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Orthodonture or Psychotherapy?

Thumb Sucking

Thumb Sucking

Thumb sucking can become a heated issue for parents. “How can I get my child to stop sucking her thumb?” is a common question asked by parents. And there are so many “remedies” on the market to help achieve this goal—bitter nail solutions, thumb wraps, children’s books to coax a child away from the act, and parenting books with numerous strategies. I rarely hear the question, “Why is my child sucking her thumb?” As a psychologist, I wish we would start there.

Yes, I too have heard from pediatric dentists that constant thumb-sucking may impact the teeth, jaws, or roof of the mouth. But I’ve also read sources (e.g., American Dental Association, 2016) that suggest that we shouldn’t be too worried for a young child. And, as noted by the American Dental Association (2016), excessive pressure to halt thumb-sucking can in fact do more harm than good.

Children can be seen sucking their thumbs even before birth in the womb. It is a natural way to self-soothe and relax, and may build a sense of comfort and security in times of stress. Some children gradually develop other modes of self-soothing by the time they reach 4 years of age, especially when they learn to express themselves and connect to others with words and other activities.

But children are not all built the same. Temperaments differ. Some children are born with more intense feelings that are harder to manage. And environments do not have the same impact on all children. Some children relish being surrounded by activity and sounds, while these can overwhelm others. Of course, an especially stressful environment can cause problems for a child, but even a normal level of stress may overwhelm the coping mechanisms of some children.

If a child is over 4 and still wishing to suck her thumb, rather than jumping to eliminate this potentially important source of comfort, I would encourage parents to consider the needs of their individual child.

• Is the thumb-sucking merely a habit which is no longer important as a source of calming?
• Is there something they can modify in the child’s environment to reduce stress?
• Can they help her develop other coping strategies?
• Or should they allow the child to continue sucking the thumb until she is ready to move on?

In some cases, orthodonture may be a more desirable alternative than years of psychotherapy as an adult.

 

What a T-Shirt and Ticklish Gorilla Can Teach a Psychotherapist About Building a Life That’s True to the Self

 

Identity Development

Identity DevelopmentI’ve learned much from both my favorite t-shirt and a ticklish gorilla about identity development, self-awareness, and building a life that’s likely to be fulfilling.

First, for the t-shirt.  My favorite t-shirt has a little label sewn on it that says, “Do what you like, like what you do.”  I’ve thought a lot about this.  How is it that we can come to know what we’ll like to do?  It’s a question that I believe is related to identity development and self-awareness—areas that I’ve long been interested in as a psychologist, psychotherapist, and college professor.

How can we come to know who we are and what we’ll like? 

Can we think our way there?  Can we read about options on the internet, consider our intellectual strengths and temperament, select a path, and live happily ever after?  Or is there benefit to meandering along unplanned trails, getting dusty and sweaty, and feeling the warm sun on our face?  Which approach will provide us with a more fulfilling journey as we proceed through life?

I spent the entire summer after graduating from high school, thinking about exactly what college would be like.  I read about it, dreamed about it, and had long discussions about it with my dog Louis, until I thought I had it all planned out.  I would be a French major and then go on to Law School.  And I would establish a law practice in Paris.  It all made perfect sense.  I loved French poetry and had taken French since the 3rd grade—something not uncommon on the east coast—and so was pretty good with the language.  I was analytical.  And I thought Paris was a beautiful city.  And so, here I am, today, a lawyer in Paris…  My point is that I really had no idea what would be in store for me over the next few years.

So, I began my first year in college as a language major.  The only field I’d ruled out was psychology—I thought that psychologists must be, by and large, strange people and kind of scary.  But then, one day as I was stumbling through the halls on my way to a class, a psychology professor stopped me and asked if I’d like to run a study with him.  What kind of study could one run in psychology anyway, I thought?  Fortunately, I said, “Sure,” thinking of it as an opportunity to try something strange—strange, like eating chocolate-covered ants might be strange.  But he soon had me researching in the library, constructing questionnaires, running all across campus to collect participants, learning about stats so I could analyze the findings…  If I’d stopped and reflected on what he’d have me doing before I jumped in, I never would have said yes.  I never would have considered psychology—a field that I’ve now been very happily working in for most of my life—if a professor hadn’t encouraged me to “try it on.”

