Text:Part I General Issues:Chapter 1: Adolescent Brain Biology

Chapter 1: Adolescent Brain Biology-A Brief Introduction

(cont'd from September 24th, 2011)

Wendla A. Schwartz, MD

Adolescent Brain Biology-A Brief Introduction
When we set out to learn how to drive a car we do not necessarily need to look under the hood, inspect the who-zits and what-sits and receive lessons on all the internal connections and causal relationships therein. We can be told, quite simply, that the gas pedal is on this side, the brake on the other, the steering wheel does this and that when turned right or left etc...And, for the most part things will go as planned. However, suppose we are given a beautiful, beloved and very special car that does not always operate as it should. What if we step on the gas and the thing stops instead of starts? What if we turn the wheel left and the car speeds forward instead of gently veering off in the anticipated direction? We will probably take that car to our mechanic for a diagnosis and, hopefully some sort of treatment. Now suppose we discover the diagnosis is something long term and the treatment is one of management rather than cure. The mechanic tells us treatment is not likely to eradicate the underlying problem but might alleviate many symptoms and thereby minimize impact on performance. Treatment efficacy, he says, is dependent on how well we understand and interact with our beloved vehicle. In other words: What if we discover we need to learn how this car operates to overcome its challenges and help it to reach its full potential? Perhaps then it would be helpful to lift the hood and gain a better understanding of all those who-zits and what-sits underneath. So, we will begin this book with a brief summary of adolescent development and brain science. It is somewhat tricky to address this topic without becoming too technical. I have attempted to keep things light marking the less relevant but still interesting technical tidbits with * for those readers who might wish to explore the subject a little more deeply. Those sections can be reviewed quickly or skipped entirely depending upon the reader’s interest.

It must be noted that, although automobiles provide a nice analogy in thinking about the study of adolescent brain development, the truth is, children are not really cars. As we know from ‘borrowed creatures’, we do not ‘own’ our children. They are not possessions and we do not have the mechanical control over them that we do over an automobile. Children are autonomous individuals possessing a pesky little thing called free will. Unlike a car, we do not have the power to move the steering wheel and make them turn right or left. We do, however, have a responsibility for them. That part is fairly obvious and can be presumed to be understood by the reader since you are already holding this book in your hands. Our role as parent requires that we provide for them an environment free of enabling behaviors (on our part) and full of useful tools and love. Whether they pick up those tools will be, entirely up to them. It is useful here to review the rules for Borrowed Creatures before launching into this chapter:

The Rules for Borrowed Creatures Are:
1. If we did not create or cause it we cannot control it, and we did not create our kids (even if we think we did).
2. The fact that we cannot ultimately control our children does not mean we are relieved of responsibility related to them.
3. Our responsibility extends only to that which we have power over: ourselves.

Click to enlarge

Click to enlarge

Click to enlarge

Click to enlarge

Click to enlarge

Click to enlarge

Click to enlarge

Click to enlarge

Click to enlarge

Click to enlarge

Click to enlarge

Click to enlarge

Click to enlarge

Click to enlarge

Wendla A. Schwartz, MD Board Certified Psychiatrist Child and Adolescent Psychiatrist and Psychopharmacologist

Book Text:Part I General Issues: Parenting the Mentally Ill Adolescent Wendla A. Schwartz MD

Part I

General Issues: Parenting the Mentally Ill Adolescent 

(cont'd from September 4th, 2011)

Wendla A. Schwartz, MD

How to Use this Book

This book can be read straight through as one might read a novel. Although that task may be daunting, it could also prove informative. The book is equally useful as a reference. Chapters can be read as individual bits and topics chosen from the Table of Contents or Index as needed. I recommend rereading when support or refresher is desired. The Resources section is a list of references I have used often with my own patients and which, at the time of this writing, I felt comfortable sending on to you. Please use them liberally as no single resource (i.e. this book) can provide near enough information to a family facing these challenges. 

