by Howard S. King, MD
The case of the B. family involves parents' concerns with "the terrible twos" and how a pediatrician might address a common behavioral problem in a single visit.
The conclusion is that a useful approach would take into account the unique aspects of the family situation, as well as the parents' past history. The relationship that develops between the parents and the pediatrician as a result of such a consultation would very likely support the parents' ability to gain more insight and better skills.
Parents are often competent to arrive at the resolution of most of their problems when they are provided with the opportunity for extended parent-physician interaction. While the child in the case of the B. family ultimately did well, the discussion of that visit does not imply that this was the only way or even the best way to approach the problem. What it does offer is one way of responding to parents' concerns.
Parents need the opportunity to express their concerns, to discuss their views about the origins of the problem, the contributing factors, and their fears about what might happen if there wasn't any intervention. Our task, as pediatricians, is to consider whether we wish to help parents look at alternative ways of dealing with such a child and, if so, to find out which approach makes sense for the parents concerned.
Mr. and Mrs. B., came in with their daughter, Suzanne, at twenty six months of age, for a well child exam. I asked, "How are things going?" They replied, "She's going through the terrible twos." I asked, "What do you mean?" This is how Mrs. B. described her daughter:
She is crabby, fussy, she is going through a whining stage. I listen to her whine for half an hour until I'm ready to pull my hair out. She seems unhappy. It baffles me. This whining kid is driving me batty ... I have this thing about candy. My husband sees her upset and says, "A little bit of candy won't hurt." So when I come home, the first thing I hear is, "Candy, candy!" She'll cry for half an hour if I don't give it to her. I don't want to put her upstairs. I feel so frustrated. What am I doing wrong? ... When people see her behaving this way, they say, "What's the matter with her?" I'm mortified. How do I get her to understand that this is not acceptable behavior?
Comment: The problem has been defined. While both parents described the problem, it was Mrs. B. who felt more intensely about it. We also get the feeling that perhaps each parent feels differently about the behavior or, at least, their strategies for dealing with it are different. Furthermore, Mrs. B. sees herself as responsible for her daughter's behavior, as the one who is going to have to find ways of modifying it. She is clearly vulnerable to how her peers regard Suzanne's behavior.
I went on to ask, "How long has it been going on for?" "Four to five months," they replied. "Is it getting better or worse?", I asked. "It's about the same," they said.
Comment: There is no point making a mountain out of a molehill. If it had just begun a week or two before, particularly in response to some obvious or self-limited incident, I probably would have brushed aside their concern. I would have said that it was quite common at that age and would anticipate that the problem would be resolved before long. It was very evident, however, both by the way Mrs. B. described the problem and by its long-standing nature, that the problem required more clarification.
I then asked, "Who is more concerned?" Mr. B. said, "I regard it as a phase. It bothers my wife more. She gets more upset. I'm more lenient. I tend to be able to listen to it a bit more easily."
Comment: To make a recommendation, one has to be able to understand the problem. To understand the problem, it is important to know who is having trouble coping with the child. On the surface, it appears as if Mrs. B is having most of the difficulty. If so, it is necessary to understand the problem from her perspective before we can offer her guidance and support.
On the other hand, Mr. B. may well be playing an important role, as we shall see. We already know that he is the more lenient of the two parents. Might Mrs. B.'s role be made easier, would she seem less of a "witch," if he took a more active role?
I then asked, "Why does it bother your wife more?" It was apparent that Mrs. B. was well along in a pregnancy which, incidentally, had been unplanned. They had become reconciled to it and were looking forward to the new baby but it had certainly changed some of their immediate life objectives.
Furthermore, Mrs. B. had been severely nauseated during pregnancy. This made it difficult for her, not only in her parental role but also in her professional work as a psychologist which she was trying to maintain throughout her pregnancy. I might add that Suzanne was the second child. There was an older daughter who had no behavior problems.
Comment: It was obvious that this was not simply a problem of a child going through "the terrible twos." There was, in addition, a mother and father working through an unplanned pregnancy with uncomfortable physical symptoms, Mrs. B. trying to cope with an active career, not to mention the responsibilities of caring for an older child. Wouldn't any of us feel overwhelmed?
What about the older child? "Suzanne is more high strung than her (older) sister," the father said. "She never stops from the moment she wakes up!"
Mr. B. said: "She scares her sister. She's such a bully. She's going to be a wild one! I never realized she'd turn out that way!"