Now for the ticklish gorilla.  A delightful article by Bering (2010) was published in Scientific American several years ago.  It was about evidence that animals have a sense of humor.  I’d like to share this excerpt from the article:

When I was 20, and he was 27, I spent much of the summer of 1996 with my toothless friend King (a 450-pound Western Lowland gorilla, with calcified gums), listening to Frank Sinatra…, playing chase from one side of his exhibit to the other, and tickling his toes.  He’d lean back…, stick out one huge ashen grey foot through the bars of his cage and leave it dangling there in anticipation, erupting in shoulder-heaving guttural “laughter” as I’d grab hold of one of his toes and gently give it a palpable squeeze.  He almost couldn’t control himself when, one day, I leaned down to act as though I was going to bite on that plump digit.  If you’ve never seen a gorilla in a fit of laughter, I’d recommend searching out such a sight before you pass from this world. (para. 2)

Now, a lot has been written in the field of psychology about identity development.  And, with the help of neuroscience, a helpful distinction is starting to be made between identity and self, putting words to elements that are related but actually quite distinct (Gerson, 2014).  Identity refers to a self-reflective third-person understanding of oneself, whereas self is a more primitive and core first-person sense or experience of oneself.  Early on, we move from a purely personal experience as and become more reflective, as we become socialized and develop language (Gerson, 2014).  We no longer merely experience with our senses, as we develop tools to reflect on and think about our experiences.  We become our own observers.  This development represents identity (me), as opposed to self, which involves our personal experience as an I.  Our gorilla friend probably experienced more self-ness than clarity about his identity—but that’s for ethologists to verify.  Human adults, on the other hand, often lose touch with their basic self.

If I asked you who you are, I might get a variety of answers.  You might say “an adult,” “a generous person,” “a teacher,” “a psychotherapist,” and so on.  These would tell me a little bit about your identity—descriptions that derive from observations of or reflections about yourself.  But, now take a moment, and think back to your earliest remembered experiences.  Try to experience what it felt like being you at the time, not as an observer, but as a participant.  Did you feel excited, timid, curious?  Now, you could probably tell me something about your self.  Probably something our gorilla friend was acutely aware of during the play experience. 

My experiences with my psychology professor had transformed both elements.  They had changed not only how I thought about who I was, but also how I experienced my self, in the first person—I.  And redirected me down a path that has allowed me to build a life doing what I really love.

Erikson (1959) (who did not distinguish in his writings between self and identity) wrote about the value of moratoria in identity development.  I believe first-hand experiences are important for becoming aware of the paths that will be consistent with the self and lead to an optimally satisfying life.

 References

Bering, J. (August, 2010). Laughing rats and ticklish gorillas: Joy and mirth in humans and other animals. Scientific Americanhttps://blogs.scientificamerican.com/bering-in-mind/laughing-rats-and-ticklish-gorillas-joy-and-mirth-in-humans-and-other-animals/

Erikson, E. H. (1959). Identity and the life cycle: Selected papers. Psychological Issues, 1, 1-171.

Gerson, M. J. (2014). Reconsidering self and identity through a dialogue between neuroscience and psychoanalytic theory. Psychoanalytic Dialogues, 24(2).

Are We Over Diagnosing Children With Mental Illnesses?

 

Over Diagnosing Children

Overdiagnosing ChildrenI once read an article by Jordan Smoller called, “The Etiology and Treatment of Childhood.”[1] It was a satirical article that described childhood as a mental disorder. He noted that childhood is congenital, is characterized by temporary dwarfism, is marked by emotional instability and immaturity, and that children have knowledge deficits and legume anorexia. Mercifully, most children recover from this condition over time.

While clearly the article was meant as a spoof on the Diagnostic and Statistical Manual of Mental Disorders (DSM), the standard reference guide for mental health providers in the U.S., the implications of this article are quite serious.  Children are being diagnosed with mental illnesses at an alarming rate and being medicated for those conditions with increasing regularity.

Over Diagnosing of Attention Deficit/Hyperactivity Disorder

Consider the case of Attention Deficit/Hyperactivity Disorder. This is a condition where a child is unable to constrain his/her behavior to the requirements of a given social context. We are not talking about criminal or psychopathic behavior, but rather the inability to sit still in a classroom, restaurant, doctor’s office, or other such environment where conformity is expected.