It should be noted that no one book can address all the issues confronted by families coping with any one of the above diagnoses.  No such attempt is made here. Parenting the Mentally Ill Adolescent is but one volume meant to assist parents who may be struggling to determine when it is time to seek professional help and then to offer some interventions to alleviate various struggles that may arise. The interventions suggested have been developed over my 20 years observing and working with psychiatric patients and their families. These are the actions I found to be most "tried and true." My families have come back often to report these particular suggestions as helpful regardless of diagnoses.  So, they are presented here, in hopes you will find them helpful as well. 

The book is written in three parts. 

Part I. General Issues: Parenting the Mentally Ill Adolescent

This section begins with a brief summary of brain biology geared toward the educated but, non-biologist parent. The section seeks to provide a foundation upon which a parent might best understand their child and the significance of the adolescent years ahead of them. The next seven chapters explore common areas of concern for parents of mentally ill teens. Each of the seven chapters focuses on one major area (i.e. home and family, academics, drugs and alcohol etc…) Within each chapter multiple subtopics are introduced. For example The Home and Family Chapter is subdivided as follows:

• Rules and Responsibilities 
• Manners and Courtesy
• Privileges
• Money 
• Sibling Relationships

In addressing the topics, I attempt to answer the questions: What is typical for a teenager with this issue? What is atypical and more likely to be related to mental illness? What should a parent do if they are concerned that the behavior is atypical?   In other words, given the world we live in and the nature of teenagers as highly variable and constantly changing anyway, how does a parent know what a “typical teenager” looks like? In a clear, and easily understood manner behaviors are listed and discussed. Summaries of typical and atypical behaviors are printed as lists in yellow boxes throughout the text for easy reference. Examples of common parental concerns include:

• Is it normal for my teenager to refuse to come out of her room all the time?

• How angry is too angry?

• Do all the kids really smoke pot?

• Why does she always tell me everything is fine?

• How come I used to know what's going on and now everything is a secret?

• How many friends is the "right" number."

• How come my kid has 900 Facebook friends but nobody ever comes over?

• How come my neighbor’s kids don't get into trouble for driving too fast?

Teenagers struggling with mental illness face the same issues as any other teenager (emerging sexuality, academic pressures, hormone overload, parent conflict and a society obsessed with youth, beauty high speed technology and 24 hour connectivity). Illness notwithstanding, parents will need to continue to provide guidance; structure, limits, consistency and foundation as teens will continue to push, cajole, irritate, challenge and demand their independence throughout their adolescent years. Additionally, teenagers with illness are often handling difficult situations with an out of control central nervous systems, mood swings or depression, poor coping skills, social alienation, and possibly limited cognitive skills and concrete thinking. They may have more severe issues such as paranoia, suicidal thoughts, violent tendencies or thought disturbances further complicating their ability to function within the already challenging world of teenagers. They may be on medications that result in side effects such as daytime somnolence (sleepiness), insomnia or agitation. All of these issues affect a child’s awareness of environmental influences and their responses to those forces. The result is a child who may or may not respond to standard parenting techniques in reliable and predictable ways. Parents often become frustrated with friends, family, professionals and the thousands of pages of literature available offering advice and guidance of a somewhat generic variety.  It doesn’t work. They’ve tried it. What they need is a specific reference. One that addresses parenting a child who is both a teenager AND a child with an illness. That is what I have attempted to provide here. 

Part II, Special Topics: Parenting the Mentally Ill Teen in the Context of More Severe Issues

In the second section I continue to explore issues that tend to be of grave concern to the parents of mentally ill teenagers. Although less common than those in Part I, these tend to be more severe and generally require a higher degree of vigilance in detecting as well as a more rapid intervention once detected.  Part II consists of three chapters: Suicidally and Self Injurious Behavior, Defiance, Aggression and Violence and Other Problems.  Chapter 9 Suicidality and Self-Injury is focused on aggression toward self and and Chapter 10 Defiance, Aggression and Violence is focused on aggression toward others. I chose to give a significant amount of attention to both of these topics because of their direct affect on the child and family and also because of the particular parenting skills required in handling an adolescent with these behaviors. Chapter 11 considers several other issues often faced including antisocial behavior, truancy, general defiance of authority and treatment noncompliance. 