Comment: Was Suzanne born this way or was it a function of being the second child, going through a commonly difficult developmental phase, in the midst of some overall family stress? I saw it the latter way. It was good that Mrs. B. had at least derived some feelings of competence from how well she had raised her first child. On the other hand, the contrast between Suzanne and the older sister certainly made it confusing for her mother.
Note also the gradual emergence of labeling with such comments as ..."She's such a bully" or, on another occasion, ..."She's such a con man!" (Mind you, we are talking about a two year old. Yet is this parent any different from the rest of us? When any of us talk about our own children, we can forget about whom we are talking.) In a similar manner, listen to the expectations ..."She's going to be a wild one!"
But we are getting ahead of our story. Did I know what I was dealing with? Was this just a management problem or was I involved with a child with many difficulties? I decided to take an inventory of how the child was functioning.
How was her appetite? "Terrific," they replied.
Was she still on a bottle? It had been discontinued six months before.
Did she have any other habits or fears? "No!," they replied.
How was she physically? Her parents wondered about her ears; she had had a number of earaches.
Friends and relatives had asked about her teething. The teeth were normal on examination.
I asked about Suzanne's sleeping habits. She had begun to climb out of her crib a few months ago, so her parents had put her in a bed. She seemed happy with her bed but she was getting up in the middle of the night two or three times a week and would have to be put back to bed.
Comment: Questions about ears, teeth, and general physical condition are very appropriate. It would be folly to give parents advice about coping with a developmental phase and miss a significant physical problem. Once having satisfied ourselves that Suzanne was in good shape physically, we can go on to helping the parents cope with their child. Incidentally, in my view, teething rarely causes anything in children. At the very least, an overemphasis on teething-related behaviors is often a misplaced concern and may distract parents and doctor from confronting more relevant issues.
In addition, we discovered that Suzanne was functioning well in most other aspects of her development. Sleeping is another matter but that will be addressed later on, under Recommendations. The parents and I could turn our collective attention to the issue of the terrible twos in an otherwise physically well, developmentally normal child.
How had they tried to cope with Suzanne up to now, I asked Mrs. B. She replied:
I've read so many books. I've tried everything with her. I put her in her room, saying ..."until you stop your whining ..." On the other hand, I try to be an understanding mother. Nothing seems to make a difference in her attitude. I'm not handling it well. A friend of mine had a child with the same problem. She talked about it with a child psychiatrist. He told my friend that her child needs limits. I tried it with my child. It didn't work. I think I'm being consistent, though.
Comment: A book is good for background and even, at times, for specific advice. But, given bright parents who are dealing simultaneously with a variety of issues, a book, by itself, is often insufficient. Most of us need to reach out to another person who objectively and empathically can help one talk and fully share one's thoughts and feelings. We may learn from the experience of others but, essentially, we all write our own book.
Furthermore, how do we cope with our mixed feelings about the child, her behavior and the methods of coping with it? It is good to be flexible in dealing with children but is that what this parent is doing? Is she reflecting her own temporary insecurity, her attitude towards herself and her husband, or perhaps feelings derived from how she herself was raised?
What else can we learn from listening to Mrs. B.?:
I know it has something to do with me. Suzanne does well with the sitter. She's very strict with Suzanne. But when I come home at night, everything explodes!
Comment: We know a lot already. This child is going through a phase that is frequently difficult. Otherwise, she is functioning well. The parents are trying to cope with a pregnancy, dual careers, divergent attitudes about approaching this child. It is Mrs. B. who is in the most pain about the problem, who is trying to figure out why it's happening and what to do about it. While Mr. B. will appreciate all suggestions from me, it will be with his wife that an alliance needs to be formed.
By her statement that, "It has something to do with me!", parents and pediatrician are beginning to move into a climate of bringing about change. It is not a matter of who should feel guilty. That is irrelevant. It is a matter of trying to help the vulnerable parental figure in the parent-child relationship understand the roots of the problem. We can then help that individual rediscover his or her own coping capacity.
While there might be many more questions one could ask, there is one that might be especially useful. I ask it to help me understand if there is any other reason why these parents might be frustrated or intimidated in dealing with their child over and above the factors cited. I might ask them, "Does this child remind you of anybody else in the family?" Or, put another way, "Do you worry about what is going to happen in the future?"
How did the parents answer these questions?
Mrs. B: "I worry about it becoming a habit of hers if she doesn't get her own way ... She scares her sister, she's such a bully, she'll be a wild one ..."
"Like who?," I asked.
“Well, I have a younger sister with a terrible temperament . It scares the heck out of me. She's the black sheep of the family. She was married at sixteen and she is already divorced. She has such a negative disposition. I wonder if it is hereditary."