Fifty years ago this condition was called Minimal Brain Dysfunction (for extreme cases) and was thought to be the result of a mild form of brain compromise that was not explicitly evident but could be assumed. The term fell into disrepute when parents resisted having their children stigmatized as damaged goods.

Then, sometime in the 1980’s, the atmosphere changed and the former stigma became, for some parents, an embraced diagnosis of ADD (then called Attention Deficit Disorder, with hyperactivity as a sub-type).

Why the change? ADD was classified as a learning disability that entitled children to special accommodations in the classroom and on standardized tests. Not only were schools required by federal law to provide preferential seating in the classroom, but the students could also have less, or no, homework, extra time on exams, less rigorous exam standards, and counseling and tutoring services (also subsidized by federal funds).

I am not suggesting that all children and parents took unfair advantage of the system. Many children needed these services and greatly benefitted from them. Some students also received these services in order to give them a competitive advantage for college placements.

I am not faulting parents for trying to get what they can to make their child’s life better and their future more promising. In fact, as a psychologist, my profession has profited greatly from this boon, as have college guidance counselors, and educational therapists. No one has profited more, however, than the pharmaceutical industry, which supplies medications to enhance focus, concentration, and task performance.  In my view, the issue of ADHD is only the beginning of a much larger problem—the pathologizing of children.

Over the past few decades we have seen enormous rises in the diagnosis of autistic spectrum disorders, bipolar disorders, depression, and obsessive-compulsive disorders in children and adolescents. It is possible that the mental health of this population is deteriorating at an epidemic rate. It is also possible that children are being dangerously over-diagnosed. Note also, that the rates of diagnosis are unique to the U.S. and disproportionately represented in middle and upper-middle class families.[2]

What Can Parents Do If They Think Their Child’s Behavior Is Questioned?

So what can be done?

First, parents need to step back and question the basis for a child’s diagnosis. If a child’s behavior is being called “pathological,” what is the normal standard for a child of the same age and sex? Nowhere in the DSM is there a guide for determining at what point a child’s restlessness, for instance, exceeds normal standards. The diagnostic criteria instead say “often.” Not how often, or too often, just “often.”

Second, parents and doctors need to consider the context of the child’s life. If the parents are divorced and the child lives alternatively in either home, how might that stress affect concentration and attention? Or how interesting is the classroom for the child?  Maybe a different teacher or school would be a better fit for the child.

Third, how much sleep is the child getting each night? Half of the children I have assessed for “inattentiveness” were sleep deprived. The child may be going to bed at 8:00, but may be on a smartphone, iPad, or computer until late in the evening. Furthermore, a sleep-deprived child may be depressed or anxious, not necessarily “suffering” from ADHD.

Fourth, doctors, psychologists, and teachers often base their diagnosis on checklists. This can be a somewhat useful starting point, but is irresponsible as a stand-alone assessment. No checklist is a substitute for knowing the person of the child. Consider that chest pain could be a heart attack or it could be indigestion! A restless, inattentive child may be lonely, sad, afraid, etc. While these conflicts and challenges are difficult and distressing, they are not necessarily signs of mental illness.

Finally, if there is a reasonable suspicion of some mental health issue, a competent specialist should be involved to thoroughly assess the child, the family, and the surrounding circumstances.  What diagnoses have been explored, evaluated, and ruled out? A range of possible interventions should be considered, with priority given to those that are the safest, least invasive, and most likely to be helpful. A child’s mental health is not the place to shop for bargains or quick fixes.

 I constantly remind my graduate students that diagnosis is more about the person than the illness and that children are people, not disorders.

Professionals who want to learn more about psychoanalysis, developing an analytic mindset, and more topics for continuing education in mental health counseling, see a list of our online courses.

[1] Published in the book by G. Ellenbogen (1982), Oral Sadism and the Vegetarian Personality, a collection of satirical psychological articles.

[2] Hastings Center, Washington, D.C. (2008) found a 20% increase in prescriptions for behavioral drugs between 2000 and 2003 and a 73% increase in prescriptions for antipsychotic drugs between 2001 and 2005.

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