Part III, Moving Forward: Evaluation, Treatment and What You Need to Know

This section is dedicated entirely to providing additional reference information to parents. Sections on the psychiatric evaluation, psychiatric medication information, educational and psychological testing are provided. My focus in Part III was not to provide an exhaustive index of all things psychiatric, but rather to supply basic information regarding subjects I am asked about most often in an easy to access format. The section on Psychiatric Evaluation can be used to direct parents in choosing to have a psychiatric evaluation or in better understanding the process of evaluation once one is under way. Sections on lab tests, medications and various psychoeducational and educational testing products are provided to assist parents who are trying to understand more about evaluations or treatments possibly being suggested for their own teenagers. 

This text will be published in sections over the next several months on this blog in the hopes that it will provide ongoing support and information for families in need.

Wendla A. Schwartz, MD Board Certified Psychiatrist Child and Adolescent Psychiatrist and Psychopharmacologist

Book Text:Part I General Issues: Parenting the Mentally Ill Adolescent Wendla A. Schwartz MD

Part I
General Issues: Parenting the Mentally Ill Adolescent 

(cont'd from September 4th, 2011)

Wendla A. Schwartz, MD

What is Mental Illness?

Parenting the Mentally Ill Adolescent is a book written specifically for parents and guardians or caretakers of teens with mental illness. To this end it is useful to define what I mean by mental illness for the purposes of this book. Over the years the term "mentally ill" has come to mean different things to different groups in our culture. Additionally, the term "mental disorder" is sometimes used interchangeably with mental illness. Mental disorder is the generic phrase used often in the international clinical literature to describe all disorders of thought and behavior related to human beings. A mental disorder can, theoretically be as severe as psychosis (seeing or hearing things that are not there) or as relatively mild and transient as very sad feelings associated with losing a job. So, what exactly do I mean in this book when I say "mentally ill adolescent"? 

One of the clearest and most concise definitions of mental illness for our purposes, comes from the NAMI website (National Alliance for the Mentally Ill), a grassroots organization of families and friends working to advocate for individuals with mental illness. According to NAMI: 

Mental illnesses are medical conditions that disrupt a person's thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life. Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD) and borderline personality disorder. 

In this book we are referring generally to the NAMI definition of mental illness.  This includes the list of diagnoses given under column 1 of Table 1 below. Because we are dealing with adolescents this book also applies to teenagers with psychiatric illnesses first arising in childhood. These are included in column 2 of Table 1 below.  It is important to note that parents and caregivers who have not yet received a diagnosis for their teen will also find this book helpful. Column 3, Table 1 is a list of specific behaviors which are addressed and explored in this book within the context of mental illness. Parents who are wondering whether to seek professional help for their child may find direction here. 

Table 1. Diagnoses and Behaviors Relevant to this Text

Serious Psychiatric Illnesses for which this book will be helpful Column 1	Psychiatric Illnesses of Childhood for which this book will be helpful Column 2	Common Behaviors concerning parents Column 3
Schizophrenia	Autism Spectrum Disorders	Sexual acting out
Schizoaffective Disorder	Asperger's disorder (DSM IV)	Drug and alcohol use
Schizophreniform Disorder	Disorders related to intellectual functioning	School Failure
Obsessive Compulsive Disorder	Learning Disorders	Hygeine and health issues
Bipolar Disorder	Attention deficit hyperactivity disorder	Excessive arguing and defiance
Panic Disorder with or without Agoraphobia	Intermittent explosive disorder	Social isolation
Post Traumatic Stress Disorder	Neurodevelopmental disorders resulting in impaired cognitive function	Changes in dress/music/friends
Evolving Personality Disorders	Temper dysregulation disorder (DSMV)	Excessive video/computer use
Conduct Disorder		Suicidal thinking/threats/self-injurious behavior
Addiction and Susbstance Abuse		Violence/aggression/criminal activity

This text will be published in sections over the next several months on this blog in the hopes that it will provide ongoing support and information for families in need.

