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Helping Kids with Anxiety

Helping Kids with Anxiety

This is Goldilocks. She’s having a tough time.

This is the final post in the 3-part series about helping kids with anxiety. I reserve the right to blog more about it in the future because it’s a big topic and this is so general. Onward! To the helping!

Cognitive Behavioral Therapy or CBT is the counseling modality of choice for kids (and adults) with anxiety. Research on effective anxiety therapies tend to focus on these three areas:

  • Understanding and addressing the physical response to anxiety
  • Recognizing and challenging the thinking errors that perpetuate anxiety
  • Using controlled exposure to the anxiety-provoking situation and practicing the tools

Again this is super simplified and super general. Kids (and adults) have diverse learning styles, challenges, expectations and histories so how this works will look very very different depending on the child. But to help you get the gist, I’ll use Goldilocks as an example. We all know her story, right? On the very off-chance you don’t, you can check out this short version so we’re all on the same page.

So let’s say Goldilocks’s mom brings her to me because she’s gotten very anxious since her disastrous meet up with the three bears. She’s having trouble sleeping, she’s having some bad dreams, she is having tantrums at the drop of a hat and she hates leaving her mom to get on the school bus because she’s afraid the bears will come break into her house. She also can’t bear the thought of eating porridge ever again and will fall apart if her mom serves it at breakfast.

The first thing we would do is talk about Goldilocks’s physical experience of being anxious. We would talk about how being chased by bears would rev anyone up but now we need to help her calm her body back down. We would talk about how since this happened every time her heart starts beating or she starts breathing fast that her body immediately thinks BEARS! even if she’s faced with something much less concerning like shoes that are hard to tie or being a little bit late for school in the morning. We would work hard on helping her identify where in her body she feels the anxiety — is it in her stomach? Does her chest feel tight? Does she make fists with her hands or does her mouth go dry? We would talk about relaxation techniques and figure out which ones work for her. She might start keeping a worry diary or we might make a list of everything that makes her anxious.

What I tell kids is that we’re going to be detectives and we’re going to work together to solve the problem of their worries. I am very strengths based (that means I encourage focus on what’s going right even as we are talking about what’s going wrong) so we would also discuss times they have managed their anxiety in the past so we can figure out what shores them up.

The next thing we would do is look at thinking errors (also sometimes called “negative cognitions”). Here are some super common thinking errors:

  • All or Nothing Thinking: If I make one mistake then I’m an idiot.
  • Catastrophising: If I don’t turn in this one homework, I will flunk out of school.
  • Overgeneralization: I fell down at the roller rink one; I will fall down forever.
  • Personalizing: It rained on my birthday because nothing ever goes right for me.
  • Discounting the Positive: Sure my best friend likes me but that doesn’t count because she’s my best friend.
  • Mind Reading: I know everyone on my soccer team hates me.
  • Labeling: I’m taking so long to learn to ride my bike because I’m uncoordinated.
  • Should Statements: I shouldn’t have such a hard time learning math. I should know how to wrap this present without help.
  • Emotional Reasoning: I am in pain therefore I am right and you are wrong. I feel guilty and that proves I’m a bad person.

There are more but you get the gist and probably these are familiar to you either because your child does them or because you do them yourself. (Some of these are so ingrained in our cultural way of thinking that to confront them can be like wandering around in the dark your whole life and then stumbling over a flashlight and realizing you can use it to find the light switch and actually turn on all the dang lights.)

This is where I think counseling can help. I know in my own family that I can tell my kids something over and over but when they hear it from somebody else they believe it. Part of this is that they get tired of the sound of our voices (I haven’t seen studies on this but anecdotally I can tell you that my children get tired of the sound of my voice) and part of it is because it’s easy to get defensive with our parents. At least it was for me when I was a kid and then a teenager. If my mom disagreed with me it was automatically an opportunity for me to argue with her but if another adult said the same thing, it was an opportunity for growth and better understanding.

Yeah, we parents get it coming and going.

