Judy Garland

 

Thinking about Judy Garland, having  just seen “End of the Rainbow” http://articles.latimes.com/2013/mar/16/entertainment/la-et-cm-tracie-bennett-end-rainbow-20130317, with fellow psychiatrists, we engaged in a heated debate about the nature of her suffering. ?Bipolar, ?ADHD, was the launching pad for the discussion, and yet my thoughts turned to her horribly sad childhood in which, she made money for the studios, and in the process, she was fed prescription drugs to keep the “machine” going. “Trauma,” I said firmly, in trying to understand this icon. She seemed robbed of a time in her life to “play” even though some might say that acting is a form of playing, Judy Garland had to play like she was told and so, by definition, this was not the kind of play in which she could make up her own rules, and have a time in her life in which her activities were inconsequential. This left an inner emptiness, a “zombie state,” as a colleague of mine says, in which she could never experience the sensation of being alive, but rather she enlisted her superego to do what she “was supposed to,” thereby leaving her feeling without satisfaction or fulfillment. She never had a chance to experience her ego, as her superego was running her life, from such an early age. Her many husbands, it seems to me, provided this superego, until one of them tired of the emptiness. She never seemed to know herself, to know her ego, and as such, she could never find a path towards happiness. As Ray Bolger, her co-star in the Wizard of Oz, succinctly stated, “”she just plain wore out.” Like a machine, the gears could no longer turn. Sad, sad, and sad. There is no diagnosis, as far as I can see, but only an incredibly talented woman who never developed a sense of herself. What do we call that? I call that child abuse.

Play Class: Update

My class is called the “Clinical Practicum,” but I would like to rename it the “Play Class.” I love that I am teaching students, hovering thirty, with so much education under their belts (along with huge debt), and yet we are talking about how to play, both for our own enjoyment and for the therapeutic benefit of our patients of all ages. We lament together how play has somehow gotten lost in our society of overscheduled children and adults. “What happened to the public schools?” One student asked. This seemed to be the central question. With parents extremely anxious about where their child goes to school, has come a pressure on children to justify the additional effort of either a private school or a public school which is a burden geographically. Now that most children are driven to school, this creates a dependency on adults in which the child is then driven to after-school activities. The social norm, at least in West LA, seems to dictate that if the child is not learning a new language, involved in a sport, and learning an instrument, then he/she is somehow going to suffer as he/she enters into the “real world.” “We need to remind parents that children need play time to expand their imaginations and develop creativity.” I say firmly and repeatedly. “Yes, but we don’t have time to do that with our fifteen minute appointments,” they respond with frustration. “Yes, so we need to lobby for more time with patients.” I say, again, feeling argumentative, even though we are all on the same page. “There are not enough child psychiatrists to play with all the children that need our help,” another student says. “Yes, that is true, but we can promote the value of play such that we can help other professionals play with children in a therapeutic manner.” I say, alluding to the idea that our job needs to be much broader than psychopharmacology. The class ends with what I call “positive frustration.” We all want to see the field change. We all want to play with our patients.

The Anxious Kid/The Disorganized Mom-Chicken or Egg?

   Leanne, fifty-one, is always confusing appointments, losing pieces of paper, and is in general a very disorganized person and a disorganized mom. Lesley, her twelve-year old daughter, feels she can’t count on her mom to follow-through in a timely fashion on scheduling doctor visits, or picking up things she needs so that she can be in the school play. Lesley compensates for Leanne’s unreliability by making a multitude of lists in which she tracks what needs to get done. At the same time, Lesley is constantly in a state of anxiety in which she is worried that she will not complete her task list. Lesley’s dad has suggested that she take medication for her anxiety. I question Lesley, “do you think you would be so anxious if your mom was more organized?” I wondered if Leanne’s unreliability made Lesley feel fearful that so much of the responsibility of moving forward in her life now fell on Lesley since her mom was not providing a safety net for her. In other words, the maternal role for an adolescent child is in large measure the job of making sure that the teenager can go to their various activities and that they have the right supplies. Without this infrastructure, teenagers are going to be impaired in their ability to engage in multiple life experiences.

