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Listening
with a "third ear"
Some pediatricians
say they have difficulty putting psychosocial concepts
into practice because they lack the expertise to diagnose
and treat families' emotional difficulties.
May I suggest
that we don't need special training, beyond our own
clinical competence, to provide good help to families
in conflict? What is needed is a willingness to listen
with a "third ear" -- i.e. hearing not only
the parent's general statement but also the language
chosen and the feelings, or absence of feelings, accompanying
their words.
A pediatric
case study
Mrs. R. was
concerned that her 6 year old daughter, Janet, was
becoming "heavy." She came in asking for
a diet so that Janet could avoid the painful experience
of being overweight that Mrs. R had encountered when
she was a child.
I was puzzled.
Janet was in the 50th percentile for height and weight.
I asked Mrs. R to enlighten me about her own weight
history.
"I
was teased a lot as a child ... I was a butter ball
until I was 15 ... If only my parents had helped
me ... I'd like her to have better eating habits
than I did ... What can I do to help her avoid the
problem I had?"
I asked her
to describe Janet's eating habits.
"When
she gets hungry, she turns into an animal! Before
anybody gets up, she'll attack the kitchen cabinet
and devour a box of crackers. She goes on these
binges ... Sometimes she'll hide a piece of bread
under her pillow ... Food is an important thing
for her ... I've tried not to make a big thing about
it."
In taking
the family history, I learned that Mrs. R's grandfather
died of cirrhosis, her father had not dealt with his
own alcoholism, and her sister was also an alcoholic.
When I later pointed out that the words she used to
describe her daughter's eating habits were similar
to those one might use for an alcoholic, her face
registered complete surprise. She had no idea she
had used words like "binges" or "hiding
under the pillow" in reference to her daughter.
It turned
out that no one in Mrs. R's family had been able to
confront how painful alcoholism had been for all of
them. In many ways, everyone had sidestepped the issue,
but Mrs. R's anxiety and preoccupation about it spread
to many unrelated situations, not the least of which
was her daughter's eating habits.
As Mrs. R.
was able, over time, to unburden herself of these
concerns, the problem gradually resolved itself without
a diet imposed by me. Listening with a "third
ear" allowed me, as pediatrician for the parent,
to be receptive to the subtle message Mrs. R was conveying.
I needed to be willing to use my feelings and intuition,
as well as intellect, to grasp the essence of what
the parent was sharing.
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The unseen visitor to pediatric
practice
Many of the
children we see with emotional or developmental problems
may have parents who are "adult children of alcoholics"
(ACOA). Alcoholism in one or more grandparents of
our pediatric patients is an unseen but influential
visitor to pediatric practice.
Who are ACOA parents?
What do we
mean by ACOA parents? I am referring to those parents
who grew up in families where their own parents were
victims of the disease of alcoholism, which may leave
a lasting effect on their parenting styles.
Consider
alcohol abuse history
How often,
in the average day, do we ask ourselves:
"What's wrong with this parent?
Why doesn't she understand what is going on?"
"Why
does he have such a hard time making decisions?
Why does he seem so insecure?"
"What
is the reason for her child's low self-esteem?"
A typical history of an ACOA parent
Many parents
describe a childhood history similar to this one:
"My
sisters and I worried every day about how serious
the drinking would become, how much screaming and
hitting would take place. Would it ever come to
an end? We never knew what would happen the next
moment. There was constant tension. We all felt
embarrassed that it was somehow our fault. We felt
like orphans."
The frequency
of alcoholism in family histories
The story
above can be recognized by millions of children who
live with an alcoholic parent, and by parents in your
practice who grew up in similar households. If the
average pediatrician meets 16 parents in a typical
day, two of them might be such ACOA parents.
What is
the emotional inheritance of ACOA parents?
"Adult
children of alcoholics guess at what normal behavior
is."
They often
"lie when it would be just as easy to tell
the truth."
They "judge
themselves without mercy."
They "have
difficulty with intimate relationships."
They
"usually feel they are different from other
people." They can be "super-responsible
or super-irresponsible."
(from
Janet Woititz, Adult Children of Alcoholics,
1983)
ACOA parents
and the pediatrician
Consider
the burden this inheritance must be for a parent who
wants to have normal relationships -- with a spouse,
with a child, or with a pediatrician who might be
unaware of the coping styles of the ACOA parent. Think
about what must be going on in the minds of such parents
when you give seemingly self-evident advice about
child-rearing practice. How do you think such parents
respond to you when, at best, they can only guess
at what a normal family life is like?
At the time
when the ACOA parents in your practice were
children, the problem of alcoholism was "the family
secret." The rule was never to share the secret with
outsiders in order to "protect the good name of the
family." Think of what it must be like for parents who
struggle with sharing the secret with you, a trusted
professional but an "outsider" nonetheless.
