Kids Do Well If They Can

All examples of clients in this and all blog posts are materially changed to disguise the identity of any individual.

Karen's a typically developing 6 year old girl.  Typical for kids who have both anxiety and ADHD and a possibility of autism.

Her older brother has autism, without any question, and questions have come up about her being on "the spectrum" as well.  I'm not too sure that she is, but other professionals have questioned it.  I think that her anxiety has blurred the picture and made her presentation look quirky enough that the possibility was raised.  But that's not the point of this story.

Karen is a kid who can be quite stubborn, even oppositional, not to mention significantly distracted when asked, or told after a while, to do things.  As her mom relates, asking 4, 5, 6 and more times to go to bed, get in the bath, come to dinner, clean up her toys etc. can get old, and even mom, a well thought of teacher admits to losing her cool after a while and yelling at Karen.

I began seeing Karen right before her mom had brought her for a more formal evaluation for the anxiety and ADHD, which I fully supported.  typical medication trials began with the typical changes of meds due to ineffectiveness or side effects.  Mom and Karen are taking this in stride.  Karen has some mild Cerebral Palsy as well, as evidenced by a hardly noticeable weakness in one of her limbs, so she's used to seeing professionals.  But mom's main concern is the oppositionality, her refusal to comply with demands at home.

So of course, I recommended Ross Greene's book The Explosive Child (see elsewhere in these blogs for discussions of his Collaborative Proactive Solutions model of problem solving with kids.)  Mom was quite open.  Dad, not so much, for a variety of reasons.  But as Greene says, that's not a deal breaker.  One parent can successfully implement CPS without the participation of the other.

We began solving problems collaboratively and Karen was very interested in her ability to have input into the solutions.  After the first problem was reviewed and she came back to my office I couldn't even finish the sentence asking how things went with the solution they came up with.  She interrupted me with "That problem's solved."  I looked at mom who smiled as she shook her head in agreement. So off we went to the next problem, and the next.  Like dominoes falling we addressed getting dressed in the morning, going to sleep at night, teeth brushing and coming to dinner when called.

Mom comes in now intermittently for coaching on CPS and related the following anecdote which made me think of Greene's "kids do well if they can."  Meaning, if they have the tools to behave properly, they're generally motivated to use them.  And if the tools come from their own collaboration, they're more likely to use them.  Mom related that she and Karen worked on a certain compliance issue that had come up and Karen, as sometimes happens with her, struggled with a clear and practical solution, but mom, not being too eager to suggest something, waited for a quiet time and wondered aloud a certain solution. Karen agreed, as she often does.  She's bright, but coming up with an articulate and a practical solution has sometimes been difficult for her.  So mom wondered aloud whether solution "X" might work.  They tried it with some success.

The next day mom and dad were going out and a babysitter who had worked with Karen and her brother before was being given the routine orientation for the evening.  Karen broke in.  "Make sure to tell her about the new solution we came up with!"  Mom smiled as she related to me that indeed, she then told the sitter about solution "X" per Karen's wishes.  Karen reminded mom, "We need to use it, she [the babysitter] needs to know."  The report from the babysitter, not surprisingly, was positive.  Karen indeed is doing well.

Kids Do Well If They Can.  Yup.

The Power of Anxiety: Leaning Into Discomfort

Whether on "The Spectrum" (autism spectrum) or not, I've been impressed lately with how powerful anxiety is.  Consider:

• The typically developing middle school girl whose anxiety is so powerful, that despite wanting to go to school, her body spontaneously vomits due to the fear of being bullied.

• The college student with high functioning autism who, despite very strong academic skills and competence, freezes during finals jeopardizing their academic standing.

• The typically developing adult woman who has lived in a sexless, loveless marriage for 25 years who (despite financial means) is frozen when she wants to address the sadness of her marriage with her husband.

• The person with high functioning who's asked by a co-worker why they always seem so nervous.