Wendla A. Schwartz, MD Board Certified Psychiatrist Child and Adolescent Psychiatrist and Psychopharmacologist

Parenting the Mentally Ill Adolescent in America

Part I
General Issues: Parenting the Mentally Ill Adolescent 

(cont'd from June 26th, 2011)

Wendla A. Schwartz, MD

Continued from June 26, 2011

Finally

“Parenting the Mentally Ill Adolescent in America” is written specifically with the distracted, distraught parent in mind. Reading a book like this generally occurs in the midst of a crisis, not when things are going well. Parents are fearful and often confused. I have attempted to provide a professional, straightforward and honest description of typical versus atypical behavior easily observable in a variety of circumstances. Parents will find here simple, direct suggestions regarding what to do about those observable behaviors. Where appropriate, resources for follow-up are listed.  Although this is not a book on psychiatric pathology and it’s focus is the application of appropriate parenting techniques in atypical circumstance considerable time is spent examining the fine line between typical adolescent behavior and adolescent psychiatric illness. Where possible indicators including symptom lists are given suggesting psychiatric illness. The book seeks to educate the reader regarding symptoms suggestive of more severe issues and illness. 

This book seeks not to repair all that is wrong with the world, nor does it seek to solve all the problems of families or teens across the country. This is a book of suggestions for those of us raising twenty-first century American teenagers.  These suggestions may enlighten, surprise, delight, disappoint or inspire. It is this my hope that some will find answers here, some will find direction and perhaps some will find precisely what they were looking for all along. One last point I would like to make is that if you have any doubt at all about the mental health of a teenager it is important that you seek the advice of a mental health professional earlier rather than later. 


This text will be published in sections over the next several months on this blog in the hopes that it will provide ongoing support and information for families in need.

Wendla A. Schwartz, MD Board Certified Psychiatrist Child and Adolescent Psychiatrist and Psychopharmacologist

Book Text:Part I General Issues: Parenting the Mentally Ill Adolescent Wendla A. Schwartz MD

Part I
General Issues: Parenting the Mentally Ill Adolescent 

(cont'd from May 31st)

Wendla A. Schwartz, MD

3. The Energy Ball

For parents, working with some adolescents is a bit like trying to win a game for them that the teenager is  not particularly interested in winning, or even playing. 

Imagine you are watching your adolescent play a game of basketball. Only it’s not any game of basketball. This game is special. Your child is the only one on the court. You are the only one watching but, for whatever reason, this game is really important. The outcome will have an impact on your child's future. On his well-being. On his very existence.  At least according to you. You sit in the bleachers feeling incredibly anxious and worried and wondering whether your kid cares enough to make things happen out there on the court.  

The first buzzer sounds and with a sinking heart you watch your teenager walk slowly out onto the court, drop the ball on the floor, sit down and pull out his cellphone.  The timer is running, nothing is happening. Your child, eyes locked on the blue screen of the cell phone, fingers busily flying back and forth across the keypad, is missing opportunities to score. This is bad. Really bad. So, like the devoted parent that you are, you leap quickly onto the court and grab that ball. You are running and jumping and sweating, dribbling that ball all the way down the court to your kid's basket and you shoot and...score!!   Then you run and jump around some more, sweating and heart pumping, all excited, grab, run, dribble, jump, you jump and shoot and...score!!!  Exhausted, you look over your shoulder. There is your teenager. Just sitting  there staring at you. You just scored for him, twice, and you cannot tell if he cares. In fact, you cannot even tell if the fact has registered in his brain.  He might not even be registering that you are on the court. He’s probably thinking about the text message he’s about to send, or just got or hopes to get. You are mad. Really mad and frustrated with him for his "attitude". How can he sit there like that and not DO anything? He is not applying himself at all. He doesn't CARE enough. Why isn't he worried about what the outcome of this game will be? Doesn't he get it? Bad things will happen if he just lets seconds tick off without taking appropriate action. So, dutifully you pick up the ball and run around some more. If he's not going to do it then you had better do it until he gets the hang of it. Otherwise some awful horrible life impact could occur. He won’t accrue the "points' he needs and he will FAIL. 

