The Silenced Child

Part One

An Endangered Art

One

On (Not) Giving Advice

D. W. Winnicott, pediatrician turned psychoanalyst, identified how parents (he refers to mothers because in the time he was writing, the mother was almost always the primary caregiver) naturally know what is right for their child. “No theory is acceptable that does not allow for the fact that mothers have always performed this essential function well enough.” In an essay ironically titled “Advising Parents,” he cautioned against the common practice of giving advice in the absence of the opportunity to hear the full story. Our “how-to” culture, with its abundance of “expert” advice, may itself be a barrier to listening, unintentionally undermining a parent’s natural authority. Offering a prevailing contemporary perspective, a child psychiatrist at a major teaching hospital who was interviewing me for a radio show talked about the “parent training management” manual he had written. He argued that the parents “haven’t been taught” and “don’t know how to parent.”

A preventive approach to children’s mental health care recognizes the stresses on parents that may get in the way of their intuition. That stress takes many forms: the stress of a fussy baby; the everyday challenges of managing a family and work in today’s fast-paced culture, often without the support of extended family; are frequent causes. Stress may come from more complex relational issues between parents, between siblings, between generations. It is not that they don’t know how to parent, but that their natural abilities have been inhibited by stress, by negative models in the past, or both. Parents who say, “I don’t want to raise Charlie the way I was raised” do not need “expert” advice. They need to develop confidence in their natural intuition. The goal is to support parents’ efforts to find a way of raising their children that is in keeping with themselves, with each other, and with their child.

Like Winnicott, who said in his article, “I have no wish to carry this attitude to absurd lengths,” I do recognize that guidance from a person more experienced and knowledgeable may at times be very useful for parents. In many cultures, grandmothers fill this role. In American culture, many mothers do not choose this route. Journalist Jennifer Senior describes how, in researching her book All Joy and No Fun: The Paradox of Modern Parenthood, when she asked parents where they went for advice, no parents named their own mothers. There may be a range of explanations for this phenomenon, but when these relationships are fraught, or when grandmothers are far away or no longer living, this source of guidance may not even be available. One colleague, a preschool teacher and gymnastics coach, suggested the word “coach.” She explained how a coach supports an athlete in being the best he can be given his unique set of traits, without dictating a set formula for success. The trouble comes from advising, coaching, and guiding in the absence of space and time for hearing the full story.

Parents in my office often sound like they are riding on a seesaw, moving from the worry “It’s my fault” to the fear “There is something wrong with him.” Well-intentioned reassurance can have the opposite effect when parents quickly move to “Then there must be something wrong with me.” Feelings of guilt alternate with fear, even panic. They worry that the struggles the family is experiencing are somehow a reflection of them as “bad” parents.

I have found that Winnicott’s the concept of the “good-enough mother” helps support parents as they make efforts to set relationships on a different path. This “good-enough” parent is present, but not perfect. In fact, it is the very imperfections in parents that promote healthy development. They offer the growing child the experience of surviving disruptions, paving the way for managing life’s inevitable disappointments. Winnicott writes:

The good-enough “mother” (not necessarily the infant’s own mother) is one who makes active adaptation to the infant’s needs, an active adaptation that gradually lessens according to the infant’s growing ability to . . . tolerate the results of frustration . . . If all goes well the infant can actually come to gain from the experience of frustration.

A hefty dose of guilt, and with that a tendency to feel blamed, naturally comes with the role of parent. A label for the child may ease that guilt. But when parents resist diagnostic labels, they may be described as being in denial. This negative language sets up relationships of antagonism. Framed in a more positive, empowering light, a feeling of guilt may translate to a sense of responsibility. “I’m guilty” can also mean “I’m responsible.” Being listened to without judgment moves parents from helplessness to responsible action.