I don't know why suddenly I've become more aware of how powerful anxiety is, but it hit me recently that the anxiety people experience can be crippling.  I often say to folks experiencing these levels of impairment with anxiety (or depression) that there's no therapeutic benefit from going through such mood disturbances.  It doesn't make one stronger or a better person.  It's just torture without profit. Which is why I am a strong advocate of doing anything and everything possible to dampen these anxious responses.

I am a believer in the benefits of the cognitive approaches that have become so strongly put forth in Cognitive Behavior Therapy CBT and Dialectic Behavior Therapy DBT.  The only challenge is that the person has to show up and do the work, and in my experience, some do and some don't.  

I am a believer in the use of medications that have a decades long track record of success in reducing depression.  I'm NOT a fan of the addictive medications (benzodiazepines such as valium and xanax) that, while quite effective have a strong addictive potential.  The non-addictive medications (the class of SSRI's, selective serotonin re-uptake inhibitors being those with the best track record) have a strong track record of success in managing anxiety and depression.  The only challenge is that the person has to be committed to taking them daily and following up with a qualified medical professional and enduring the time - sometimes months - until a therapeutic level can be reached. They also might need to endure the time it takes for the sometimes needed medication changes.

And yes, I'm a fan of good old fashioned talk therapy.  I've heard over and over that despite the hesitation to discuss things that are upsetting, anxiety producing, depressing, that afterwords people (kids, adults, on and off the spectrum) feel better.  I still believe that people relieve their emotional pain by talking about it, as doing so reduces the pressure their emotions build up.  

So yes, anxiety is powerful, very very powerful.  And yet I continue to have faith in the power individuals have to change.  There's lots of ways to change and most of them involve leaning into what is uncomfortable.  It's hard, but it's do-able.

AUTISM and ADHD

ADHD is the most commonly diagnosed mental health disorder in kids effecting about 5% plus or minus.  Autism's incidence is soaring, explained well by none.  Autism strikes about 1 in 68 children (according to CDC's April 2017 posting.)  People with autism have a 30% to 50% incidence of ADHD according to The National Institute of Health and US National Library of Medicine in 2014.  (The interested reader is directed to the following link:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4010758/) though one study found the rate to be over 80%! Regardless of how often it happens, the combination of Autism and ADHD presents a very challenging package of symptoms for kids and parents.

Autism is so well known for the challenges it brings kids in the areas of communication, social relationships, symbolic play and repetitive, or "self-stimming" behavior.  ADHD is famous for it's triad of hyperactivity, inattentiveness and impulsivity (as I've said elsewhere in these pages, why they don't call it ADHID, to include the "I" of impulsivity in the title I don't know.....)  Now think of all of these issues, throw them all together, or even some of them together, and you have the potential for some very challenging behaviors.

The signs and symptoms of each combine with the other to create what parents sometimes experience as an almost toxic mix.  For example, kids with autism can become perseverative - overly fixated on games, shows, toys to a point greater than annoyance.  Combine that perseveration with the impulsivity of ADHD and you've got quite a behavioral package.  Or consider a great deal of hyperactivity, which can make it difficult for some kids (and adults) to get to sleep (often a challenge with autism anyway) - and put with that a lack of ability to communicate well.

I often remark that impulsivity is, in my view, the hardest part of ADHD.  The simplest example of impulsivity is one in when the adult gets the child's focus, including eye contact (already a tough one for lots of the spectrum kids) and gives a simple "don't" or "do" kind of instruction, immediately followed by the child's doing or not doing the exact opposite.  Now sometimes kids will display what is called "oppositional" behavior with a bit of a glint in their eye trying to make it a bit of a game. That's hard, but not what I'm talking about.  I'm talking about a more pure impulse, one that is almost lightning fast.  It's a  unique challenge - and many of the higher functioning kids with ADHD have the same challenge that kids with ADHD without Autism have:  The KNOW what the rules are. They just "impulsively" acted.  It's an explanation, but not an excuse.  It's certainly maddening for parents and teachers and so very frustrating for kids who are not really "bad,"  they're just, well, impulsive (or hyperactive or fill in whatever blank you want.

