Here are some thought -provoking comments from a psychologist to a 'social thinking clinician' regarding two teen clients who are struggling to benefit from treatment.
NOTE: We know most parents are working extremely hard to set limits and we also know that not all children respond even if parents try! This blog is not for you - we know you are trying!
This article is for the parents who are not sure if they should set limits or have clear consequences for desired and undesirable behavior, yet would like their children, adolescents or young adults to be rid of their behavior problems.
For these parents we strongly encourage they work with a professional to learn how to clearly set limits; as parenting does not get easier especially with scientifically "smart" teens who have social learning challenges and who don't think the rules are made for them.
The psychologist would like to stay under the radar, so he asked to be identified as Dr. Panglos.
From Dr. Panglos to the 'social-thinking clinician' he is working with:
Okay, here is what I think. Symptoms are multiply determined. Even though Albert and Steven both have profound social deficits that, on the surface, make them appear to meet the criteria for being 'on the spectrum', I no longer feel that A.S. describes the true nature of their deficits. That said, they are very much alike in how they present. So if it is not Asperger's than what is it? And what do you do about it? If not A.S. then what?
It would be great if we could list the behaviors/symptoms and pull out the DSM-IV and look these guys up but their pathology is not so simple. The way I see the ingredients that make up both boys is this. They came into the world with particular temperaments that made them difficult from day one. The parents were disappointed and felt burdened by these difficult kids. Early on they lost hope and deciding that there was nothing that they could do to mold them, they became conditioned to avoid conflict by meeting their boys' every want and need. No frustration went un-rewarded. So on top of having difficult temperaments the tail ended up wagging the dog and THIS, makes therapy a real challenge. These boys, and kids like them, have never learned to delay gratification, (never needed to). They have poor frustration tolerance, (never had to wait), and this leads to difficulties with sustained attention, motivation, and yes, even profound social deficits.
By age 5, around the time that school started, the die had been cast. In their respective families they knew not the meaning of the word "compromise". As for "sharing", that was something other people did, not them. Lacking any basis of comparison, they were ill prepared to co-mingle with age mates on the playground or in the classroom. Given their skewed self-perception, laced with entitlement, they expected to be seen by their peers not as their equals, but as their superiors.
As it would be with a prince set among commoners, so it was for Albert and Steven. Their angst was genuine and it was intense. From the boy's perspectives the world was not recognizing what to them was obvious – that their sense of entitlement was their birthright. After all, were they not their parent's sovereign? Was it not reasonable to believe that that was true in the home would also be true in classroom?
The slings and arrows they encountered at school pierced their inflated self-worth deeply. Lacking the psychological equivalent of armor, shields, or helmet to protect their fragile sense of self, they were forced to retreat deeper into the bosom of their families where their reigns went unchallenged, and their hegemony was secure.
During the period when age mates were making forays into the larger world via activities of every type, our warriors were pacing in their castles, stewing in their juices and giving vent to their rage by constantly reminding their parents who was ruler and who was ruled.
And just when they may have come to terms with their own limitations, they found "World of War Craft" and other online "games". Here was the world they had yearned for. So captivated by this "pseudo" world of war, rage and the illusion of mastery that no one in the family seemed to notice the onset of puberty. While age-mates began making forays into the larger world, our boys, sealed in their bunkers, fought on, racking up points and "feeling" as if they were doing something important.
Enter the therapist:
Disheveled, intense and articulate about their one true love, MMORPG (Massively multiplayer Online Role Playing Games) they sit across from me and plead their cases. They are not very good perspective takers.
Many other kids with social/communication problems can be taught the skills they lack in a straightforward manner in a group setting with a white board and examples. But these boys and kids like them present as something of a challenge as their sensitivity to criticism is pronounced and a group setting is experienced as exceptionally demeaning. Such boys are apt to challenge the qualifications of the therapist and work to prove their point by encouraging dissent.
Scorned by the world the contempt they feel towards those who want to help them is real. To admit to needing help is tantamount to admitting weakness and so they dismiss their parents, their teachers and yes, their therapists.
What can be done?
One thing I've come to appreciate is that any work with boys like these is going to be glacial. Involving the parents is worth attempting but I have found that it is rarely fruitful. Change is always difficult and the status quo is often stronger than promises made in session. I have found that parents conditioned reflex to "appease the prince" with trinkets and tributes is very difficult to change.
If truth be told, there are days when I feel like a hanger-on in the court, a part of the retinue of hired help, a participant in the parade that parents surround themselves with to show the world their level of commitment. Together we "professionals" form a palisade behind which the family hopes to hold off intrusions from the greater community. But, the moment we buy into the argument that "the world needs to change" (and not the family) we become unwitting diplomats in defense of dysfunction.
On other days I am more sanguine. Between the epiphanies we hope for, trust is being formed and strengthened. Push some- then pull back. Socratic questions create conversation and sow the seeds for self-reflection. Let them talk about what interests them but all the while looking for openings to tug the conversation towards core topics, like cooperation, participation, and how to behave in ways that girls might like to get to know them.
Although stretches of time go by without much overt reason for me to feel hopeful, it is crucial to fight the impulse to view kids like these as being sick, damaged or disturbed beyond repair.
For deep down this is what they fear most about themselves and this, I suspect, is what they doggedly fend off from awareness. The energy it takes to keep this thought at bay makes them prickly, arrogant and at times, even paranoid.
Message from Michelle:
I felt this is important to post, although it may be uncomfortable for some to read. Our clients are members of families that most often help with tremendous positive support and outcomes are brighter; which means the family held the student accountable to how he or she behaves as well as how they impact others. However, we also have to wrestle with the client who fails to participate in society in part because there are too many allowances given to his or her challenges in the home, so they fail to learn to tolerate any choices other than their own. Their own poor choices often back them into corners without them realizing that by ruling their worlds they end up living in an incredibly confined space.
Unfortunately, there is no public law about how to parent children with difficult temperaments. There is only public law about how to handle them during the school hours by the teachers and administrators who are powerless as Dr. Panglos states above. Helping our parents learn to say "no", limit hours of computer time and watching their children cry or fuss in the name of learning to cope without resolving the negative feelings in the moment are all things we also have to advocate for to help our students become adults who can function as part of society.