Now...imagine there is a second basketball. The minute you jump onto the court, you notice you are holding a second basketball. In fact you were holding a second basketball all along. This is your ball. You own it. It has your name on it and you are responsible for it. Now you have introduced your ball into your teenager's game. To manage the ball that belongs to your teenager you either have to put yours down, manage it poorly or put so much energy into managing both balls that you are physically, mentally and emotionally drained and exhausted in a very short time. 

Oh, and by the way, your ball has it's own clock, it's own baskets and it's own court. You belong over there. It's really hard to play two games at once. (But that is the subject of another book.)

That is about what it feels like to work with an adolescent who isn't really all that interested in working with you. In other words, if you are carrying someone else's ENERGY BALL you are playing in their game and they are not. So the energy ball works like this: Imagine your 15 year old is refusing to go to school because he has been very depressed and missed a lot of school and got very far behind and so now he doesn't want to go. His doctor says he can go back to school but he doesn't want to go. So you feel bad for him and you pick up the energy ball that he left laying next to his bed. You call the school and say he is sick (even though he is not) and let him off easy. He refuses to do any homework and you tell the teacher's he will get it in later. You call all his teacher's for him to work out a plan for his late work. He still refuses to do anything. You go down to the school to try and work something out. You make lots of phone calls and talk to people. You try to get him to talk to the school counselor. He is not too interested. You do some pleading with him. He says OK but only if he can have his cellphone back. You give him his phone back. He kinda does a little homework but then skips a bunch of school the following week. You call the school to excuse him because if you don't then he will get Saturday school which you are worried will make him very depressed. You try to have a discussion with him about school but he is not really that worried about his school situation. He thinks it will "work out.” You are sweating bullets about it. 

Guess who is dribbling that ball all over the court? 

We will revisit the idea of the Energy Ball throughout this book. 

This text will be published in sections over the next several months on this blog in the hopes that it will provide ongoing support and information for families in need.

Wendla A. Schwartz, MD Board Certified Psychiatrist Child and Adolescent Psychiatrist and Psychopharmacologist

Book Text: Part I General Issues: Parenting the Mentally Ill Adolescent Wendla A. Schwartz, MD

 Part I
General Issues: Parenting the Mentally Ill Adolescent 

(cont'd from May 9th)

Wendla A. Schwartz, MD

2. Borrowed Creatures

Lisa and her daughter Courtney had been coming my office for many years. Lisa came to me for

therapy and medications and I had, over the years, seen her daughter intermittently for ADHD

treatment. Unfortunately Courtney rarely complied with treatment and at 18 was now finishing

high school and looking toward college. Sort of. One particular day, Lisa came in very distraught

because her daughter was "not applying" herself in any way. She was doing essentially nothing

in terms of worrying about improving her grades. She was minimally concerned with studying

for SAT's and had no particular interest in working with the expensive college counselor her

parents had chosen for her. Courtney had never been terribly interested in school. Generally a C

student, she preferred shopping and socializing and, for reasons that were a mystery to Lisa,

seemed unmotivated to work hard at school. Lisa was "mortified" and "ashamed" that her

daughter would not be attending a prestigious University (or maybe not to a four year college at

all) as would most of the other kids at her high school. Courtney did not really care. Lisa worried

about Courtney’s future. The teenager did not worry. Lisa felt she had failed as a mother because

of her daughters' lack of motivation in this area.

Lisa had become lost in the greatest delusion of parenthood. It is the DELUSION OF

CONTROL. Jennifer believed she could "DO" something that would control the outcome in this

situation. Not change the outcome, but really control the outcome to force it be what she

thought would be best for her daughter. Specifically, Lisa saw it as her duty to DO something

that would MAKE a specific outcome occur. She asked me "How can I make her more

motivated?” The answer, of course, is that one cannot make another person more motivated. One

cannot insert an agenda into another person. The idea that we have ultimate control over our children (or any other human being that is not us) should be abolished from our minds. We do

not. We do not have control once they are adults. Many parents can accept this. The reality is, we

never had it. Not when they were teens, not as grade schoolers, not even when they were babies.