 Lack of reliability can create anxiety in someone who is dependent on them. That is straightforward. Am I “blaming” Leanne for Lesley’s mental state, or am I understanding what Lesley is up against? Am I stepping on the therapist’s toes, by suggesting that the more Lesley understands that she is anxious because her mom is disorganized, the better Lesley will be able to cope with the demands of her life. The nature/nurture debate continues. Lesley is probably wired to tilt towards anxiety-an internalizer as we say. Her environment exacerbates her condition. She can learn coping skills and she can probably also benefit from medication. This is not a binary system. Yet, our brains wish for binary. We want answer, and sometimes that answer is medication. Multiple answers are usually harder to grasp, especially in crisis. Staying broad-minded is the goal. Lesley is going to do well. She needs help understanding her mom and her mom’s frailties, and she also needs help understanding the vulnerability in her brain to be anxious. She is up for both of those tasks. So, chicken/egg, does not matter.

Nature or Nurture: Will The Debate Ever End?

   Daniel http://shirahvollmermd.wordpress.com/2012/02/07/the-aggressive-child/ is out of control in that he throws chairs when he gets frustrated with his video games. He punches his mother when she asks him to do homework. Is the problem a parenting issue or a mental health problem or both? Although seemingly complex, the issues become straightforward. All children, especially aggressive children, need to have very clear limits: a “holding environment” as Winnicott has taught us. By clear limits, I mean that Daniel has to be told that hitting is not acceptable. He needs help to use his words when he gets frustrated. He needs to be exposed to video games which are age-appropriate. He needs to have guidance with self-regulation when it comes to eating and sleeping. The parents need to make sure that he eats well and has a regular bedtime. They also need to make sure that the school is attending to his academic and emotional needs. Finally, they need to make sure that Daniel is exposed to playdates so that he has the opportunity to learn social behaviors from his peers. When all of this is in place, and Daniel still has problems with frustration and aggression, then the discussion about diagnosis and medication management needs to begin. It is not that Daniel’s parents are responsible for Daniel’s aggression, it is that Daniel’s parents can provide the basic nurturing environment such that we can see that even with a clear “holding environment” whether Daniel can control his impulses. It is hard to know if Daniel can control his impulses when the environment is chaotic and unpredictable. In this latter circumstance, many kids, with or without a mental illness, become anxious and physical. I think I am stating the obvious, and yet controversy ensues. What am I missing?

The Oedipal Triangle: Freud Lives

  Elaine lives out Freud’s hypothesis that negotiating the oedipal triangle is one of the big challenges of development. Elaine is  thirteen, loves both her parents, yet her parents do not love each other. Gloria and Edward, Elaine’s parents, feel that it was a mistake to get married, but they cannot get divorced because “it will hurt the children.” Instead, Gloria and Edward live completely separate lives. Gloria goes to Church every Sunday. Edward does not think much of religion. Elaine is forced to go to Church, even though Edward says “that’s ridiculous.” Elaine is rude to Edward, and by Edward’s report, Gloria secretly encourages Elaine’s disrespectful behavior.

   Crisis, Elaine’s crisis, has forced Gloria and Edward into my office. Elaine got suspended from her parochial school. Edward is not too unhappy. He wanted her to go to public school any way. Gloria is quite upset as there are few other school choices which suit Gloria’s criteria. Nevertheless, both Gloria and Edward are worried that Elaine is having behavior problems at school. They want help for Elaine, but they are not willing to compromise with each other. Elaine is torn between pleasing her mother and alienating her father or the other way around. Elaine cannot see how to navigate her family life such that her parents are both happy and as such, she is acting up at school in an attempt to bring her parents together, or so it seems to me. By contrast, if Gloria and Edward could present a united front, be they married or divorced, then Elaine could identify with her mother, but still feel the love from her father: a successful oedipal resolution. Elaine’s inability to come to such a resolution creates such inner torment that following the rules at school seem nearly impossible to her. Without Freud’s understanding of this oedipal triangle, it would be more difficult to articulate why Elaine is having behavior problems. Freud did not help us treat kids like Elaine, but he sure helped us understand them.

Teaching Psychoanalysis and Child Development: Together Again

 I am back to my teaching role, that I posted over a year ago about how sad I was to end my class. http://shirahvollmermd.wordpress.com/2010/11/18/the-last-class/ Now, I am with five new students to me, although they are second year students, at a psychoanalytic institute in town. This is not the psychoanalytic institute I trained at, so although I have taught there for years, I still feel like a visiting professor. Perhaps that is because I pay dues to the organization that birthed me as a psychoanalyst. Like families, psychoanalytic training is a developmental process where there seems to be undying loyalty to where you started. The personal and professional transformation that takes place as one goes through training is hard to articulate, yet it feels like a major personal growth spurt, with all of the tumult of a second, and maybe for some of us, a first, adolescence.

