In our book A Womb of Her Own (Routledge, 2017) author JoAnn Ponder writes as follows:
Several years ago, a concerned mother contacted me for help with her five-year-old son, “Sam.” She was worried about his noncompliance, anger, and aggression. After doing some research and reading, she had become convinced that these problems were symptomatic of oppositional defiant disorder. She further believed that Sam had a poor prognosis and was headed for a life of crime. She described herself and her husband as educated professionals, active in their church and devoted to family. Almost as an afterthought, she mentioned that Sam and his younger brother were adopted, whereas her third son was biological. She thought that adoption had no bearing on Sam’s problems, however, because she loved all three children equally. The clear implication was that something was wrong with Sam.
I met with Ms. X for an initial consultation to gather some background history. I learned that she was a full-time homemaker since adopting Sam, and previously employed as a preschool teacher. Mr. X was a professional soccer coach, also experienced in working with children. He and Ms. X got Sam at birth in an open domestic adoption. When I asked if they experienced fertility problems, she snapped, “Isn’t that why most people adopt?” I saw that I had treaded on a sensitive topic, so I attempted to repair the wound. Though I do not typically self-disclose much to clients, I thought that it might help to reduce her defensiveness if I took a more open and collaborative approach with her. I quietly affirmed her, “Yes, I know. I’m an adoptive mother, too.” Ms. X seemed surprised, but her anger gradually dissipated. I learned that Sam’s biological father was unknown, his birth mother an unwed teen who dropped out of high school. Sam’s birth mother was now married and living in another state. She telephoned Sam occasionally, but had not visited him for about two years.
According to Ms. X, Sam was colicky, irritable, and difficult to soothe as a baby. I thought about infant observational studies, which have found that boys are more affectively reactive and less able to self-regulate their affective states than girls, thereby requiring more assistance from their caregivers (Weinberg, 1992; Weinberg & Tronick, 1992). Boys remain more demanding and emotionally reactive as they grow up (Weinberg, 1992). According to Tronick (2007), the boys’ problems in regulating their affective states render them prone to frustration and anger which may give rise to aggression. Sam was a sensitive baby, possibly with a particularly reactive temperament. His mother said that he had speech problems and became increasingly temperamental at age two years, when his parents adopted his next younger brother. Sam’s speech problems subsided, but his aggression escalated when Sam started kindergarten. Ms. X said that he had one or more temper tantrums daily upon arriving home from school. He excelled academically, however, and had no major behavioral problems at school. When I hear of children who have angry outbursts at home, but not at school, I consider a number of hypotheses: (1) there are family problems, (2) there is inadequate structure at home, and/or (3) the child has struggled to manage his emotions all day at school and has little energy and few internal resources left to cope with problems after school. Sam’s mother also was bothered by his fidgeting at church, which she considered to be another sign of his unruliness.
When I asked what was happening at home when Sam started kindergarten, his mother said that she became pregnant as he finished preschool. It was a high-risk pregnancy, so she was confined to bed most of the summer. Obviously, she was less available to help him as he started school. Three months after Sam entered kindergarten, she gave birth. It turned out to be another boy, though she was wishing for a girl. Moreover, Ms X was unable to breastfeed. After years of trying to become pregnant, I imagined that her pregnancy and early maternal experiences were disappointing, possibly reinforcing her feelings of inadequacy as a woman and a mother. Coincidentally, Sam’s birth mother telephoned often that summer and fall. Mr. and Ms. X disapproved of her prior lifestyle and feared that she might have a negative influence on Sam. Therefore, Mr. and Ms. X asked Sam’s birth mother to stop calling so often, whereupon she virtually discontinued contact with Sam.
First Meeting with Sam
During my first meeting with Sam, his mother sat in the waiting room with his infant brother. She had a faraway gaze, seemingly oblivious to her surroundings and eerily staring into space even while the baby screamed. I was concerned about her lack of attunement to the infant, but a little hopeful about the baby’s continued bids for attention. Sam readily separated from his mother to accompany me into my office. He was polite and seemed eager to please me. Though he flitted from activity to activity, he was easily redirected if necessary. After the session, I accompanied him back to the waiting room. When I told his mother that I found him charming, she retorted that he was conning me. Indeed, he showed a pronounced change when reunited with her, becoming agitated and hyperactive. He ran around the room, kissed the baby repeatedly, and started poking him despite his mother’s frustrated directives to stop. It was almost as if Sam could not hear or restrain himself, as if he were somehow in another world.