BUT! Let’s not resort to Overgeneralization! Sometimes parents have a lot of success doing this work at home without a therapist and there are workbooks (note I haven’t reviewed these so I can’t recommend one in particular) to help parents help their kids. AND even when kids are in therapy, we really need the grown ups in their lives to help them do the work. (I see a child an hour a week. Their parents are the ones bearing witness to the other 167 hours.)

Anyway. That’s the cognitive part of CBT therapy and it can take awhile. We’re talking about challenging ingrained ideas that make perfect sense to the person thinking them. That’s HARD and it takes practice.

For lots of kids, this is when we’re really leaning on the play part of play therapy because every little step we take needs to be ensconced in trust, respect and acceptance, which means a lot of time just hanging out and enjoying each other. The play therapy space (and the talk therapy space) is a place to safety say anything and be anyone and sometimes anxious kids just need one place where they can come and PLAY away from their worries.

tumblr_lsne2yzAIw1qh59n0o1_250Particularly with anxious kids whose anxiety ends up all centralized in their need to Do Good and Be Good, too much CBT pushing just triggers their anxious need to perform well. So sometimes my office is all about creating an island where they can goof off a little and experience themselves in a new way.

I’m emphasizing the slow part of this time in therapy because sometimes parents get (understandably) frustrated. They want to see change. At the beginning they get some concrete tools (breathing, relaxation, etc.), which feels great and proactive but it’s not a cure all. And then at this point things slow down and they may not see the any progress. But progress really is happening. Not to mention that this is where grown ups start slowing down, too, because it’s one thing to hear about Personalizing but it’s another thing to really get it and see how that kind of thinking is actually impacting your life.

The other thing is that anxious kids (and adults) have had people trying to talk them out of being anxious for a long, long time and that can make people hold on to anxious feelings even more tightly. They don’t mean to do this but being anxious, which many of them see as being concerned or cautious or careful or responsible (“I study all of the time because I’m a good student and if I’m not anxious about it then I’m being irresponsible.”) and often they get a lot of praise for being “good” in other anxious ways. (Oh the perfectionist students I see in my office! The ones who are running themselves into the ground for the praise and academic rewards!) To ask them to give up this way of thinking, well, that’s scary. It takes time.

Goldilocks may say to me, “You know this is all well and good but the minute I let my guard down I’m pretty sure Papa Bear is going to come charging in here, paws waving, and I can’t risk it.”

And so we’d keep working on it.

The next step of CBT is taking it out into the world and confronting those anxieties. Remember we’re simplifying these steps and we’re making them look more clear cut than they are (although they’re presented pretty clear cut in the Coping Kids group because we have a curriculum but we will adjust it as needed).

Goldilocks and I would keep on playing detective, we’d see what’s working for her and where she gets stuck. Maybe her big issue is not being able to eat porridge. Maybe I would get an empty box of oatmeal to have in the play kitchen or maybe we’d pretend to feed breakfast to the dolls.  When she’s ready maybe we’d have ourselves some porridge together. We’d go slow and we would be mindful of how it feels. We would see any small move forward as a victory even if she never actually gets the spoon in her mouth for a long, long time.

Maybe I’d ask her mom and dad to take her for a walk in the forest and practice her relaxation techniques and see how that goes. She and I might might write a game plan beforehand that confronts the “what ifs” and has strategies in place for whatever scenarios she can imagine. Again, we’d go slow. She might only get herself out the door the first time and we’d applaud that step even as we think about how to get her off the stoop next time.

Or maybe she’d need to play out what happened, putting the bears in the sand tray and working to make sense of the event by playing out the scene over and over again, trying out new ways of experiencing it and new outcomes.

There are other more specific ways to deal with particular kinds of anxiety. Treatment for OCD, for example, is more complex. Which brings me to medication.

Medication for kids is a tricky thing. Although many family practice and pediatricians will prescribe medication, it’s best to seek out help from a child psychiatrist. But this is hard. Columbus — like lots of other areas — has a dearth of child psychiatrists and parents don’t always have time to go search one out. I encourage parents to have an ongoing conversation with their family physician and to be aware that having a psychiatrist becomes even more important as the child gets older because hormones can make getting the right meds in the right dose super challenging (and things can turn on a dime if someone hits a growth spurt).

