A Tale of Two Cities: family warfare and global warming

January 2006

The protagonist of Charles Dickens’ novel, A Tale of Two Cities, proclaimed: “It was the best of times; it was the worst of times.”*

Dickens’ era was marked by competing and contradictory attitudes toward government and rules. The era of adolescence is also similarly marred by this same attitude of contradictions — especially for a teenage girl toward her own form of government — specifically, her own mother.

Let me tell you two stories depicting this same “I hate you, I love you” attitude, as it was expressed by two memorable teenaged girls.

Just like the narrator of the Dickens novel, when I encounter a troubled adolescent girl in the office, I too must “ponder the secrets and mysteries that each human being poses to every other.” * And just like the theme used by Dickens, every troubled person in each room that we encounter likely possesses some dark secrets. Some will never be revealed. Others can be cajoled into divulging. Compressing all of this information into a single visit is daunting, as this may be our only opportunity to help.

“The worst of times”*

“It was the spring of hope, it was the winter of despair …”*

On a typical busy November afternoon, I walked into the examination room to be greeted by Britt, a pert, smiling 14-year-old young lady, who had a subtle look of mischief in her eyes that only an experienced observer could detect. Her pleasant demeanor and affability were charming and disarming.

As is my custom, initially I listened to the complaints of the parent(s) about their teenager with both parties sitting in the room.

Her mother wanted to know if Britt needed counseling because she was caught sneaking out of the house late Saturday night, walking down a major thoroughfare in Nelson County. She added that Britt did not want to follow rules and “screamed and yelled a lot” at her siblings, mother and stepfather. She used to be on the honor roll at school, but now she had one C grade with A or B grades. (A problem?) Her mother tearfully claimed that her defiance was “driving her crazy.”

Finally, Britt blurted out, “She is being a stupid ‘B…’

Whoa, Britt. Give your mother a chance to tell her story, then I will give you your turn to explain your point of view while we are alone. Let’s try to refrain from any mean words. She cordially smiled at me and allowed us to continue.

Mother explained in detail that she has since grounded Britt from the telephone, television and activities for a month.

So how are other things going at home, Mom? Is everyone else getting along?

Britt injected that “her mother is a perfectionist and over-controlling,” which her mother did not deny. Her mother shifted in her seat and looked downward. She had forced the stepfather to leave the household last week due to his alcohol problems. She further admitted that she has not been very happy lately. I noticed that she looked somewhat despondent and even slightly disheveled.

I then asked to speak with Britt alone. Britt’s smile returned and she readily opened up about her situation. She enjoyed school, performing very well. She has had trouble sleeping, averaging about five hours of sleep nightly. She had a steady boyfriend of one month, but she denied a physical relationship, as she was not allowed to date yet. She also denied any recent depression, although last year she was cutting her arm, which she said she has not done for over a year. Her emotional outlet has been drawing and writing, as she did not like athletics. She further denied any sexual intercourse, rape, molestation or bully problems.

During the conversation, she appeared to possess an amazing wisdom and insight beyond her age as she discussed her family life. She said she was actually quite happy, as long as she was out of the home, or with her friends —“and away from that alcoholic!”

What initiated your idea to run away this weekend?

This weekend, her stepfather had rejoined them, and she “really despised him.” Then the trouble began. Challenging her curfew that night, her defiance lead to a screaming argument, which escalated to the point where her stepfather had slapped her face. She immediately bolted out of the house and she began running down the street.

I noticed multiple light bruises on her arm. So, I pointed them out to her.

She said matter-of-factly: “Oh, I had refused to get out of the car to go into school yesterday. So, Mom was trying to drag me out of the car. I guess I resisted too much.”

Later, I had the mother rejoin us in the room.

With Britt’s permission, I discussed the multiple issues with the two of them present.

Let’s look at the global picture regarding Britt. Britt is actually doing quite nicely outside of your household issues. She is actually doing well in school, has many friends, gets along with her teachers, her mood is generally good when not arguing with her parents. She has a delightful spunky personality normally, although a challenge for a parent, and is quite bright and attractive. She is not doing drugs or running around with a worrisome crowd. She loves her mother and siblings. Her attitude is sometimes challenging and often approaches that of a 2-year-old with a tantrum. But that was commonplace at her age.