  Our first two-hour session is a meet and greet along with reviewing three articles that I assigned to them. The meet and greet part is fun and interesting, but of course, I start out a bit nervous, as I enter into an unknown world of a class, like all classes, has a dynamic that I am not familiar with. I don’t know who likes to talk a lot. I don’t know who is shy and reserved. I don’t know if one person likes to dominate another, but I will find all that out in short order.  Meeting these five new folks was inspiring. These are five (three women, two men), hard-working individuals who are devoting a substantial amount of time and money re-tooling themselves to work in their private practice with  psychoanalytic tools. I give them a lot of credit for that, given how hard it is to find the resources to be so focused in this day and age of continual multi-tasking.

  After about twenty minutes, I calmed down internally. We were getting to know each other, and the enthusiasm carried us through the uncertainty of whether we could all work together for the next ten weeks (eight week class with a two week break for the holidays). We then dived into the material; material I love to talk about. We talked about how important childhood is for the development of enjoying leisure time. The “latency” of childhood refers to the only time in one’s life which is free of the sexual pressures of pursuing bodily passions. We discuss how schools influence the childhood sense of morality and how certain schools reinforce the parents’ value system over others. We have a rich interchange involving patients, personal experiences, and raising one’s children. Understanding the developmental train, leading to the formation of personality is fascinating. It is nice to share that fascination with like-minded curious and dedicated folks. Like my blog, my teaching is a labor of love. The romance has begun.

Moderate ADHD

   Larry, eleven, entering sixth grade, is about to enter into the pressured-filled world of applying to seventh grade, secondary school. Like the pressure of eleventh grade, where kids have to seriously consider how hard they work might impact their choices for college, so too, in the private school world, going to sixth grade forces kids to pay attention to their grades, not only for the sake of pride, but for the practical reason that their performance in school, to a large measure, will determine their secondary school. Larry is thrown into this pressure cooker, with the added burden of ADHD, and as such, although he is very bright, he does not perform up to his potential. He does not check his work. He hurries through his tests. He often forgets to turn in assignments. He has tutors, extended time, and he is on medication, but with that support, he is still underperforming, based on the discrepancy between his IQ and his grades. Should the parents try harder to have Larry perform in a way which matches his IQ? I wonder. Or, should they accept that ADHD limits his scholarly performance and that is just who Larry is? Maybe. Or, as Larry’s parents did, should they tell Larry to work harder because it is “really important.” 

  Understanding ADHD, like understanding anxiety, is a deep issue. Larry’s mom, Carol,  has ADHD, yet that does not seem to give her empathy for Larry’s struggles. Carol did fine in school, although now she has trouble organizing her life. I explain to Carol and Joe, Larry’s parents, that helping Larry with medication, educational tutoring, and extended time, is useful, it is also useful to understand that Larry may not perform to his potential, and maybe, just maybe, that is fine for now. Yes, he may go to what they call a “tier two” school, but maybe that is appropriate for him. Larry, like many ADHD kids, tend to be late bloomers. “Maybe he won’t hit his stride until college and maybe that is fine for him,” I say, knowing that Carol and Joe are thinking that he won’t go to a good college unless he goes to a “tier one” secondary school. Although I understand their concerns, the linear nature of their thinking concerns me. Like so many parents, there is a feeling that if things don’t go right when the child is eleven, (or even earlier in some circles), then the child will then be denied all of the privileges of the élite. There seems to be little allowance for deviating from the “path”. There also seems to be fear that such deviation will land that child in a “different” world, a world unfamiliar to the parents. It is not that Carol and Joe do not want the best for Larry. They do. Understanding what “the best for Larry” means is the tricky part. I offer an alternative point of view of the “best for Larry” based on my understanding of the disabilities associated with moderate ADHD. Layered over that, I feel for Larry and his struggles. Larry is a nice, sweet and charming kid. I wish he could just go seamlessly into the seventh grade. Unfortunately, that is not going to happen.