Not all anxiety disorders NEED medication but medication can certainly make sense if a child is completely hamstrung by his anxiety to the point that he isn’t going to be able to participate in his therapy. (Some kids are so anxious that relaxation techniques aren’t going to be enough to get them to a place where they can do the cognitive work.) Or if her behavior is so problematic (tantrums, rages, violence) that the rest of her life is at a standstill then medication can make sense.

Ultimately this is a parenting choice and I support parents in making their own informed choices for their kids. I do think, though, that medication alone isn’t enough. We all need to learn how to function as our best selves within the gifts and limits of our particular personality make-up. Medication can help us get functioning but we still need to understand ourselves and how we work. We need to know how to get help.

Eventually, too, our children will be adults and will make their own decisions about how to manage their anxiety (since for most anxious people it’s part of their lifetime experience since our personality can be molded but we are essentially who we are) and getting therapeutic support gives them options.

I like the idea of saying to kids, “Hey, counselors are there to help us when we need it. You need to know how to find the right one for you and how to do the work of therapy and I will help you do that when you’re young so you can help yourself when you’re older.” So we can teach them how to be good consumers of therapeutic support by helping them find someone they like and feel comfortable with (because it all comes down to the rapport in the relationship).

This is a positive way to talk about anxiety and anxious temperaments. After all, some of us more athletically gifted and some of us need more help. Some of us are terrific musicians out of the gate and some of us need more practice. Likewise some of us have more struggles with anxiety or depression and that’s why we have therapists and that’s why we learn about medication options and that’s why we learn to take good care of ourselves.

Have questions? Let me know. Want to sign your child up for Coping KidsLet me know. (I’m trying to plan summer offerings so if Coping Kids is something you’d like your child to attend then, please let me know so I can email you when I get scheduled and also find out if there are particular days or times that might work for your family.)

First in the series: Anxiety in Kids

Second in the series: Child Anxiety Symptoms

Child Anxiety Symptoms

child anxiety symptomsThere isn’t one way to be anxious so when we look for child anxiety symptoms, we need to be aware that they will manifest differently in different kids.

This is a very (very) broad overview of the kinds of anxiety disorders seen in kids. And remember, it goes from regular worry to a concerning disorder when the anxiety gets in the way of functioning.

Ready? Ok.

Most Common Anxiety Diagnoses

  • Generalized Anxiety Disorder
    • Kids with generalized anxiety have excessive worry across a variety of situations. They worry about missing the bus, about whether the kids at camp will like him, or about the laundry getting done in time to wear her new shirt tomorrow.
    • They may worry about things that didn’t happen, too. (“But what if last night’s thunderstorm DID turn into a tornado?”)
    • You may feel like your child is always humming, always looking for something to worry about. You may start to feel like any television show, book or movie is a potential worry generator and you may even find yourself editing things ahead of time because you don’t want to trigger a new round of anxious “What ifs?” before bedtime.
    • For these kids, the worry is pervasive and ongoing. If you find yourself constantly trying to reassure your child (often without success) then she may be struggling with generalized anxiety.
  • Separation Anxiety Disorder
    • Almost all kids go through a developmentally appropriate phase of separation anxiety when they’re toddlers and sometimes when they’re preschoolers. Kids who still have trouble separating by age seven should be evaluated.
    • Kids who have separation anxiety are usually worried about something bad happening — often to the people and pets they love — while they’re away. Sometimes separation anxiety appears after a difficult event — a parent who was ill, a threat in the neighborhood, etc.
    • For some kids, this will result in them refusing to go to school.
    • NOTE: I work with a lot of attachment parenting proponents who co-sleep and homeschool and make other parenting choices that keep kids close and I think that these decisions need to be respected and understood when therapists are evaluating kids for separation anxiety. A child who is happily ensconced in the family bed at an age where our culture expects them to be out is not necessarily struggling with separation. I start looking for anxiety when their reluctance to leave mom or dad goes beyond preference. If a child is truly crippled by his anxiety — if he wants to go to a sleepover but can’t, if he wants to join his friends at the movies but can’t unless you to come, too, and sit in the back row where he can know you’re close, then separation anxiety may be an issue. I mention this because some of the assessments that therapists use are not culturally sensitive to parenting choices outside the mainstream.
  • Social Anxiety Disorder
    • It can be tricky to differentiate social anxiety from natural introversion. In both cases kids may have a hard time around new people and may be reluctant to join groups (at birthday parties, soccer teams). The difference is that the socially anxious child may worry more after the fact (“I probably said something stupid and won’t get invited again”) and will usually want to want to do the things that scare her while the introvert may be perfectly happy avoiding social events.
    • Social anxiety is common as kids head into adolescence. Part of this is that the middle school years are HARD. Social groups start to split apart and come together in new confusing ways. Hormonal changes have everyone turned topsy-turvy. And kids start trying on new personas. An introvert may wish she was more extroverted and so she may push herself past her comfort zone. Kids become more self-critical and more worried about what other people think. Again, it’s normal but that doesn’t mean it doesn’t deserve attention and support.
    • Selective Mutism (a child who won’t speak to people outside his or her family or who will only speak to friends but not adults) is a form of Social Anxiety Disorder and is usually diagnosed once a child heads to school and people notice she isn’t speaking up.

