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Observant parents,
potentially troubled by their own child’s behavior, have increasingly turned to
mental health professionals for advice. It is not uncommon for educated people
to know a psychologist, a psychiatrist, possibly a social worker, a counselor,
or a life coach whom they may consult under such circumstances. One such
situation arose in my own clinical practice with children. A case that I will
share with you involves a four-year-old girl whom I will call Tammy. At the
time, she was an only child in a well-functioning two-parent family but with a
sibling on the way. She was a happy and well-adjusted child until a red flag
emerged at school. There was a single behavior that was of concern to her
preschool teachers: Tammy refused to go to the bathroom. It seems that she
resisted having a bowel movement, in particular.
Observant teachers
noticed that at the designated school “potty time”, Tammy did not line up with
the other children. She hung back and did everything her clever four-year-old
mind could conjure up to avoid the ritual; she would try to become invisible.
Often she would surreptitiously hide out near her “cubby”, pretending to search
for a toy she had presumably brought from home. After a few days of this
behavior, the teachers were sufficiently concerned that they alerted the
parents. Was this just a problem at
preschool or had parents also observed it at home?
The parents were not
aware of the problem. Tammy had been easy to toilet train and since the age of
three, she had been using the bathroom on her own. However, upon closer
observation, the parents did notice the same behavior at home; she seemed to
avoid having a bowel movement, in particular. Her mother also noted that
recently she had become uninterested in food at mealtimes. However, up until
now, she had always been a good eater. A bit defensively, the mother worried
that her own preoccupation with being thin (she was drawn toward media images
touting thinness as the prevailing route to attractiveness), might be impacting
her observant daughter. Her mother was aware of the risk of anorexia for
teenage girls. But surely, not at age four, she reasoned.
Tammy’s mother had
taken some psychology courses in college. Thus, she recalled that Freud had
postulated that certain forms of psychopathology were linked to the anal stage
of development which occurred around age two. In recent years the symptoms were
primarily relegated to the metaphorical given that Freud’s theorizing had
fallen out of favor. Nevertheless, educated parents would speak of people who
manifested an anal-retentive personality, with controlling and withholding
features. However, as a four year old, Tammy had displaying none of the
childhood precursors of such behaviors. In fact, the parents reported that
Tammy showed no signs of any troublesome behaviors at home, she was happy and
well-adjusted. The preschool teachers observed that her avoidance of the
bathroom was only a very recent behavior for Tammy and recommended that they
take her to their pediatrician as soon as possible since constipation could
become a major medical problem if allowed to persist. Before returning to this
case, I will share with you my own general perspective on normal and problem
behavior in children. I view them both through the powerful lens of development. After applying this
framework to Tammy, with whom I worked intensively for a short period of time,
I will end the article with the following question: Does this particular child
need psychotherapy?
A developmental perspective
During the preschool years, young children
obstinately possess very clear “mini-theories”, as it were, about their
competencies and the many occurrences in their daily lives [3]. Be it their
physical virtuosity (“I can run faster than my dad!”) or monsters under their
bed (“I’m sure because I hear them in the middle of the night”), their accounts
provide a mix of fantasy and their own version of “fact” or “reality.” At
times, their stories can be quite endearing. However, they are not to be
dismissed as mere humor or to be taken lightly, parents need to take their
children’s theories very seriously. Their perspective can also include
descriptions of their emotional
reactions to events in their lives. Often these involve fear, young children
often feel genuinely scared. Rather than dismiss these thoughts and emotions as
fanciful because they defy adult logic, we would do well to listen, to lend a
supportive ear. Tammy, as it turned out, was extremely and legitimately scared.
THE EVOLVING CASE OF TAMMY
Her preschool teachers had recommended that
the parents take Tammy to their pediatrician as soon as possible which the
parents did. The doctor’s first reaction was to prescribe a gentle laxative.
Perhaps that would be an immediate, if only temporary, solution until further
examination might reveal the cause of her avoidance of the bathroom. Tammy
tried valiantly to resist the laxatives since they gave her diarrhea which was
very distressing. However, the pediatrician could find no medical reason for
her symptoms; constipation was not a common medical condition in childhood.
Perhaps the problem was “psychological” but he offered no specific hypotheses
given that his training did not include the psychological disorders of young
children.
The pediatrician suggested to the parents that
she be referred to the Yale Child Study Center, a highly recommended
psychiatric clinic for children and families, where I was the Chief
Psychologist at the time. I was asked to perform a psychological evaluation of
Tammy. I first met with parents and teachers who were quite perplexed about
Tammy’s refusal to go to the bathroom. The teachers were experienced and
generally quite perceptive. However, they could offer no obvious explanation
for this isolated behavior. Tammy’s behavior at school had been quite
appropriate, she enjoyed the classroom activities and she played well with
other children. Perhaps her refusal to use the bathroom was a manifestation of
some deeper psychological problem but if so, “what”? And why?