So many of the parents I see all but tear their hair out with the Autism-ADHD combo.  Meds can often help, sometimes a lot, but some kids have sensory issues making swallowing meds, even the liquids difficult, notching up the challenge to parents and teachers to a "whole nuther level."  Positive reinforcement can be helpful as well, but that's generally precluded on a strong sense of emotional relationship between child and adult, not something that all those with Autism have.  All are used, properly so, but the unique challenges that the child with Autism and ADHD bring makes it such an unusual hill to climb.

Despite the difficulty level of these challenges, parents of kids with Autism and ADHD can only do what they always do - their best; trying to be creative and advocate for their kids as much as possible; working with their physicians, teachers and schools.  I always encourage families to find parent support groups, because it's unlikely that their challenge hasn't been met by another family, and so often that's where we can get not only ideas, but strength.

For so many parents and so many professionals, the Autism - ADHD combination is almost a boring fact of life.  But ask any parent, it's never mundane.  Exhausting?  Yes.  Mundane, never.

Balancing the Physical and Emotional Protection of Our Children

Funny how personal and professional can often combine.  This might be another example discussed by Jung regarding the collective unconscious.  As always, descriptions of clients are materially changed to protect confidentiality.

A client contacted me re: his adult son with a longstanding history of emotional problems.  The man, in his late 20's was wanting to travel to see his newfound girlfriend for an impromptu holiday get together, much to the consternation of his parents.  The relationship was his first, and despite his age, his parents were concerned about his travelling to see her.  In order to do so, he needed to borrow their car to drive hundreds of miles away from home despite his lack of experience in highway driving, concerning his parents re: his safety on the road. Ultimately he was convinced that driving was not the wisest choice to make the trip and she, with more driving experience, came to see him.

I've known the young man for a while and have competing concerns.  One is for his independence. He is old enough to be independent.  On the other hand, he's inexperienced enough as a driver that his parents understandably are cautious about giving him the keys to their car to drive.  All in all, however, he deserves the chance to spread his wings some to experience the realities of relationships and life.

At the same time I'm travelling over the holidays, staying with friends who confide in me that their son, in his late teens, seems to have some poor judgement about his life. He's doing the right things: he's in school, doing well in his studies, but at the same time he's pretty immature as to how he's considering his life goals.  He's unconnected with his emotions, despite being in therapy (which, after all, is supposed to help one focus on being in the present with both thought and feeling) regarding a number of key issues in his life.

In both cases my response has to do with the boundary between parents' responsibility for the physical safety of one's child and parents' responsibility for the emotional safety of one's child.

We hate to see our children hurt, but at the same time our ability to protect them from hurt is finite. Toddlers are bound to take their first steps, and will fall and scrape their knees.  Or their elbows, chins or noses.  These are indeed painful lessons, lessons that teach, hopefully, how to hold ones self in the world.  I remember when my youngest was in his teens and we were playing catch - a reasonable activity for a father and son to do.  The ball got away from me and when I ran to retrieve it I mis-stepped and fell, ripping open a patch on my elbow.  Even as an adult we sometimes have to learn lessons of childhood about safety.

There are some things we can do to protect our children from physical harm. Giving the keys to an inexperienced driver is unwise.  At the same time parents of children, both on and off the autism spectrum, have to assess carefully how much they can protect their children from the reality of life's scrapes and pain.

I often say to my clients' parents that the older the child, the less influence a parent has, parental influence fades as children age.  The amount of influence we have on a twelve year old is very different than the influence we have on that same seventeen year old.  Knowing the individual strengths and challenges of one's child is skill that parents have to practice is an ongoing challenge, and some parents are better at it than others.  Some kids make it easier for parents to learn than do other kids.

Providing safety is the number one job of parents - think of the care parents take with their newborns. Over time, however, the ability we have to protect our kids grows thin.  Our job as parents is to measure, with care and accuracy, when we do, and when we do not have power over re: our ability to protect our children both physically and emotionally.  It's a tough balance, but it's what parents are charged with in parenthood.