Less Commonly Diagnosed

  • Obsessive-compulsive disorder (OCD)
    • People tend to be confused about OCD as evidenced by the casual, “Oh your collar is crooked. I know I’m so OCD but let me straighten it.” True OCD is magical thinking run amok. It’s believing that if you don’t straighten the collar then your friend will die. We all do a little magical thinking and children in the tween years may flirt with it an awful lot (that’s the age of “don’t step on a crack or you’ll break your mother’s back”). The difference is that kids with OCD get stuck. They have Obsessions (“What if mom’s car crashes?”) and Compulsions (“If I skip every other step coming down the stairs her car won’t crash.”).
    • Kids who have OCD are slaves to their rituals, which become more and more complex as a simple compulsion no longer quiets the obsession. Compulsions are like drugs — they become less effective the longer one uses them. So the staircase needs to be traversed twice. Then four times. Then eight. If they aren’t allowed to complete a compulsion, these children may fall apart.
    • Children with developmentally typical magical thinking can more or less roll with it if you tell them to quit walking on just the white tiles because you need to get home before lunch; kids with OCD can’t. They don’t want to be stuck in the bank stepping on white tiles while you’re fuming but they truly can’t help it.
    • Children with OCD may be constantly checking, cleaning and ordering things a certain way. They may hang their obsessions on superstitions (“I saw a black cat and now I need to walk backwards the rest of the way to school so I don’t die.”)
    • OCD can be very complex. Some kids will struggle with intrusive thoughts (“What if I killed my dog”) and then have rituals to “counteract” the thoughts. Other children will hoard things because they become obsessed with the idea that they might need the candy wrappers later.
    • Parents may become part of ritualized behavior without realizing it, having to repeat things in a certain way or reassure their child with particular words or phrases or to do the bedtime routine in a very specific order.
    • OCD is usually diagnosed around age 10 and interestingly is more commonly seen in boys before puberty, and more commonly seen in girls after puberty.
  • Panic Disorder/Somatic Symptoms
    • Panic Disorder is generally diagnosed in older children but younger children may display somatic symptoms like stomach aches and headaches. Older children may have full blown panic attacks — heart racing, fear of passing out or dying. Kids are unlikely to connect their pain with worry and parents may believe they’re faking to get out of something — a test, a visit outside the home — but the children genuinely feel sick.

As you’re looking at this list you may think, “Wait, my kid does that! Should I be concerned?” My answer is that you should be aware but note whether or not the worry is getting in the way of your child’s happiness. Remember, a diagnosis depends on interference with a child’s everyday functioning.

That said, learning skills to manage anxiety is useful no matter who you are. We all have times in our life where we’re dealing with more stress than usual and learning anti-anxiety tools certainly never hurt anyone.