What can you, as a pediatrician, offer to such parents?
When pediatricians
sit down with parents to figure out whether their child
has a behavior problem and why, it is important to remember
that there may be "an elephant in the room."
What I am referring to is a family secret which may
be playing a significant role in the development of
the child's problem. Family secrets loom large and occupy
much space in the emotional life of the family, but
may never be acknowledged, like the metaphorical elephant
that everyone must accommodate, at great inconvenience,
but no one ever mentions.
One of the
most important "family secrets" that I have
come upon is the past (or present) history of alcoholism
in one or more members of the family. We have already
acknowledged that many feelings may be associated with
the history of such a secret in a family member. They
may include feelings of shame, guilt, anger, or fear.
If you can
help parents acknowledge such a history and its significance,
in the context of a caring professional relationship,
parents will have made a significant first step not
only in understanding their child's problem but also
in beginning to resolve it.
If knowing
about alcoholism history is potentially so important,
how might you discover it? Of course, you might simply
ask! But there are also indirect ways of exploring alcoholism
history.
For example,
you might ask why a child's grandparent died when he
or she did, particularly at a relatively young age.
A parent's
parents might be divorced. You might ask, "Why?"
and the parent might reply, "My father was abusive
to my mother ... He was an alcoholic."
A parent might
reveal that one of his or her siblings had a "drug
problem." You might ask if anyone else had a problem
of "addiction," at which point the parent
might say, "My father was an alcoholic ..."
A parent's
sister might have been "anorectic." Because
you are aware of an association between that condition
and a family history of alcoholism, you might ask if
that was the case.
Perhaps a parent
might reveal that she became pregnant as a teenager.
You might ask, "What happened?" She might
reply "I was drinking at the time."
In short, finding out if there is
a family history of alcoholism may come out in the course
of taking a family history, and by skillful listening.
On the other hand, if a parent seems overly distraught
about certain habits in his or her child, e.g. persistent
thumb sucking, nail biting, or prolonged use of a pacifier,
that also may be an opening to obtaining a family history
of alcoholism.
I have often observed associations
between a child's minor, but problematic, behavior with
the behavior of an older alcoholic relative. The alcoholism
may have left a legacy of anxiety which may become expressed
in parents' exaggerated concerns about the minor behavioral
issues of their children.
In summary, you should assume that
a family history of alcoholism may exist in any parent
with whom you work. Think of eliciting such a history
if the timing is appropriate and if parents give you
permission to inquire. You might consider encouraging
the parent to share feelings about what it was like
to grow up in such an environment. It will require time
and compassion on your part.
When you do discuss these sensitive
issues, you create a model of listening between two
adults (assuming that there are "healthy boundaries"
between you and the parent) that can serve as a corrective
experience. In turn, the parent may then be able to
use this experience in interactions with her spouse,
her child, and even her own parents as she struggles
to undo the effects of past experience.
When to refer
Sometimes in the course of discussing
a family history in a matter-of-fact way, the parent
may begin to look like she or he is undergoing some
very painful memories.
I would encourage pediatricians not
to be afraid to ask further, but to proceed slowly and
compassionately. It is worth asking, periodically, "Do
you mind if I ask you...,?" "Is this OK what
I am asking you ...,?" "Would you like to
talk about this another time with me or another person?"
Despite your skillful interviewing,
you may sometimes feel like you are on the verge of
opening up Pandora's Box. You may think that the parent
is about to share things she or he has never brought
up before. If the parent feels great trust in you and
you have confidence in yourself, you may wish to discuss
it on another occasion. On the other hand, you may conclude
it would be more appropriate to refer the parent to
a mental health counselor. The parent should feel that
you are doing so out of respect for his or her pain,
and that you feel counseling would be helpful for the
parent.
The ideal outcome
If you can offer this corrective experience,
it is possible that such parents may, in time, give
up the useless task of always trying to "rescue"
the people they love, whether it be their parents or
their own children. Preferably, they will encourage
both to take responsibility for their actions.
If pediatricians could play such a
role, they might help ACOA parents interrupt a family
pattern of addiction and dysfunctionality. Their children,
when they become adults, and particularly when they
become parents, might be better able to get in touch
with past memories and, hopefully, develop healthier
relationships and more successful methods of managing
life's challenges.
Children as "agents for change"
ACOA parents often raise child
development concerns with their pediatrician because
they secretly worry that their child will "inherit"
the family illness. Ironically, it is their concerns
about their own children, your pediatric patients, that
can provide the parents with a second chance to revisit
their own past. If you assist them, these parents may
be able to start life anew even though their first concern
originated with their child!
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