Comment: In my opinion, it is not hereditary. Mrs. B. and her husband are very different from Mrs. B.'s parents and their personalities. Her parents had a difficult marriage with stressful life circumstances. Her sister's personality was possibly an unfortunate adaptation to that relationship.
Unfortunately, parents often worry that traits such as those demonstrated by Mrs. B.'s sister might be hereditary. In the absence of any current family problems, these traits, when passed on to the next generation, are more likely a result of a self-fulfilling prophecy. In contrast, Mrs. B. had a strong marital relationship with much love and mutual support. It is common in dealing with our own children to forget the many sources of strength in our current family life.
It would be unrealistic for one visit to result in the disappearance of "the terrible twos" in Suzanne. Nevertheless, I would suggest that as a result of this brief visit much useful information was shared and the process of resolution was initiated. Looking back, what had been accomplished in this single encounter?
Mrs. B. was looking forward to the end of the terrible twos. She was also looking forward to the end of a long, unplanned, physically and emotionally difficult pregnancy. It was probably unlikely that she would really feel better about Suzanne until the end of her pregnancy. Supporting her and her husband during that time, reassuring them that this, too, would pass, was tantamount to saying that the terrible twos, one day, would also pass.
Substitute "stressful" or "painful" for "terrible." Who are we to say that this period shouldn't be stressful? Think of what we are asking the child to do, even in the absence of the family stress that the B.'s were experiencing. Suzanne was being asked to develop some control of her free will without the benefit of language and minimal ability to reason. Add to that the fact that her parents see her as "independent" with "a mind of her own." Suzanne must try to cope with a mother who says of herself, "I expect a lot from people."
Parents and their children can have it both ways; the child's free spirit can be preserved and even nurtured. It just doesn't have to be at the expense of parents. Parenting styles are often characterized as either permissive or authoritarian. Neither approach may end up being overly satisfying to the parent or the child. You can encourage parents to create a comfortable style that captures parts of both, perhaps "authoritative," which can be more gratifying to both parent and child, by virtue of its flexibility and mutual respect.
Finally, I suspected that Mr. B. might be more afraid of confrontation than his wife. Superficially, he seemed more easygoing than she. It is possible, however, that the use of candy is something he might have picked up from his own family growing up. Avoid confrontation at all costs -- give the child something to eat! (And making his wife feel doubly guilty to boot!)
There is nothing wrong, of course, with giving your child a sweet as long as you're not doing it to thwart the expression of a feeling. There is nothing wrong with the child having a tantrum. She can cope! So can her dad! And think of what dads might learn as they give their children permission to express negative feelings.
It can make us think back as to how we were raised and why. Our children can teach us something about ourselves, just as we attempt to teach them!
Should you expect more insight from a parent who is a psychologist? We should not, nor should we from a parent who is a psychiatrist, pediatrician, social worker, teacher or nurse. When we are dealing with our own children, we are all in the same boat -- our rational, objective side often gets deferred and the intuitive, gut side comes to the forefront, as well it should in the early years of our children's lives.
Encourage parents to formulate a small goal and, fortified by success in achieving that, parents may feel competent in other areas of interaction with their child. Thus, I suggested to the parents that they develop a plan for helping Suzanne sleep through the night, initially by insisting that she remain in her own room. What does this accomplish? By so doing, we help parents be more assertive with their child in an appropriate way, and we help parent and child cope with the pain of separation.
Parents begin to feel more competent by making a reasonable demand and sticking to it. The child begins to feel more competent by discovering that she can cope with separation, and everyone becomes a winner. In addition, by getting more rest the parents are better able to cope with the child's demands the next day! They have less fatigue, more flexibility and good humor.
Indeed, once that was accomplished, Mr. and Mrs. B. as well as Suzanne seemed to have a real diminution of tension. The child was already in the process of being trained. Once the sleep problem had been engaged and mastered, the parent-child relationship began to take on an easier tone. The problem regressed briefly after the new baby, a little boy, was born. Once it turned out that he was healthy and began to sleep through the night, Suzanne welcomed the role of the big sister and she, too, slept regularly without interruption.
Finally, a visit like this is not "the end of the story." Rather, it begins a new chapter in family life for the parents and can establish a precedent. The parents can look forward to future opportunities when they can share a concern, share a feeling and, in the context of a mutually respectful relationship, continue to find answers to the new problems that will inevitably emerge.
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I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center, and the families of my medical practice.
I hope you find this site useful and encourage any comments.
- Dr. Howard King, M.D.