First in the series: Anxiety in Kids

Last in the series: Helping Kids with Anxiety

Anxiety in Kids

anxiety in kidsAnxiety disorders are the most common mental health diagnosis in kids; ten to twenty percent of all children will meet criteria for an anxiety disorder before the age of 18. But it’s hard for parents to figure out when worry is part of typical child development and when it’s a concern.

Some anxiety in kids is normal. Anxiety can inspire children to do stuff like wash their hands and double-check their homework. Anxiety becomes an issue  when kids get stuck in it to the point where its getting in the way of their lives. For example, it’s fine if a child double-checks his math sheet; it’s not fine if he can’t sleep because he’s obsessively going over and over the numbers, erasing the paper to the point that his pencil rips through and begging you to check it for him.

When worry becomes extreme and/or intrusive, that’s when it’s time to get help. If your child is missing out on her regular everyday life or missing out on events that you know she would otherwise enjoy then her anxiety has become a problem.

Anxiety is often co-diagnosed with depression (particularly in teens) and anxious kids may also be misdiagnosed as having attention problems. (Anxious kids often have a hard time focusing particularly in contexts that worry them — at school, for example.)

Which Kids Become Anxious

Some kids are born with a more anxious temperament than other kids and these children often have anxious parents (because temperament — innate personality traits — is generally believed to be nature although how we live out our temperament depends on nurture). If you have struggled with anxiety there’s a higher chance that your child will, too.

The kind of temperament that tends to anxiety is sensitive, cautious and negative. You might recognize yourself in some of these traits, too.

Sensitivity: These kids are aware of their surroundings and may pick up on details that other people miss. They may be the first ones to notice someone’s new haircut or when someone else replaces their contacts with glasses. They may overhear adult conversations even though they’re in a room four doors down. They may detect subtle changes in someone’s demeanor and ask you later why Aunt Cora was mad. These kids may also have sensory sensitivity; the world feels less comfortable for them whether they are sensory seeking (wanting more intense sensory input) or sensory avoidant. His anxiety may be heightened because he’s uncomfortable in his socks or because he doesn’t like the way this new school smells.

Cautious: I’ve met plenty of anxious kids who go hurtling into space on their bikes or rollerblades but lots of anxious kids will be the ones hanging back from the fray. They may be the ones observing the party before they join or the ones who read up on shark attacks in Florida before your summer vacation. They may be the ones who need a lot of cajoling, the one who makes the family late for the wedding because she wants you to tell her — again — exactly what’s going to happen there. They may be reluctant to try new foods or new things.

Negative Emotionality: This is another way to say pessimistic. These are the kids who are sure bad things will happen. They’re the ones who counter your encouragement with a lot of concerning “what ifs.” Says Dad, “Let’s head to the pool!” Says child, “But what if the lifeguard isn’t on duty? What if I get a cramp? What if you don’t notice I’m drowning?” This is a child whose theme song could be Mel Brooks’s “Hope for the Best, Expect the Worst.” And when you say, “You’re being ridiculous” they’ll counter with, “I’m being realistic.” This is a genuine worldview they have and logical arguments may not make a dent in it.

You can see that these can be great traits in small doses — and the anxious kid can be a pleasure much of the time — but when taken too far, these traits can be crippling.

Sometimes there’s a specific event that triggers a child into an anxiety disorder. For example, a child who gets lost at the mall or who witnesses someone get injured. Or a big life event like a move or a change in school may impact some kids differently than their siblings or peers. Lots of children will spend their early years worrying and then when they hit their tweens, that’s when the worry turns out to full blown anxiety.

Anxious parents can inadvertently make things worse for their anxious kids both because they share certain personality traits but also because anxiety is one of those super-catching emotions. Think about it — back when we were hunting and gathering, it made sense for one person’s anxiety to trigger another person’s anxiety. If a tornado is bearing down on your tribe it’s a help if everyone gets ready to run. We have mirror neurons — so called because we reflect our emotions back to each other — to keep us all in step. This is why when faced with a child wailing about the upcoming spelling test we get revved up, too, and pretty soon everyone is yelling.

If you have questions, hit me up.