I have treated hundreds of families for whom this kind of listening has led to significant shifts in development and to new levels of connection and communication. However, sometimes after setting out on this path to discover meaning, a family will not return. While in each individual case I may not know the reason, there are some recurring themes. It may be that if the disruptions have occurred over many years, the concept of the “good-enough mother” is not sufficient to neutralize the guilt. Often social pressures, from family, friends, teachers, and others, to diagnose a disorder overwhelm parents and so do not allow for this patient exploration. Sometimes years later I learn that that the parents have divorced. A “problem” child may have been hiding a troubled marriage. I may have, in the face of parents who wish to know what to do, given advice before I understood the full story. Or we may have been too quick to explore deeply painful, long-buried issues.

Listening for the True Self

        The story of a human being does not start at five years or two, or at six months, but starts at birth—and before birth if you like; and each baby is from the start a person, and needs to be known by someone. No one can know a baby as well as the baby’s own mother can.

—D. W. Winnicott

When parents worry whether there is “something wrong with my child,” I try to reframe the question, drawing on another central concept of Winnicott’s, the “true self.” When the “good-enough mother” recognizes her child’s experience and helps him make sense of it, his true self begins to emerge. Stress, fear, guilt, and issues from other relationships may get in the way of that recognition, of understanding his behavior in the context of his unique strengths and vulnerabilities.

Instead of joining the parents in looking for “what’s wrong,” I suggest to them that we take some time to think about why the child might be behaving as he does, why his behavior might make sense from his perspective. I have found that with this opportunity to be heard, and in turn to listen to what their child is communicating, most parents prefer not to have their child labeled with a disorder.

A big roadblock, however, is set up by our health-care and education systems. These may push parents in the direction of labeling by requiring a diagnosis to obtain services. There is often a frenzied need to give a name to a problem so as to feel that something is being done. In all of the stories I tell in this book, treatment is definitely needed. It is important not to fall in to the trap of thinking that if a child does not have a disorder, families don’t need help. The “disease” vs. “normal” split is inaccurate and potentially harmful. In my practice I get around this problem by diagnosing almost everyone with the nonspecific “adjustment reaction.” I then bill for the number of minutes spent in counseling that in reality is mostly listening. One reader commented on my blog, “I hope that by giving them time and space to listen this doesn’t mean a delay in treatment.” We have lost sight of the fact that, especially for a developing child and his family, listening can be the treatment.

In his wise book Far from the Tree, Andrew Solomon explores the process of acceptance for families who have children with a wide range of differences. He speaks to the need to strive toward strength and healing by constructing meaning. Unfortunately, both our health-care and education systems force parents and professionals in the opposite direction by requiring that something be “wrong” with a child for us to be able to pay attention.

The story of Mary and Liam offers an example of offering space and time to support a mother’s efforts to recognize her child’s experience and reach what Winnicott would call his true self. Mary was convinced that her three-month-old son, Liam, was autistic. She felt she couldn’t connect with him. Her third child, he was remarkably different from his older brothers, now three and six years old. They had both been colicky in the early months, but had grown into active boys with a lot to say. Liam, in contrast, was quiet from the moment he was born. He hardly even cried in the delivery room. Despite the doctor’s reassurances, Mary wondered from those first moments if there was something “wrong with him.” As the weeks went on, not only was he quiet, but he also seemed to her not to be connected. She would put her face up close to his and try to engage him to look at her face and follow. But she was rarely successful. As the weeks went on, her efforts intensified while her anxiety escalated.

With a full hour together, we sat on the floor and observed Liam together. I noticed right away that my attempts to engage him by talking to him and looking in to his face were met by a rather remote expression. He appeared to be looking past me, perhaps at the lights on the ceiling, but it wasn’t clear. I saw Mary’s rising alarm. Resisting a similar reaction in myself, I said, “Let’s give it time.”