As psychologists we are armed with a variety
of tests and evaluative procedures [4]. We often begin with a standardized
intelligence test in order to identify or to rule out any possible cognitive
deficits. But in addition, in our armamentarium we have a variety of
“projective tests” the most common of which are the Rorschach inkblot test and
the Thematic Apperception Test where one tells their own stories to
standardized pictures of people engaged in ambiguous activities or social
interaction. However, in the case of Tammy, time was of the essence since
constipation can be a serious and potentially life-threatening condition if not
treated as soon as possible. At a first meeting with Tammy, it was obvious that
she was a bright preschooler and I saw no need for an IQ exam. Nor did I feel
that projective testing would be very fruitful; the tests were designed for
adults and, at the time, clinicians had little experience in either
administering them to children or in interpreting their meaning. Tammy was
potentially very verbal, that was a positive sign. However, she could not
really explain her unwillingness to use the bathroom, although she did admit to
her refusal to do so. But then I did not expect a child of her age to have any
direct understanding of the causes of this unusual behavior.
I felt that doll play might be revealing and
our play rooms included a dollhouse fully equipped with all of the trappings of
home. They also possessed a range of dolls which could be assigned a variety of
roles. In observing the child’s play, including dialogue that usually involves
the adult clinician, it is hopeful that clues can be provided that may suggest
reasons for the observed symptomatic behavior. In this case, I was also talking
with the mother to determine if there was anything going on at home that might
shed some light on her seemingly inexplicable behavior. I had noticed that the
mother was quite pregnant.
The pregnancy was a new event in the life of
this four year old, the first child in her family. Her mother, at the time, was
eight-months pregnant with a boy and Tammy seemed quite excited about having a
baby brother. The mother talked lovingly to Tammy about how the baby brother
was currently in her mother’s “tummy” but soon would be born. She encouraged
her daughter to feel Mommy’s tummy when the fetus started kicking, much to
Tammy’s delight. Wanting to be what she thought was a good, female role model,
the mother also told her young daughter that “someday you may have a baby,
too.”
I spent concentrated sessions with Tammy in
one of our clinic playrooms because time was critical, given the on-going
constipation. I observed her dollhouse play behavior, where she first actively
selected a girl doll and I chose one of the adult dolls and a boy doll. She had
obviously engaged in doll-house play before, she had one at home and thus she
began with relatively safe and mundane daily activities. Not at first, but I
eventually tried to steer her play behavior toward the area of the dollhouse
bathroom. However, this produced play in which she had the child doll
characters systematically avoid any attempts to go even near the bathroom.
“They want to play outside” she insisted. While this was consistent with her
actual behavior at school, her play gave few clues as to the causes of why.
In my own use of dollhouse play with children,
I typically do two things, at first; I make interpretations about the child’s doll behavior, within the play. It is only later that I make more direct
interpretations about the child, herself, initially pointing out that she is a
bit like the play doll, inviting the child to elaborate [4]. In this case, I
had also taken the boy doll, asking Tammy to tell me what she wanted him to say
and do although I took some control over the boy doll’s behavior. Thus, after
some time, during which I had observed certain patterns to the play, I would
have my doll character point out that “...it seems to me that your girl doll
really doesn’t want to go near the bathroom, she would rather play outside. I
am wondering why your girl doll doesn’t want to use bathroom but that the boy
doll is OK with the bathroom, what do you think?” Initially, this did not yield
any productive comments from her; she simply said “...he thinks it’s more fun
to play outside.” But then she added something that made me curious, she
commented that “...and besides, he’s a boy.” So this suggested that in her
thinking, gender played some role. Why wouldn’t girls use the bathroom whereas
this was no problem for boys? Frankly, I was pretty clueless, at this point in
time.
Dollhouse play can often take an arduously
long period of time to be productive. The child’s defences carry over from
their real life actions, in this case, avoidance of the bathroom. Plus, the
direction that the play takes will in part depend upon the thoughtfulness of
the hypotheses that the clinician holds with regard to the causes of the
child’s symptoms that are then spelled out in play. Novice child clinicians are
sometimes eager to engage in dollhouse play with their child clients thinking
it will be “fun”. I tell my students that if you are having “fun” with
dollhouse play, then you are not doing the hard “work” that is required! That
is, our goal as child clinicians is to be constantly formulating hypotheses
within the play and testing them out, observing the child client’s reaction.
Where was I to go with the slim clue based on
her comments about how the girl doll would avoid the bathroom but the boy doll
would not be so concerned? Space and time do not permit me to describe the
different hypotheses I attempted to put forth, within the play. Some were
fruitless in that they did not advance the reasons for her avoidance of the
bathroom. More progress was achieved when I had the boy doll enter the bathroom and say “See, nothing happened to me!” On
this occasion, the girl doll, in Tammy’s words, said with great agitation, “But
you can’t have a baby, you’re a boy”! This had obviously struck a raw nerve for
Tammy. Where did I go from here? What did having a baby have to do with being
in the bathroom? I offered the general interpretation that I thought she was a
little bit like the girl doll because she
too was afraid to go into the bathroom but I could not advance a reason
why. I had my adult doll ask her girl doll what would happen if she went into
the bathroom, as I had my doll take her doll’s hand and move toward the dreaded
bathroom which the dolls observed but did not enter. At that point, quite
unexpectedly, a major, although only partial, breakthrough occurred. She
blurted out with emotion some of her personal four-year-old theory that I
thought just might be related to her own bathroom behavior: “If I had a baby, I
would burst in half, it would be too big! I’m really scared!” However, I did
not yet understand the specific location for her obvious fear, notably why it
occurred in the bathroom.