Second in the series: Child Anxiety Symptoms

Last in the series: Helping Kids with Anxiety

It Bears Repeating

it bears repeatingOne of the hardest thing for us parents to wrap our heads around is how often we have to repeat ourselves.

“Shut the door.”
“Pick up your shoes.”
“No, you can’t have cookies for dinner.”
“Hitting is against the rules in this house.”

You’d think they’d figure it out after the 457th time we’ve said it and yet there we go, repeating ourselves over and over and over again.

Argh! Frustrating!

There’s a reason we have to turn into broken records; our kids are always growing and so they need to learn some things over and over and over again.

When your child grows from one stage into a new stage she’s learning things in an entirely new context. She has new developmental tasks to master, new facts to contemplate, and new skills to integrate. In this entirely new environment the things you’ve taught her — shut the door, pick up your shoes, etc. — don’t mean what they used to mean and she has to learn them again.

For example, your average everyday 3-year old may be pretty good about not slamming the door. She’s anxious to please you, likes your approval and wants to prove what a big girl she is. That’s the context she’s learning that whole “shut the door quietly” rule.

That very same child as a 4-year old may start slamming the door again. Her curiosity may be more intense at this age so she may be so anxious to move onto the next thing that the door slams behind her before she even notices. 4-year olds may also be more interested in challenging adults, leading to more door slamming because now she wants to explore what happens when she breaks your rules.

Totally the same behavior happening in totally different contexts with totally different things to learn. We just see the annoying behavior, we just hear ourselves saying it yet again — “Don’t slam the door!” — but for her it’s not just a slamming door, it’s a whole new thing to learn in a whole new way.

What parents need is faith that all of our repetition is sinking in because it is. We also need to know that continued commitment to the house rules and values create a structure that makes it safe for our children to grow and that part of that growth includes challenging that structure. It’s not easy, I know, but know that with every repetition you are offering your child a new opportunity to learn.

Parenting is a long-haul operation, lemme tell you. Hang in there!

And now for your listening pleasure (because parents need a little pleasure to get through some of this rough stuff) is The Bird and The Bee singing Again & Again.

The Bird And The Bee “Again and Again” from Miky Wolf on Vimeo.

Parenting for Now

parenting for the futureWe parent our kids to help them grow into the people we hope they can be. We parent them to be their best selves, to be the most resilient, to be successful (however we define it), to be loved and we make most of our decisions based on the future we want for them. That’s the point of parenting, right? To prepare our children for the future.

Well, kind of.

Even as we work to prepare our kids for their somedays, we also need to parent for today, right this very minute.

Many of the kids who come to see me have said things like, “In first grade they told me I needed this math for second grade and in second grade they told me I’d need this math for third grade and so on all the way up to high school, which they tell me is going to prepare me for college. But what about now? Can’t I just be in the now?”

In truth, now is all we have. We don’t know what will happen ten weeks, eight months or six years from now. We don’t know what the economy will look like or what the most in demand job skills will be or who our children will settle down with (if they settle down) or anything else. We are making our best guesses and we need to do that but we also need to remember that this moment is just as important. This moment, this interaction, it matters for its own sake and not for what it might owe to a future we can’t even see clearly.

Some of us are so future-focused that we start parenting from an urgency that makes our children’s simple mistakes or struggles seem overwhelmingly scary.

Sometimes when I’m working with a parent trying to help them understand why an issue feels so consuming — a child who sleeps through her alarm or who is struggling in his friendships — we follow the path all the way to a very specific fear. What if her inability to get up on her own will ruin her career because her boss won’t put up with her being late all of the time? What if his problems on the playground mean he’ll end up in an apartment with 43 stray cats and no one to call when he’s lonely?

Those often unspoken outsized fears can make it hard for us to allow room for developmentally appropriate bumps and bruises. If everything — future partners, future careers, future success and happiness — seems to depend on the SAT scores we may forget that there are other things to learn here, too. Things like preparing for big tests, dealing with pressure, confronting uncertainty, etc.

