry is a 12 year old boy, small in stature, quiet, whose sister died in a car accident last month when another car jumped the median.  His sister is described as a charismatic, smart and involved sibling and child.  She had finished college and had begun working in her chosen field, living with Harry and their parents in the meantime, saving her money for a while before getting her own apartment. Harry's parents are, understandably, devastated.  Harry, quiet, struggled with how to articulate his feelings at Dawn's death.  I asked him about his religious beliefs and he began to discuss his basic understanding about the afterlife, consistent with his religious upbringing.  It quickly became clear that his religious education had been thorough, but that this was one of those topics that called for a deeper review of the family's religious doctrine.  He wondered whether God was punishing Dawn, was this some Divine retribution for her behavior - though he admitted she was a great sister whom everyone loved.  Maybe, he wondered, he and his family were being punished for something - what, he didn't know.  Maybe there is no God at all?  How do we find meaning in this tragic and senseless loss of life?  These are questions that are normal, human and very difficult to answer.  Harry's parents, tearfully, are rallying with him to find meaning in something that admittedly does not easily make sense.  As we all know, the lessons Harry is learning are those that we all learn one day or another. Painful, but a normal part of human development.

Susie is a 10 year old girl who came to see me due to tantrums that began about a month ago, seemingly out of the blue.  She has High Functioning Autism (Asperger's) and has until now been a lovely young lady, her "little professor" presentation not withstanding.  It was mentioned in passing that her mom underwent a fairly routine surgery last fall that had unexpected consequences and ended up with complications that took a couple of months to resolve.  It was serious, but she was never in danger of death per her physician.  Susie was told that all was OK and had no follow up questions about her mom's status.  They went around their business, her mother recovered fully and all was well.  Until the tantrums began. 

As Susie, her dad and mom and I spoke, I learned that her mom's recovery hadn't really finished until about a month before the tantrums began.  I asked Susie whether she thought her mom was near death.  Not only did she say yes, but she feared that throughout mom's recovery (at home) that mom might at any second, die, inaccurately extrapolating that the tenderness mom had at her surgical site when she came home was permanent, an everlasting vulnerability through which her mom could die.  She also stated that she feared she could have the same need for the same surgery her mom needed and that feared dying from it.  Her parents' eyes grew wide.  

The good news for Susie is that she's smart.  We immediately began the education process, having learned that her silence upon being told that her mom's surgery was not as simple as hoped, did not mean she fully understood her mother's prognosis.  Her parents understood that they would need to be on guard as to any connection between Susie's behavior and other issues and engaged her multiple times afterwords in discussing what she really understood about lots of things, physical health being high on the list.  Two weeks later, Susie came back and the tantrums had stopped.  Cold.  

Mortality is very hard for us to understand.

Panic Attacks and Self Monitoring

As with all posts that describe individual clients, materiel changes in descriptions are made to insure client confidentiality.

Kevin is a pleasant 16 year old junior in high school.  He began seeing me due to depression and anxiety a bit more than six months ago and has generally done well, not needing medications for either, though I admit it was close there for a while.  He's insightful, thoughtful and a very enjoyable kid to work with.  He's struggled a bit with some panic attacks that have been (understandably) frightening.  He's smart, but the depression and anxiety distracted his ability to keep the good grades he'd been used to last fall - he's not on the autistic spectrum.  He needed to pull his academics up, anticipating the coming focus on college applications and the importance of junior year grades in that process.  Pressure, but the kind that most kids tolerate.  Since the beginning of the year with a new semester, he has done very well with his academics.  

He came in and discussed another panic attack after a 4 month respite from them.  So we discussed what was going on around the time of the panic attack that might have triggered it.  He was quite clear and didn't hesitate - he had been having a bad day anyway, having not done well on a paper he had worked on and invested a lot of time in.  His friends and parents noticed he was a bit edgy but he couldn't really put his finger on the problem.  Then he was asked to go to the store by his mom to purchase an item for a recipe she was working on and needed right away.  It wasn't there.  She needed it.  He panicked. Shortness of breath, pounding chest, fears of death.  Another panic attack.

He managed this one pretty well.  He called his mom who was understanding and quickly helped him see that the priority was his emotional stability much more than the recipe she was making.  She encouraged him to just come home, reassuring him that the recipe was not that important.  With that, he was able to calm down more quickly then he has in the past.  He came home (while his mom went to another store, understanding, to her credit, that he was more overloaded than she had anticipated), and was soon fine, but perplexed about having had another panic attack after having been doing so well.

So Kevin and I began to talk about how self monitoring might be a useful tool in helping him see when and where he's vulnerable to panic attacks.  We reviewed past panic attacks and saw a couple of themes - when he feels pressure to meet the needs of others and when he's unhappy with himself.

He rightly asked: now that I know what the triggers might be, what do I do? Which led us to a discussion of self monitoring.