ADHD: Slowly Developing Brain

   “When is she ever going to grow up?” Arline, the mother of Jolie, age eighteen, asks me, with a tone of frustration, impatience and anger. “ADHD tends to cause a three-year lag in emotional development,” I try to explain to her in a flat tone to say that Jolie is going through a slower developmental trajectory than the average child her age. “Yea, but look at her,” Arline continues, “she is not motivated to do her homework. She is texting all the time. I mean all the time.” Arline continues with her frustrated tone. “I think you should use an incentive program for her to do her work, but at the same time, I think you need to understand that she is a late bloomer, so you need to have some patience with her development.” I try to explain in a way which is supportive to Arline and Jolie at the same time.

    Developmental change, the rate of development, is a variable in personality which is hard to contemplate because we cannot measure it. I imagine that the brain is developing, along with the other organs in the body, and as such, the DNA instructs this rate of development, as it does for height. Everyone grows at different rates, but most people stop growing around twenty. The rate at which people achieve their final height varies. Some people are done at twelve, whereas others are still growing in college. Girls tend to start their growth spurt before boys, and they tend to stop growing before boys as well. Brain development is probably similar. Girls mature before boys. In general, they reach their developmental milestones earlier. They develop speech sooner. Girls, in general,  are not smarter than boys, but a three-year old girl who has sophisticated speech seems smarter than a three-year old boy who is still speaking like a telegraph. Understanding that the brain is also developing at a rate which we cannot measure, but we can infer from the type of decisions the person makes, helps us understand that growth is in progress. With this understanding, intervention can be tailored to the person’s developmental, not chronological age.

    Arline looks at me and says “do you have children?” She seems to be trying to figure out if I have any idea about her parental frustrations, her worries, and her guilt. “I am happy to answer that question,” I say, “but tell me why you are curious. Do you think that if I have children, then I have a better idea of what it might be like to be concerned about how a child is eventually going to be independent, whereas if I don’t have children, then I would not be clued in to the feelings associated with having a child who is not responsible.” I ask, trying to guess why she is feeling so alone in our session. “Yea, I am not sure you understand how worried I am.” Arline says with deep feeling. “I am sorry if I have not conveyed my understanding, but I feel as if I do understand,” I say, trying to state that although she feels alone, I can feel, at least in part, her trembling anxiety over Jolie’s future. “I am going to think about this slowly developing brain idea, but right now, I don’t get it,” Arline says in a calmer voice. “Think about it,” I say, feeling like Arline is a bit more open, and perhaps more able to accept Jolie’s biology. “It is not easy being a mom,” Arline says with lightness. “Yep, I get that,” I say, mirroring her easy going tone. “There is a lot at play in helping a human being develop,” I say, stating the obvious, but feeling like I need to express the complexity of parenting. “More than I ever thought,” Arline says, allowing us to connect in a warm way.

Child Development

     Motor, fine and gross, development, language skills, social skills,  cognitive skills and emotional vulnerabilities all unfold to different skill levels and at different rates of change such that a child can seem “odd,” or worse yet, be diagnosed with Asperger’s Disorder, if his development is off track of the majority of other children. Liseth, age six, has an IQ of 170, as determined by the Stanford-Binet IQ test, a test which tends to give children higher IQs than other tests, but even taking that into account, Liseth is a very bright child. She has poor gross motor skills; she has trouble playing catch. She appears not to recognize faces such that other kids that she has seen repeatedly seem unfamiliar to her. However, after a lot of exposure to certain playmates, she begins to recognize them and show them signs of familiarity. As a result, when a child who recognizes Liseth, but Liseth does not recognize him, there is an odd interchange. It is as if there is a facial recognition part of the brain which is either undeveloped or nonexistent in Liseth’s neuroanatomical structure.

    Liseth is impulsive and inattentive to things she does not care about. She loves learning about architecture, so she spends a great deal of time on the internet looking at building design. On the other hand, when it comes to waiting her turn to play games, she struggles with the wait. She does not pay attention to follow instructions such that she will be in her own world while a teacher is telling the class to move on to the next subject. As such, many of her teachers have experienced her as “odd”.

  Liseth also suffers from anxiety; she thinks about catastrophic events and she worries that something bad will happen to her parents. She has trouble sleeping because she is preoccupied with negative and scary thoughts. She speaks about her gloomy thoughts in an articulate manner and she has since she was two. Liseth’s verbal skills far exceed her peers.