When parents allow their imaginations to run away with them — when they let themselves do it out loud instead of ignoring the fear so it sets up camp in their deep dark worries — then we can talk about it more realistically. Sometimes a slept-through alarm is just a slept-through alarm. Sometimes it is its own problem to be solved instead of a symptom of a greater issue.

And if there are greater issues at play, it makes more sense to focus on the moment as we contemplate our options than to let our fears take us down the road to hopelessness. Because this child, sleeping through her alarm, is just as important as the adult she will someday be.

There is not one way to be happy or successful. There isn’t one path to a really good life. We may get only one shot at a specific opportunity (winning the 5th grade spelling team or qualifying for the Olympics) but that doesn’t mean that there aren’t other opportunities waiting for us.

It can be a tricky balance to both grow kids for the future and be here with the present child in front of us at the exact same time. But the dual perspective is necessary both for our child and for ourselves, so we don’t miss what’s happening right in front of us while we are looking out so far ahead.

My thoughts on Lena Dunham

questionning-sliderI’ve been asked about my thoughts on Lena Dunham and the passages in her book that detail her sexual behavior with her sister. At first I declined to post them here because I felt like there have already been so many people talking about it that I really had nothing to add to the discussion. But then I realized that as a therapist and with the understanding that you might be wondering if I’m the right therapist for you or your child, I ought to weigh in for no other reason that my clients — current or potential — have the right to know where I stand on such a contentious and difficult issue. So here are my thoughts.

First, I haven’t read the book and I have no plans to; I’ve only read the quotes and passages (that link will allow you to read them, too) that have appeared on other sites. Because of this, I can’t really discuss the context in which those quotes and passages appear, which is one reason I can only speak in generalities. Also I don’t know Lena Dunham or her sister, Grace (obviously) and I don’t know the family in which they grew up and I don’t know the way their relationship was or is now. I only have these passages, which are in Lena’s words and further words in a memoir, which means they have been shaped for a general thesis. This means that I can’t really trust their reliability. Therefore any commentary I am making about Lena Dunham and her sister aren’t really about them; my commentary is more about our general discussion of child bodily exploration, sexual play and the potential & possibility for sexual abuse between siblings.

Child sex play is a normal, developmentally appropriate part of growing up. Some children keep to a mild “show me yours and I’ll show you mine” and some may do more graphic sexual play. What makes it play and not abuse is the absence of a power differential and coercion and this can be very hard to ferret out. A six year age difference — Lena is six years older than her sister — is always concerning. Always. Whether or not it is sexual abuse or a serious boundary issue depends a whole lot on exactly what happened, how and when. Is it a one time thing? A pattern of enmeshment? Is it straight forward bodily exploration or is the more powerful sibling using the younger sibling for his or her sexual satisfaction or to act out an unhealthy power dynamic? What is certain is that a relationship that Lena describes (while acknowledging that the reality of that particular relationship may be much different) deserves more attention from parents.

This leads me to a discussion of culture. Family cultures differ and so family boundaries differ. There are families where privacy and general touching (hugs and cuddling) are more or less important, which is another thing that needs to be considered as we talk about boundaries and the violation of boundaries. While there are values that we as a broader community can agree on, there are others that are murky. When I read the quoted passages I feel I’m also missing this important context. I do not know what (if anything) her parents did about their relationship. I don’t know if Lena was reprimanded for the intensity of any of her actions towards her sister (the bribes with candy and quarters). I don’t know if Grace protested or if she was silent (not that her silence equals consent but I don’t know how much her parents were aware of their dynamic). In my office I sometimes see some parents describe a closeness that I, as a therapist, find concerning but I can’t know at first glance. It’s easy to jump to conclusions and misunderstand what’s actually happening. It takes continued discussion, questions, and observation to get a better sense of what’s going on. So when I feel my antennae go up I remind myself to go slowly and listen hard.

I also want to honor Grace’s right to label and define her own experience. Grace has said she does not see herself as a victim; I believe her and want to give space for her assertion. I also want to give her space to think differently at some point if she chooses to. Many of us think about our family of origin in one way and then we grow to think about it in another way later on. This is our right and important part of growth and empowerment. Whatever I may think of how I might feel if I were Grace, I am not her and in this important conversation about violation, I do not want to participate in a violation of her right to speak her truth.