Self monitoring is one of those things that's easy to discuss and easier to advise, but not near as easy to do.  Despite that, Kevin has some important insights:  He knew he wasn't feeling good about his academic work either time he's had the panic attacks.  Last week it was a paper.  Then really tried to help his mom - he feared disappointing her when she needed him.  The  panic attack of 4 months ago had similar themes - his friends were desperate for him to join in an activity when he had schoolwork he needed to do in his weakest subject at a time his grades were slumping.  Again the themes of not feeling good about his academic performance connected to the pressure to please others.

Kevin's a good kid.  I can't say that he'll never have another panic attack, but he's aware, wanting to learn and seeing that there are times he's vulnerable to emotional distress.  I think that's a great start.

The End of "Why" Questions

There is a question that I've long struggled with, despite its standard use in most of our lexicons, therapist and parent alike.  It is arguably our most frequently used question: "why."  "Why did you (fill in the blank)." This is a standard parenting and therapeutic question.  It so frequently comes up with kids, particularly those with ADHD in response to their "impulsivity."  (See my post of 7/17/13 on "The Missing 'I' In ADHD").  

Asking "why" to a kid with ADHD is almost always silly question, albeit understandable.  Impulsivity means action without thought.  If I was thinking, I wouldn't have bleached the dog's fur.  It’s the Dennis the Menace response that lands him sitting in the corner – to no long term avail.  We ask "why" because we're programmed from infancy to do so.  If we understand why, we understand a lot.  But in the arena of human behavior, "why" often leads us down a dead end.  We've all been there - we ask "why" and receive no real satisfaction with the answer.  We are quite satisfied, however, with OUR answer of "why" which, as Ross Greene points out, is usually a theory, often creative, sometimes accurate, but used often as a figurative club to beat sense into the child.  Now I don't know about you, but I struggle enough with regular questions. When I'm being emotionally clubbed, I have a much tougher time.  When kids are being emotionally clubbed with our theories, they shut down.  

Indeed, the "why" question has been choice in my quiver of questions until recently. I'm using it less and less, and I may be even approaching the end of "why" questions altogether. The corner I've turned with "why" questions has come under the tutelage of Greene who wrote The Explosive Child and Lost at School.  I'm taking a certification program with him in the model outlined in these books. "Collaborative Proactive Solutions" (initially developed under the name of "Collaborative Problem Solving" until Greene's rights to his own intellectual property was challenged in court.  Another topic for another day.)

In the CPS model Greene asserts that "why" questions so often lead to a dead end. "Why did you hit your brother?" is likely to be responded to with a "He's a jerk" (often said much less graciously) or "He started it" or "He said I'm a jerk" and the like.  How does a parent or a therapist follow up to such a response?  Do we believe that knowing "why" will inhibit the problem from happening in the future?  That thinking is rooted in the Freudian theory of finding the "kernel" of the problem that, when explored, extricates the problem like a dandelion pulled from the ground extricating the entire root system.  The problem with dandelion pulling is that it invariably leaves a fragment of the root in the ground that regenerates.  Like the regenerated dandelion, the answer to “why” does not uproot the behavior which will invariably rear its ugly head again.  Knowing "why" does not give us the solution - the behavioral change - we want.  

We ask "why" I believe, due to our own inquisitiveness and desire, our need to figure things out and understand how things work. Why does the apple fall from the tree?  Gravity.  Why did my tennis serve not make it over the net? Simple, if I'm able to learn the mechanics of how to serve a tennis ball.  Why did I leave dirty dishes in the sink?  That's actually a complicated question with many variables and influences.  And that's just the dishes!  When exploring the cause of human behavior, it's quite difficult to find a satisfying answer to "why" mostly because the answer to "why" doesn't lead to behavioral change.  Maybe I didn't do the dishes because I was tired.  Maybe I didn't do the dishes because I'm angry at my wife for what(ever) happened yesterday and not doing them is my way to get back at her.  Maybe I didn't do the dishes because it's an expression of my sublimated rage for my mother's ignoring my emotional needs when I was three.  Yes, theories can be very creative.  

Greene famously talks about a child who he treated who was quite the behavioral challenge and had gone through many therapists, more interventions, all to no avail.  The common narrative about the child had to do with the "theory" (code for "why") of the tragic death of his father when he was a toddler.  It was taken as faith that if he could fully explore his grief, his behavior would be wholly uprooted and all would be well.  When Greene asked the child about his father's death, the kid looked at him quizzically and responded that there were no real memories of his dad.  The child was two years old when he died.  The theory connecting the behavior to the loss of the mother was not applicable.  This is not to say that dads are unimportant – or that the child might not benefit from some “dad” based discussion, but we have to include what kids' experience is in solving the problem.  

What's a therapist (or parent) to do?  That, says Greene, involves engaging the child in a very specific definition of what the problem actually is and then collaborating with the child to find a solution.  Which is a discussion for a different post (stay tuned).  In the meantime, I encourage you to consider: is the payoff for the "why" questions getting you where you want with your kids?