Moreover, her theory was incomplete. What did
having a baby have to do with the bathroom and, more importantly, her
constipation? My own interpretive wheels were churning as I tried to fill in
the gaps of her thinking. From her perspective, I reasoned, she seemed to feel
that a large baby might be growing in her own tummy, like her pregnant Mommy’s.
In point of fact, her stomach had become somewhat distended as a result of the
constipation and she surely felt some different internal sensations such as
fullness. I went back to the girl doll, asking “Does your doll think she is
going to have a baby? “ “Yes” she replied, “a big baby.” Something prompted me to ask, “Is she going to have the
baby sitting on the toilet?” “Yes”, and she anxiously answered about herself,
“...and it will break me in two, it will just be too big.” And why, I had my
doll ask, would she have the baby sitting on the toilet? She was choking back
tears at this point but managed an interpretable reply: “Well, that’s where
babies get out of your stomach!”
She had come close to completing her own theory,
at least enough for me to understand, if I had put the pieces together
correctly. I surmised that her four-year-old logic took the only analogue to
birth that she could imagine in her experience, namely, defecation. Something
solid, coming out of your body as you sat on the toilet. But she was terrified
because she knew the size of a baby in relation to the size of her own small
body. She had every right to be terrified about how having a baby would
literally tear her in two. But fortunately, in the short term, her body
empathically responded by becoming constipated. This was the only way that her
body could remarkably conspire with her mind and her emotions, in an attempt to
prevent the dreaded outcome. This would explain why she never wanted to go potty
again.
Yet there was more challenging work to be
done. They key was to encourage her to change her very compelling and
entrenched child theory. With further talk, eventually she accepted the fact
that she was far too young to have a baby; her body would not be ready until
she was much older. More importantly, with further explanation, she came to
appreciate the fact that babies came out of a special place in her mother’s
body, not where she herself had her bowel movements. We drew rather simple
pictures that helped her to understand this fact. Soon thereafter, the
constipation symptoms abated, as did her fears about giving birth, which had
been based on the only theory that her four-year-old mind could construct.
Tentatively, she was able, once again, to use the bathroom at school and at
home. After a period during which she came to be further convinced that only
her bowel movements passed through her body at her age, eventually her use of
the bathroom was no longer a problem.
CONCLUSION
Two related observations are noteworthy.
First, this case demonstrates the importance of appreciating the fact that
children, beginning at a young age, automatically construct vivid theories
about their behavior, consistent with their developmental level of understanding
[1-3]. Even more importantly, these theories have a powerful impact upon
children’s actual behavior. Her own personal theory led directly to her
constipation. This case clearly emphasizes the critical need for parents to
encourage and be open to their children’s theories of their own behavior,
however immature they may appear on the surface.
Secondly, this article was entitled Does
this particular child need psychotherapy? My own short answer would be
“no”. Professional intervention in the form of my clinical evaluation did
appear to be helpful in allowing this child to come forth with her own theory
of her symptoms that could then be addressed. But beyond that, this child was
not in need of any extensive, therapeutic treatment. Her symptoms did not stem
from any deep-seated pathology. Rather, this was an isolated problem that could
be explained developmentally, by an age-appropriate theory that rested on a
misunderstanding of bodily functions. With some effort, her misunderstanding
was eventually amenable to correction. She was not, in my opinion, a candidate
for longer term psychotherapy, per se. This is not to say that other children,
with symptom stemming from a more serious history of pathology, cannot profit
from therapy, many can and do. An evaluation, by a trained clinician, can aid
in this decision and should be conducted, given a child’s puzzling problem
behaviors. Such an evaluation may or may not point to the need for therapy
[4,5]. In the case of Tammy, fortunately no further intervention or therapy was
indicated.
1.
Harter S (2017) What were you thinking? J Psychiatry
1: 1-8.
2.
Harter S (2012) The construction of the self:
Developmental and sociocultural foundations. New York: The Guilford Press.
3.
Harter S (1988) Developmental and dynamic changes in
the nature of self-concept: Implications for child psychotherapy. In: Shirk S
(Ed.), cognitive development and child psychotherapy. New York: Plenum, pp:
119-160.
4.
Harter S (1982) Cognitive developmental
considerations in the conduct of play therapy. In: Schaffer CE (Eds.), Handbook
of Play Therapy. New York: Wiley.
5.
Shirk S (1988) Cognitive development and child
psychotherapy. New York: Plenum.
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