In other words, this is a discussion that we need to be having but I think it’s extremely important that we do not expect her to uphold our own take or Lena’s take on their relationship or the scenes Lena describes.

These are things I do know.

Kids make mistakes. Some of those mistakes will certainly be violating the boundaries of siblings, cousins, friends and pets. In some cases those boundary violations may be bodily (kids who hit, hug too hard, hold down a cat who wants to get up) and sometimes those bodily boundary violations may be sexual. It is normal and developmentally expected that a child’s self-centeredness would lead to boundary violations. Remember that normal does not mean OK; I am not excusing or shrugging off the seriousness of boundary violations.

I am also not saying that normal means that no one gets hurt. One child’s normal behavior can harm another child. I mean, it’s normal for toddlers to bite but that does not mean it’s ok and it does not mean that the child doing the biting does not hurt the child who is bitten. Normal does not mean we ignore things.

If the type of activity Lena describes truly was typical of her behavior then her parents should have been intervening. (They may have been; we don’t know because we only have Lena’s side of the story.)

If one child is treating another child as a toy or as an object, that’s concerning and needs interrupting whether or not that treatment includes sex play. If a parent only jumps because the play turns sexual, that’s a problem because I would argue that there is likely a pattern of coercive play that needs parental attention and intervention. To a child, dressing up a reluctant pet and coercing a sibling into allowing genital exploration may come from the same misunderstanding of the division between self and others.

It’s our job as parents to protect our children from each other and also from themselves. Many of carry a great deal of guilt for the way we treated our siblings when we were kids but we needed adult help to figure things out. We can own our responsibility but also acknowledge that our childhood selves did the best they could with what they were taught; many of us were not taught how to treat each other.

Sometimes parents have trouble intervening because they don’t know what good boundaries between siblings looks like since we were not protected from ourselves or from a violating sibling. We see a certain amount of roughhousing and conflict as perfectly normal and it’s true — some of that is normal. But we should pay special attention when:

  • One child is always the victim;
  • One child is much older or stronger or otherwise more powerful;
  • If we detect real hostility in the interactions;
  • If the hostility is pervasive (if they never really get along).

In the case of sexual boundary play, I would also check in to ask where the children got the idea. Sex play is common in kids, absolutely, but a check in can help us know if something is happening to the child who is acting out (did they learn this from another child? from sexual abuse at the hands of an adult? unsupervised time watching HBO?). I would ask parents not to react as if sex play is always concerning but I would ask them to remember that sometimes it is.

Interventions do not have to be shaming. Parents can and should interrupt inappropriate behavior in a way that promotes empathy, compassion and an understanding of where a child leaves off and the other person begins. This starts when we protect that child’s boundaries. That means no forced hugs, no forced kisses, no forced sitting on Santa’s lap. There are lots of times where we have no choice (diapers changes of wriggly toddlers!) so when we can protect our child’s right to say no, we need to do that.

Finally parents need to be aware of their own understanding of boundaries and violation. Many parents who are struggling with their children’s sibling relationships are acting out their own experiences growing up. When I talk to parents in my office I’m always interested to know where they are in their own family configurations because this can illuminate my understanding of dynamics they are repeating (or trying not to repeat) in their own homes.

It also helps me understand why some parents are reluctant or afraid to make changes. To say, “This should not be happening to my youngest” may mean saying, “This should not have happened to me” or “This is not something I should have done to my sibling.” These are painful things to confront and I see some of that happening in the discussion around Lena and her sister.

We all come to our reading loaded down with our own baggage and it’s pretty hard not to bring that to a discussion about someone else’s very biased, perhaps somewhat fictional, and certainly manipulative (in the way that all writing — even this — is meant to sway the reader) story.

I don’t know what happened between Lena and Grace, not really. I cannot speak to it. I can only speak to the general things I know to be true and hope that I can help the individuals and families who come to me for care, informed by what I know about kids, about siblings, about families and about the truly hard work we all do growing up.

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