Pushing Past Comfort, Spectrum or Not.

As with all postings, materiel changes to description of individuals is made to protect confidentiality.

A client of mine (neurotypical) recently told me of a coined phrase he learned from his sales team. His sales were OK last year, but not at the pace he wanted to meet the needs of his family causing not a small amount of stress at home.  The phrase is "pushing past comfort" to get the desired sales results. He's been doing that with his supervisors and has weekly and monthly sales goals and marketing strategies he's responsible for to keep him on track.  So far he's optimistic about the system and has a positive, active plan to increase his productivity this year.

That same day another (neurotypical) client of mine came in, struggling with a new relationship she was in.  She's been in a number of relationships in the past and has found herself in a pattern where the pace of the physical relationship is faster than the pace of the emotional relationship.  This is not uncommon in our society, a result, I believe of the "free love" explosion of the 60's and 70's when sexuality became an end unto itself, creating a great wave of permission for communication before, during and after physical intimacy which is a good thing.  But in her case (and in the case of many people), she's ended up in a pattern where the physical has preceded the emotional and she's struggling with how to change that with her new boyfriend.  She didn't use the language, but is also "pushing past the comfort" of her old patterns, of which I'm very supportive.

The same day (really), another client came in who might be on the autism spectrum - I know lots of clinicians who might diagnose him with high functioning autism, though I'm personally more conservative about throwing the label around without more clear data (happy to discuss that elsewhere if you want).  He's one of these guys who's extremely bright and extremely anxious - his anxiety first evidenced since some emotional challenges, not trauma, he experienced at an early age - but he's never been able to treat the anxiety effectively despite great efforts on his part and the part of his mom, step dad, many psychiatrists and therapists.  He's about to venture into a new career at which he's eminently qualified, but it will demand some social schmoozing within the professional network in his field. He's ready.  He's planned out what to do, how to do it, even though doing so "pushes past his comfort" to which his anxiety traditionally restricts him.

The day before a (neurotypical) woman in my office was struggling with her role as a step mother to her husband's two young children.  She fears if she doesn't bend over backwards - and then some - for the kids, her husband will be upset with her.  We began to discuss where and how she learned that kids needed to be indulged (as her mother did with her) and whether that's a necessary pattern to continue in her current family.  It's painful for her for a variety of reasons, and I thought about "pushing past comfort" zones to accomplish one's goals.  I think she's doing this as well.

Carl Jung, a psychoanalyst who famously broke with Freud in 1913 was a proponent of "the collective unconscious," a phenomenon positing that different people can have shared unconscious experiences.  I've not really studied Jung, but from time to time I have a "collective unconscious" experience.  Recently, it seemed to span these four clients....maybe....  Why maybe?, Because as I consider it "pushing past our comfort zone" is a common part of the human condition.  Isn't it what we do when we're tired of whatever status quo we're in and want something more in our lives?  I don't know the answer.  I only know that last week, when I had these four folks in the span of two days, all of whom had this theme in their lives, it gave me pause to wonder about how they, and I, push past comfort zones for the sake of positive change.

Tears for Kids I Never Met: Autism and Grief

As with all posts on this blogs, materiel changes in the descriptions of clients have been made to insure confidentiality.

It happened somewhat suddenly.  She's a 10 year old child with high functioning autism who has been coping pretty well with her parents' divorce last year.  We were discussing, again, the death of a grandparent a couple of years ago - a topic she often revisits, her child's view of heaven where grandma is, where grandma will greet her when it's her time to go to heaven.  The topic of prayer came up and she casually mentioned her prayers for a child she knew from her school who had been injured in a freak accident and was in the hospital.

Mom mouthed to me that the peer had actually died that morning while her daughter's head was turned in my direction clearly hoping to avoid the discussion right now when suddenly, innocently, she turned to her mother and asked if her friend would live.  Mom was caught a bit by surprise, just as the accident and death of the classmate had caught her by surprise.  She gathered herself strongly, softly, and told her daughter that her friend had, actually, died that morning.