Liam lay on a blanket on the floor, at first continuing his seemingly random scanning of the room. I spoke quietly to him, noticing how he was sticking out his tongue. I imitated his movements and gradually he began to engage. Mary noticed that he seemed to be responding to my mirroring of his expression. We observed a gradual yet remarkable transformation. In the quiet calm of this space, so dramatically different from the normal chaos of his everyday life, he seemed to come out of his shell. It started with a smile, at first seemingly random, but then clearly in response to my smile. Mary continued to speak with him in a soft voice but, following my example, rather than putting her face up close to him, she spoke in a more natural way as part of our conversation. Liam became increasingly animated. Mary and I noticed, with rising joy and relief, that not only was he fixing on and following his mother’s face, but he was cooing in a responsive conversation with her. He kicked his legs and moved his arms in an expression of increasing delight.

Marveling at this little baby’s extraordinary capacity for communication, we wondered whether his quiet nature was part of an extreme sensitivity to the relentless sensory input from a busy household with two older brothers. Perhaps he was adapting by tuning out. He was in fact very engaged, but he preferred a quiet voice that was not “in his face.” He was finding his own way in the world.

What had happened between Mary and Liam was a kind of miscommunication, a dance of stepped-on toes. The less he connected, the more her attempts to engage him intensified. An illness model that places a problem squarely in the child leads us to miss opportunities for growth and healing. The “problem” was neither in Mary nor in Liam. They just needed to learn a new dance. With the help of a quiet space and time to listen, Mary could recognize that her well-meaning efforts might have been experienced as intrusive, given Liam’s sensitivity. As her anxiety grew and her efforts to engage Liam intensified, he withdrew further.

Relief flooded Mary, but her anxiety did not let go. Had she caused him harm by missing his cues? I pointed out how easy it had been for us to engage Liam. He was ready to communicate. Clearly, Mary had been doing something right. Research supporting Winnicott’s concept of the “good-enough mother” has shown that even when parents miss an infant’s cues in 70 percent of interactions, as long as these misses are recognized and repaired, development moves forward in a healthy way.

When I saw them together a month later, she spoke joyfully of the fun the family was having with Liam, who had developed into an engaged and happy baby. Now, taking a few minutes every day to have some quiet time with him, she fell deeper and deeper in love. She marveled at his individuality even at the tender age of four months. This “disruption” led to new levels of intimacy between Mary and her son.

Stories: A Path to the True Self

When I was a medical student, I had the privilege of sitting in on a child development class taught to child psychiatry fellows at Cornell Medical Center by the late Paulina Kernberg, a gifted child psychiatrist and analyst. One of the fellows brought his nine-month-old son as a subject. I vividly recall witnessing the joy of his accomplishments. I saw child development as a wonder of nature that unfolds with purpose and clarity.

When a child struggles without progress, whether in infancy, adolescence, or somewhere in between, that developmental path has somehow become derailed. Continuing the metaphor, to get a train back on track requires going back to the beginning. It requires telling the story from the start, to make sense of where and how it got derailed. Only then can development begin to go forward in a healthy direction. Listening offers the opportunity to tell the story, and to have the story heard, from the beginning.

Development is the child’s story. Storytelling is equally important for parents. A person might have a narrative of his life that makes sense to him, only to have it completely upended when a child comes in to the world. A different narrative is formed that includes a new individual with unique qualities and needs. Relationships both between parents as well as with each individual parent’s past may be significantly altered in this developmental stage of parenthood.

The frenzy of activity that parenthood entails often leaves little time for reflection. By the time there is a “behavior problem,” be it colic, sleep problems, separation anxiety, explosive behavior, or any number of issues that young families contend with, parents may be so focused on just getting through the day that there is no time to make sense of what is happening. The stage is set for the appealing array of advice about what to do that our culture offers to parents. Yet taking time to tell that story may in fact be the solution to the problem.

Supporting a child’s healthy development calls for an ability to remain calm; to respond to what is happening in real time, without letting your own history interfere. When the way a child’s behavior echoes past experiences is out of your awareness, this kind of response may not be possible. Knowing your own story can make it possible for you to be present with your child in a way that allows his or her true self to emerge.