The next few weeks, I administered some psychological tests, including projective tests that Sam completed, and symptom checklists and behavioral rating scales that his parents and teachers completed. The results suggested the presence of impaired affect regulation and underlying depression. Based on Sam’s behavior and test responses, I also wondered about the possibility of disorganized attachment. Sam identified one of the Rorschach inkblots as a monster with broken, dangling arms, and other figures had transparencies that revealed their hearts. I interpreted that Sam felt helpless, damaged, and brokenhearted, with poor object relations. I told his parents that sometimes children become aggressive to take control when they feel powerless. A child who anticipates rejection may unconsciously provoke it rather than passively waiting for it to happen. When Ms. X asked if my child had emotional problems, I replied that she became frustrated and aggressive when I failed to notice her speech problems. I told Ms. X that, even for us trained professionals, our biggest blind spots are with our own children. My acknowledgement of my imperfections in parenting possibly made it easier for her to begin to consider hers.
With regard to a psychodynamic formulation, I believe that Ms. X currently was resentful, disappointed, and depressed due to her fertility problems. Although I do not know for certain if she was depressed at the time of Sam’s adoption, I cannot help but wonder, given that she was still depressed even after bearing a biological child. Her depression likely contributed to poor or inconsistent attunement to Sam, a boy who had a particularly reactive temperament as an infant. Hence, Ms. X was ineffective in helping to emotionally regulate him. When his parents adopted his next younger brother, Sam experienced sibling rivalry. At the same time, Sam was frustrated due to his speech problems. These issues compounded the oppositional behavior that two-year-olds present to establish their autonomy. When Sam was five years old, his mother gave birth after months of bed rest, and his birth mother stopped telephoning. He likely perceived these as rejections, intensifying earlier feelings of loss and abandonment from his relinquishment. Sam experienced little emotional support with separation anxiety upon entering kindergarten, in that his mother was bedridden, then busy caring for his newborn and three-year-old brothers. She projected her inadequacies onto him, finding his aggressive drives unacceptable, giving undue significance to his fidgeting at church, and attributing badness even to his desires to please me. It was as if she considered him a bad seed from troubled birth parents, malevolent projections that contributed to his damaged self-image.
I believed that Sam would benefit from treatment, though he might require fairly long-term intervention. I recommended individual psychotherapy using a play modality, and parent consultation to address the negative projections and assist in developing improved strategies for dealing with his emotions and behavior. This case example will focus on the parent consultation rather than the therapy with the child. The parent consultation used a combination of psychodynamic, educational, and family systems approaches. Though I believe that Ms. X could benefit from individual psychotherapy, I did not think that she was ready, given that she denied any significant depression on her part. I also would have recommended infant-parent intervention, but she denied any problems or risk on the part of the baby. Therefore, I retained Sam as the identified patient and designed interventions to address the parenting problems without labeling them as depressive symptoms.
I reviewed developmental norms and basic behavioral principles with the parents, emphasizing their competencies in working with children. I suggested brief time-outs from stimulating activities if Sam required calming. I recommended that he remain in their presence due to his fears of abandonment, however, and that they actively assist him with self-soothing strategies. When Ms. X announced that she had begun keeping a log of his angry outbursts, I asked that she also record what was happening prior to the outburst in order to determine what triggered it. As it became obvious that Sam reacted with anger when feeling slighted or ignored, his parents became more adept at heading off his tantrums.
Whereas Ms. X initially dwelt on Sam’s problems, his father minimized them. I helped them explore Sam’s strengths and weaknesses, in order to develop more integrated object representations. I encouraged them to talk to Sam, get to know his feelings and opinions, and see how he viewed the world, in hopes of improving their mentalization skills (Fonagy et al, 2002). When the parents described an incident, I facilitated their reflective functioning (Slade, 2006) by asking how Sam might have perceived the event. I recommended Siegel and Hartzell’s (2003) book, Parenting From the Inside Out. I especially like its emphasis on reparation following emotional ruptures, which helped in my own parenting.
Siegel, D. & Hartzell, M. (2003). Parenting from the inside out: How a deeper self-understanding can help you raise children who thrive. New York: Jeremy P. Tarcher/Putnam.
Tronick, E. (2007). The neurobehavioral and social-emotional development of infants and children. New York: Norton.
Weinberg, M. (1992). Sex differences in 6-month-old infants’ affect and behavior: Impact on maternal caregiving. Unpublished manuscript referenced in E. Tronick (2007). The neurobehavioral and social-emotional development of infants and children. New York: Norton.
Weinberg, M & Tronick, E. (1992). Sex differences in emotional expression and affective regulation in 6-month-old infants (Abstract). Society for Pediatric Research, 31, 15A. Referenced in E. Tronick (2007). The neurobehavioral and social-emotional development of infants and children. New York: Norton.