The pain was honest.  Immediate.  She cried out after double checking what mom had said the way we do when we're preparing to absorb something for which we are unprepared, and then buried her head in her mom's lap, crying and talking at the same time about how sad it was.  She then came to me, her arms spread open looking for the physical validation of life a  hug provides and cried on my shoulder before returning to the comfort of her mom's arms.

Mom went on to note with sadness about another child who had died in another freak accident a couple of years before.  Coincidentally I had known of that tragedy via another client who  had known that child. It all came back to me; the description of the circumstances of the child's death, the mother's attempts to cope, my client's struggle to absorb the reality that mortality brings to the forefront in the face of a tragedy.  A surprising and sudden turn of events that moved us so deeply.

And all three of us were suddenly tearful together.  My 10 year old client, openly crying at having to learn the lesson of death again.  Her mom, having had to tell her what no parent wants to tell a child - the inherent message that challenges the assumed safety we expect from life.  Me, adjusting to the rapid sequence of events that afternoon; the tragic death of my client's friend and my concern as to how this sweet little girl would cope with the complexities she suddenly faced; the coincidental review of the another child's death with the immediate recall of the pain that loss brought to another client.

It was not quite bittersweet - there is nothing much sweet about death. Yet as I consider the meeting now, there was such love in mom's eyes for her daughter, and the daughter's seeking comfort from her mom as she struggled to comprehend the frailty of existence.  My fullness of emotion at the depth of connection this child with autism has to her friends and family.  Maybe, as I think of it, there was an unlikely and unexpected kind of sweet to the moment.

Autism: The New Racism?

On December 6th, 2016 our nation may have turned a new corner in the annals of hate.  Richard Spencer, who advocates that the United States become an Aryan nation - a man who hides behind a seemingly benign and objective "National Policy Institute," was confronted when he spoke at Texas A&M about his favorite topics, like the need for oppressed whites to have their own country.  What was curious was his response to the person exercising the first amendment right of protest - the same right he invokes when he plants the seeds of hate.

His response to the woman opposing him was "Cool down the autism...." followed by "...look how fat you are."

So it's come to this.  The epithet that people, from adolescents to those of hard core of hate will now be using as a slight is the accusation that someone has "autism." It reminds me of my high school days when we used "mental" as a bash.  Now millions take Prozac and it's quite normal.  15 years ago when my kids were in high school and the put down of the day was how "gay" something was.  It took a lot of work for us to teach them that sexual orientation was not a topic to bash.  It took a lot of work for us to teach our children that demeaning others was wrong.  Period.  Whether sexual orientation, weight, religion, we worked hard to instill in our children that hate speech is wrong.

So now, someone in the spotlight of the news, using the 15 minutes of fame accorded him by Andy Warhol accuses another opposing his hate baiting of "autism."  Autism that can be cooled down.  This is not the forum to review what autism is.  His ignorance won't be changed by reviewing the neurological complexities and subtleties of the disorder, the breadth of autism's wake or the intensity of its most severe presentation, the emotional or financial expense endured by families with a child with autism.  I imagine those who believe in the unique nature of "whiteness" would also believe that autism is an affectation of some sort that can be "cool"ed.

That spotlight, one in which the Nazi salute is normative, is one that sadly is influencing the ignorant quotient of the nation.  The thought that his brand of hate is now legitimized in the bashing of autism as the new "N" word is as appalling as it is absurd.  But racism and hate, as we know, is indeed absurd.  Absurdity seems to now be the new norm.

A junior high school mentality might be, can I say, forgiven?  After all, people in their early teens are not those to whom we look for moral guidance.  They're still developing.  But Mr. Spencer is an adult. Maybe we can blame his parents for not intervening?  Maybe it all started with his potty training?  Nope, he's just a hater.  And even people with autism know that hate is wrong.