How Listening Promotes Knowledge

Listening has evolutionary significance. Knowledge about what is needed for survival is transmitted from one generation to the next. The ability to understand one’s own and others’ behavior as a reflection of underlying feelings is a uniquely human quality that allows for this transmission of knowledge. When children feel heard and understood, they develop what psychoanalyst Peter Fonagy has termed “epistemic trust.” Epistemic means “of or relating to knowledge.” He defines the concept as “an individual’s willingness to consider new knowledge from another person as trustworthy, generalizable, and relevant.” In other words, the way we acquire new knowledge about ourselves, others, and the world around us is intimately intertwined with how we are listened to as a developing child. Children learn, from the cues a trusted caregiver offers, to whom they should listen and what is important for them to learn. They develop the ability to think not only about their own feelings and behavior, but also to understand the motivations and intentions of others.

Being listened to, or held in mind, is thus of central importance if children are to manage in increasingly complex social environments. Flexibility in thinking, and with that openness to new ideas, goes hand in hand with the early experience of being heard. In contrast, when children grow up without this openness and trust, they may be closed off to new information. A lack of knowledge and skills may be perpetuated from one generation to the next.

Decades before Fonagy, John Bowlby was among the first to identify the evolutionary significance of our earliest relationships, as he describes in his book A Secure Base. Capturing the essence of what many would agree we want for our own children and for the next generation, he writes that a child who is held and heard in this way is likely to “become increasingly self-reliant and bold in his exploration of the world, co-operative with others, and also—a very important point—sympathetic and helpful to others in distress.”

Two

Listening Devalued

In the context of rising reports of depression and suicide in college, one student described a school administrator’s coming to visit her in the hospital following a second suicide attempt. He asked, “Are we going to make this a pattern?” and then handed her his business card.

In another example from my practice, a parent described calling the emergency student support services when she was worried about her son Evan’s emotional state during his first semester at college. After a five-minute conversation, she was told by the person who responded to her call, “We can make an appointment with the psychiatrist to see if he needs medication.”

Significant forces in our society work against listening. These forces come into play when a parent, whose child may be struggling with a range of issues, comes in contact with a system of care that offers only behavior management, parent training, and increasingly diagnostic labels and medication. These forms of treatment may crowd out space and time for listening.

Psychiatric medication may be useful and necessary when a person is unable to function without it. In cases of severely out-of-control behaviors and emotions, medication can offer symptomatic relief. In certain circumstances, it may even be lifesaving. It may make other forms of therapy possible, including relationship-based therapies and self-regulating activities, such as yoga, music, or meditation. But that is not the way these medications are being used. Because they can be so effective at eliminating distress in the short term, they are very appealing, almost irresistible, as a single solution in our fast-paced, quick-fix culture.

A 2013 CDC (Centers for Disease Control and Prevention) survey reported that close to 50 percent of adolescents who have taken psychiatric medication in the past month have not seen a mental health professional in the past year. It suggests that we are becoming comfortable with medicating away feelings, without opportunity to gain the insight and understanding that are central to true healing and continued growth.

Controversy swirls around the subject of psychiatric medication, in both adults and children, not only of antidepressants, but also stimulants and increasingly antipsychotics. “Are the medications useful?” “What is the role of the placebo effect?” “What are the long-term side effects?” “Should we blame the drug companies?” Marcia Angell, former editor of the New England Journal of Medicine, grappled with these issues in a series of articles in the New York Review of Books, concluding:

Our reliance on psychoactive drugs, seemingly for all of life’s discontents, tends to close off other options (italics mine.) In view of the risks and questionable long-term effectiveness of drugs, we need to do better.