   Liseth’s mother, Ella, was just like Liseth when she was a child, except that no one thought Ella was “odd”. Ella grew up before the diagnosis of Asperger’s floated around in our universe. Ella explained to me that everyone thought she was “insanely bright” and so they cut her a lot of slack for her “atypical” behaviors.

   My impression is that Liseth is outside of the bell-shaped curve; both in her basic abilities and in her rate of development. In some areas, like her language skills,  she is far ahead of her peers; in other areas, such as her gross motor skills, her developmental delay is significant. Since her skills are not in line with her peers, both her excellent language skills and her poor motor skills create a social liability. Poor facial recognition hurts her too, in the social arena that is. As Liseth develops, as her peers develop, there is likely to be a leveling off, such that the discrepancies in skill level will be smaller. Still, this remains a hypothesis, a guess, which only time will answer. Time is a large variable in development. The rate of change for each child is different, making the diagnosis of Asperger’s Disorder, at least in some children, premature. Until we have a better understanding of  child development, we have to respect that maturation is a dynamic process; one that humbles clinicians.

The Rule-Loving Six Year Old

This blog is part of my series on child development.

This is a time of remarkable changes in social and cognitive skills. This is the beginning of moving towards more independence, both intellectually and emotionally. There is a shift from learning through observation and experience to learning via language and logic. Choices can be difficult at this age, as the child is struggling with the impact on their decision downstream. That is, if they choose chocolate ice cream over vanilla ice cream, then they have to accept the fact that they are not going to eat vanilla ice cream. This realization of the impact of their choices on the quality of their lives can be profound in some children.

The six year old craves affection from parents and teachers.  The six year old is beginning to understand that words can hurt their feelings, and yet at the same time, each person has different sensitivities.

As with every age, structure is important to facilitate adaptation. In the case of the six year old, the structure provides him help with adapting to school. Watching your child perform is critical to their self-esteem, as they need a meaningful audience for their newly acquired skills. Likewise, praise is very important at this age.

The sad part about the six year old is that they are beginning to lose their imagination. Fantasy play diminishes considerably. Six year olds want to collect “real” things and they want to take “real” photographs. They want to engage in the world as if they were adults. The fancifulness of their play is receding.

The six year old loves rules. Rules bind their anxiety so that they do not have to worry about what they should be doing. Left to their own devices, they often develop games with extensive rules and rituals. Order is extremely important. Order gives the six year old the opportunity to feel secure in what would otherwise be a scary world.

This is the age where same-sex play is dominant. Girls and boys play differently. Boy play tends to be rough, competitive and not very berbal. Girl play involves creative fantasy and it tends to be more cooperative. Many parents worry about their child who wants to play with the opposite sex at this age, and yet, play preferences is about temperament, not sexual orientation.

JoAnn Deak PhD has suggested that 20% of girls have a boy-style brain and 20% of boys have a girl style brain. In other words, children at this age want to play with other children who have similar brains.

As feelings are evolving, so does the ability to have a best friend and to have an enemy. Children at six are understanding relationships, both positive and negative ones. As their cognitive skills develop, this is the age of black and white thinking. Things are right or wrong, wonderful or terrible. The middle ground has not entered into their thinking yet.

Group play gives them a sense of security. Clubs are very helpful with this, so there is a draw towards activities such as girl scouts and boy scouts. A group activity such as working on a jigsaw puzzle or planting a garden can feel very rewarding. They need a sense of accomplishment.

Collections are important to many six year olds as this gives them a sense of power. Collecting things reminds them about their place in the world. A collection gives them a sense of uniqueness and a sense of ownership. This also helps them develop a sense of responsibility to themselves.

Reading begins at this age and as such they enter into a new world of story telling. Reading helps them develop ideas which they love to share with others (similar to the joy of blogging). By engaging in the written word, they are better able to understand the feelings of others.

Sharing is common at this age. Part of sharing is the ability to wait their turn, which is part of the larger area of developing self-control. Conflicts can develop, but they can also negotiate to find happiness. They enjoy cooperating for a group goal (eg a play).

In essence, six is the age of loving rules, goals, friendships and appreciation from others. The six year old child is developing new areas of mastery and they want appreciation for that. As adults we still crave the joy of learning new things and  we still crave others to appreciate our growth. Thinking about six year olds reminds us how our past developmental stages are both past and present. As William Faulkner said, “the past is not dead. In fact, it’s not even past.”