Think, for example about the preposterous notion of deciding when an infant will urinate. Or

when they will eat. Really when they will eat. Not when you will feed them. That you can

decide. Whether they will eat is ultimately up to them. Similarly, with a teen, a parent can

provide tools, education, love, support, guidance. Whether that teen takes a particular action

(verbal or physical) is ALWAYS up to the teenager and NEVER up to the parent. We will revisit

the delusion of control later. It is a particularly appealing delusion for parents of mentally ill and

addicted teenagers because it offers the seductive notion that one can fix a desperate situation if

one just tries hard enough or thinks carefully enough or runs fast enough or some such nonsense.

For now, suffice it to say, the DELUSION OF CONTROL is just that: a delusion.

Why there exists such a DELUSION OF CONTROL has to do with the fact that we have

forgotten exactly what children are. Children are not possessions, like toys. They are not

purchases. We did not go to a store and buy them to take home and fiddle with until we are tired

of them. They are also not objects we created with our hands out of materials found or bought at

the store. Objects to be dressed up and manipulated and admired. No matter what we think about

where kids come from, we did not create them. We couldn't even begin to figure out how to do

that. We did not create them and we are not responsible for everything that has happened, is

happening or will happen in their lives. We are just not that powerful. Children are a mysterious

gift from somewhere or something else. During my residency, I delivered or assisted on the

delivery of dozens of babies. I also had three of my own. Still, I have no idea where they come

from. To me they remain a mysterious gift and not really a gift at that. They are more like a loan.

We are entrusted with the care of this precious creature for an extraordinarily brief time and then

we must let the creature go. If we are lucky we are given the privilege of continuing to care for

and love that creature for the rest of our lives but really it is only on loan to us. We do not own

the creature. The creature belongs to the Earth, the Universe, to whatever it is you believe in and

understand, but certainly not to us.

For many parents, discussing the idea of "Borrowed Creatures" is, at first, terrifying. How can I

let go of my child like that? If I am really only the short-term caretaker of this child then how is

what I do of any use? Why read this silly book? How can I not do everything in my power to

control the outcome for my child? Isn't that being irresponsible?

Fully accepting the idea that our children are borrowed and that we delude ourselves into

thinking we have any control takes time. It certainly does not mean we throw up our hands and

do nothing. On the contrary. It frees us to focus our energies on the types of actions over

which we really do have power. Although we do not have power or control over OTHER

people, places and things, we certainly do have power over ourselves. We can avoid

enabling negative and unhealthy behaviors in our kids, we can reward and support positive

behaviors, we can provide treatments, tools, education, guidance, and of course love.

However, in the end, we do not know what will happen. We cannot choose how or what our

child will do with the actions we take.

The key is not in not doing anything, it is in accepting the outcome of what we choose to do.

The Rules for Borrowed Creatures are:

1. If we did not create or cause it we cannot control it. And we did not create our kids (even if we think we did.)

2. The fact that we cannot ultimately control our children does not mean that we are relieved of responsibility related to them.

3. Our responsibility extends only to that which we have power over: ourselves. 

This text will be published in sections over the next several months on this blog in the hopes that it will provide ongoing support and information for families in need.

Wendla A. Schwartz, MD Board Certified Psychiatrist Child and Adolescent Psychiatrist and Psychopharmacologist

Book Text: Part I General Issues: Parenting the Mentally Ill Adolescent Wendla A. Schwartz, MD

Part I: General Issues: Parenting the Mentally Ill Adolescent 

(Cont'd from May 7th)