Then I discussed some approaches to Britt’s behavior, including continuing with the good limits her parents had already set, more negotiating with her on some minor limits, using a modified “time out” or going to separate rooms when arguments escalated, praising her good deeds and avoiding any physical discipline. Unfortunately, I had to warn the mother (with the daughter listening) that any further slapping or hitting of the daughter would likely result in a protective services visit. She was much too old for this form of discipline to have any beneficial effect. I asked that this message be relayed to the stepfather as well. I would be happy to help them get counseling, which I highly recommended particularly for the mother, who seemed so stressed and anxious. She actually had the heaviest burden, dealing with an alcoholic spouse.

Britt also agreed never to “run” again, with its inherent dangers in the middle of the night for a young girl. Instead, she would seek a safe haven from a relative or go to her room and contact help.

I asked the family to return in a few weeks to update their progress. Sadly, she did not show up later. During a follow-up telephone call by our nurse, Britt said, “things were somewhat better. No problems with the stepfather so far.” The upbeat nuance was still in her voice. The nurse asked her mother to arrange for a follow-up appointment. None was ever obtained. Hopefully, “the winter of [maternal] despair” had not squelched “the spring of hope” in Britt.**

“The best of times”*

“It was the age of wisdom, it was the age of foolishness.” **

The very bright-eyed, somewhat obese, petulant 18-year-old young lady, Kate, was sitting beside her mother, as I casually introduced myself to both her and her mother. She was neatly groomed with a somewhat Gothic appearance, dressed in black. She had a moderate productive cough, but was otherwise healthy. I inquired as to why Kate was here.

The mother said that Kate was failing two of six courses in school. Kate immediately began to contradict her mother about the level of failure, with her voice rising 20 decibels.

The mother continued, “Is there anything you can do to help her with her academic problems?” Kate was not turning her work in, and failing most of her tests. Her grades were entirely As and Bs last year. Her mood was generally upbeat outside of her mother’s interactions with her. “Does she have attention-deficit disorder, a learning disability, a drug problem or depression? She is going to fail this semester.”

Using a little academic “CSI”: So how did she score on her ACTs (or achievement tests, etc.)? “She scored a 28.” Really?!? “She still wants to go to college,” Mom acknowledged quizzically.

Yes, getting two Fs does not endear oneself to the college admissions person? I teased. Any outside activities?

No sports. However, she had the second-leading role in her school play, which by the way received a second place award in the state high school competition. Kate’s mother worked as a teacher. Her father had just opened and was managing a new restaurant. His dream finally came true. He was working mostly nights there as well. Her 12-year-old brother was usually at home with their sister, and Kate watched over him very carefully.

Alone with Kate…

Smiling, she said her mood is good, she thoroughly enjoys her thespian roles, and she actually loves her mother and father.

So what other problems are going on?

No boyfriend issues, no drug use or experimentation, only recently sexually active. (“You won’t tell my Mom, will you?” Between you and me only. What kind of contraception are you using? “Condoms alone. But my current period is normal.”)

Showing slight tears, “My Mom is never home, since they took over the restaurant. She is always at the restaurant six days a week, and I even have to go up there and wait for them often. She never has time for me. Dad even missed my play.” Ouch!

So you are telling me that a bright young lady like yourself, who can easily do her schoolwork, is actually failing on purpose. Just to get your Mom’s attention???

She agreed to allow me to discuss the family time issues with her mother.

Mother was shocked that Kate had created this academic mess for herself. As the true “drama queen,” this was her theatrics for help, and for much more time from her mother.

“But at age 18?” Mom grilled me.

Yes, having raised four teenage daughters, even older daughters often really do still thrive on your undivided maternal attention. They still need their Mommas, I explained. But this was a positive sign, actually, as it indicated that her daughter loved her deeply, and still valued her.

I complimented them both for her successes, as Kate was actually well adjusted, capable and avoiding most of the common potential teenage trouble.

I suggested that the two of them work out a plan for “daughter time” and less restaurant time for Kate’s sake, and eventually, just as importantly, for the upcoming adolescent boy who was going to need more than cursory supervision after school these next several years.

“What about her cough, Doc?”

Time is pressing, now.

Yes, she did have pneumonia on my quick examination.

She will need antibiotics for a few days, and a follow-up visit for this illness (and a plan for confidential and secure contraception) next week.

The mother thanked me profusely, along with her daughter, as they shuffled out the door warmly hugging each other.

“It is a far, far better thing that I do, than I have ever done….”*

Quotes with * are from Charles Dickens’ A Tale of Two Cities.

For more information:

• Stan L. Block, MD, has a pediatric practice in Bardstown, Ky., and is a member of the Infectious Diseases in Children editorial board.