Angell calls on us to “rethink the care of troubled children.” The question of using psychoactive drugs in children is fundamentally different and on a greater order of magnitude than with adults. It goes beyond the relative merits of psychotherapy or medication, or even of the potentially serious side effects. As Angell says, the problem lies in what is not done when psychiatric medication is used to treat children.

Blocking the Path to Resilience

In my first book, Keeping Your Child in Mind, I describe the extensive research showing how children become capable of emotional regulation and overall mental health when those who care for them respond to the meaning of their behavior, rather than the behavior itself. Children develop resilience when their struggles are acknowledged—but not erased—through the inevitable stresses of life. When, however, starting at a young age, rather than learning to handle stress in the context of supportive relationships, a child’s “symptoms” are “managed” or increasingly medicated away, the areas of the brain responsible for emotional regulation may not develop properly. The brain is actually wired through relationships. The areas of the brain responsible for emotional regulation develop when children’s immature abilities are regulated together with a trusted caregiver who understands what they are feeling.

If, as the challenges of life increase, dosages are simply increased in strength and complexity, often with added diagnoses, children may learn to be defined by their disorder and by their medication. It is not uncommon for children in preadolescence and even younger to be diagnosed and started on medication that is then continued despite ongoing massive developmental changes. The control of behavior with medication may then continue to interfere with these children’s emerging sense of self.

In a course she teaches entitled “Keeping the Brain in Mind,” Francine Lapides referred to psychotherapists as “neuroarchitects.” In a relationship with a therapist who is carefully listening, fully attuned to the patient’s feelings, the patient’s brain may actually change, in turn changing the way that person responds to stress. The changed biochemistry of the brain may actually help a person learn to think about feelings and manage difficult experiences.

Parents are the original neuroarchitects. When a child is struggling, whether with sadness, anxiety, or explosive behavior, a parent’s “presence of mind” helps that child to make sense of and manage his own strong emotions. Parents themselves need to feel supported so as to recognize what their child is experiencing, and be with their child in a way that promotes healthy emotional development.

The Rising Use of Psychiatric Medication

The widespread use of medication has fundamentally changed the landscape of mental health care. We condone their use alone, without concurrent relationship-based treatments. A recent study documented that pediatricians, who diagnose and treat the majority of cases of ADHD, use medication without any psychosocial support in close to 90 percent of patients.

When medications can be used this way, in the absence of time for relationship-based treatment, the professionals who offer opportunity for listening and human connection are devalued, both culturally and monetarily. Such attitudes and financial disincentives decrease the availability of qualified professionals.

Pediatricians, whose long-standing relationships with children and families makes them ideally suited for preventive interventions, are discouraged from using their time to listen. In our current reimbursement system, a practice will better survive financially when primary care clinicians see four to six children in an hour, rather than spend one hour listening to one family, even though, as we will see throughout this book, an hour of listening can have great preventive value.

Social workers, psychologists, and others who offer relationship-based treatment in which feelings can be recognized and understood are reimbursed less and less by insurance companies. At the same time, they are required by the health insurance industry to exert increasing effort, jumping through an increasing number of hoops, leading many not to participate in insurance plans. Families struggle to find a qualified clinician who accepts their insurance. Thus the drugs themselves, because they can replace people, become inextricably linked with the shortage of quality mental health care. With fewer qualified professionals to do the work of listening, those who remain are overwhelmed. Finding help from people with time and space to be present in a way that promotes healing grows harder and harder.

Evan had been a patient in my practice for many years when I received that call from his mother about her conversation with the college emergency support services. He had always had a tendency to be anxious, but it was not a significant problem for him until he applied to college. He was struggling with this developmental step. But rather than prescribe medication, I referred him to a therapist. I was fortunate to have an excellent colleague who had time and took his insurance. She helped him make sense of his fears.

During a rough patch in the winter of that first year away, following that disturbing call, his mother filled me in. Knowing that confidentiality prevented me from talking about my relationship with Evan, his parents simply wanted to talk about their experience. They told me they had discovered that in his moments of