Wendla A. Schwartz, MD

1. Good Enough
I met Judith when her son, Adam, was about 13 years old and was first diagnosed with a severe psychotic disorder. He had been very hard to deal with for some time but she and her husband had found it difficult to acknowledge there was something medically wrong with him. They had spent many years trying a variety of behavioral approaches, diets, exercise plans and the like. When he began to hallucinate and developed clearly delusional thinking, they blamed themselves. Judith was especially hard on herself. It seemed impossible to her that her son could be so ill and she could not somehow be responsible for his state. Judith became obsessed with parenting "perfectly,” with finding the right treatments and doctors, with behaving correctly in the complex situations that confronted her family daily. She wanted to be sure she was handling these situations correctly at home, responding to her son in ways that were most helpful to him and providing the best type of environment possible. The standards she set for herself were high, very high. She felt overwhelmed with guilt at times for not being able to live up to them.

On one particular afternoon when Adam was about 16, Judith called me very upset. She had lost her temper with Adam and screamed at him in the car.  She had picked him up from school and told him "No, she would not take him to the video store to buy a new video game". He attacked her verbally from the backseat, calling her names, accusing her of all sorts of evil intent. Likely, harboring paranoid thoughts that included his mother, Adam was behaving in an entitled, demanding and vicious manner. Judith was exhausted and really angry.  She just lost it. She turned around over her shoulder and told him to "SHUT UP" and then said a few more words, somewhat out of character for her. Judith was stricken with guilt over the episode. She wondered if Adam would be traumatized, if he would forgive her. She was plagued with thoughts that her words might cause a full psychotic episode. I let her know that one episode of parental "losing it" was highly unlikely to cause a psychotic episode. Nor was it likely to cause Adam to think his mother didn't love him or traumatize him for life.  As we talked Judith came to understand that her behavior was really OK. Parents are, fundamentally, only human.  We are not perfect and we are not required to be perfect for our kids. We are only required to be good enough. There might even exist benefits to being `imperfect’ and only ‘good enough.’ For example: Adam needs to have his extremely inappropriate outburst responded to negatively. The rest of the world will not respond to it well. Why should his mother? Granted, it is probably not therapeutic to scream or curse at a 16 year old psychotic person but, on the other hand, it is not helpful to beat oneself up for doing it after it has happened.

The original idea of 'good enough' mother applied to infant development and was originated with Donald Winnicott (1896-1971), a London Pediatrician and psychoanalyst. Winnicott wrote that the infant required the presence of a 'good enough' mother to develop his or her own sense of self as an independent being. He saw the role of the 'good enough' mother as gradually "failing" to provide for every need of the baby thereby allowing the infant to learn to adapt. Winnicott wrote:

"The good-enough mother...starts off with an almost complete adaptation to her infant's needs, and as time proceeds she adapts less and less completely, gradually, according to the infant's growing ability to deal with her failure" (Winnicott, 1953)"

(Of course some experts have taken Winnicott's work to imply a requirement of excellence in mothering in order prevent problems due to forcing an infant to adapt too quickly. Winnicott himself actually took pains to empathize with those who could not provide adequate parenting. However, for our purposes, this argument is not relevant.) Winnicott was not referring to adolescents but rather to infant development and how that relates to psychotherapy later in life. He probably never had any intention his work be referenced in a book about parenting adolescents. With that in mind we are  borrowing the concept and loosely applying it to teenagers in this way: We cannot continuously and perfectly provide for an adolescent's needs, demands and requirements. We will fail sometimes. It's inevitable. It's the nature of being human. Failing in small doses (like the Winnicott 'good enough' mother) is OK. The adolescent with mental illness often has failed to attain the same level of independence as the typical adolescent and is still working toward an independent self.  Therefore they may demand more, require more and need more from us than a more typical child of the same age. We may, therefore, find ourselves with more opportunities to fail. The ideas behind 'good enough' can get complicated and wordy. Suffice it to say:

The Rules for Good Enough Are:

1. We do not have to be perfect but only Good Enough

2. Good Enough means failure in small doses

3. Failure is inevitable

This text will be published in sections over the next several months on this blog in the hopes that it will provide ongoing support and information for families in need.

Wendla A. Schwartz, MD Board Certified Psychiatrist Child and Adolescent Psychiatrist and Psychopharmacologist