John Thorndike | The Last of His Mind |

Posts Tagged ‘alzheimer’s’

Words

Saturday, August 27th, 2011

From an early age, words were what I loved. I read early and steadily. I read children’s books, I read the magazines my father brought home for the office (he was editing Life at the time, and later American Heritage), I read Classic Comics, I read Uncle Scrooge, I read cereal boxes, I read Jules Vernes’ The Mysterious Island, I read anything and everything. I remember sitting on the toilet and needing to read something. A magazine, the back of a toothpaste tube, but something. (Have at that, you Freudian analysts.)

I’m sure it came from my father and mother, who were both writers, both editors, both great readers. They didn’t press it on me, it happened automatically. The printed word was a constant in our household, and in my dad’s later years it was no different, his house was filled with books and magazines and his own handwritten research and notes. And then, Alzheimer’s.

His aphasia (“Partial or total loss of the ability to articulate ideas or comprehend spoken or written language, resulting from damage to the brain caused by injury or disease”) came on quickly, even though he hid it from us early on, and in six months, perhaps nine, he was having a difficult time with ordinary speech. Any word might escape him, nouns in particular, and he took it hard.

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A friend of mine is now suffering from aphasia. He’s the son of two friends, actually, a big healthy 25-year-old who was recently diagnosed with a large, benign tumor in his brain. He’s had it out, and you can see that it was quite the operation, leaving quite the scar. (If I can get that photo to upload)

I went up to visit him a couple of weeks ago in Columbus, on his second trip out of the hospital. Amazingly, there he was in a restaurant parking lot, standing and smiling, his girlfriend and other family members beside him. He was lively, engaged, hungry and cheerful. His movements are all coming back to him, some more slowly than others, but his biggest problem is aphasia, the same as with my dad. Ed couldn’t get a grip on the words he wanted to use, they were all elusive. (I’m happy to say that he’s doing much better now, and that his language is slowly coming back to him.)

His predicament reminded me of my father—but there was a fundamental difference. Ed is recovering from his aphasia. There’s a good chance that his brain, that amazingly plastic and adjustable organ, will compensate and rechannel, and do whatever it takes to give him back his speech. With my father it was all the contrary. His words drew further and further away, and his spirit suffered. Whereas Ed wants to talk to people, wants to take a look at the construction project he was in charge of, wants to laugh and whisper to his girlfriend, wants to inspect and figure things out—my father didn’t want anything.

It is the downward slope of Alzheimer’s that’s so devastating. It simply crushed my father that he could no longer read or write or eventually even talk. He gave up on starting sentences, after thousands of attempts that went awry, when he could not get hold of the words he needed. With Ed, it was heartening to me to sit across from him at a Red Lobster table and see his frustration, but also his continued desire to grab hold of a word. If he got close enough, one of us might come up with what he was trying to say, and even when we said the word, his face lit up. How rich it was to even recognize the word, to get that close to it.

Alzheimer’s might pin me at the end, I guess there’s a good chance of it. (There’s too good a chance of it for everyone, if we live long enough.) In the meantime, how lovely it is to swim in this bath of words that most of us share.

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In The Here And Now

Thursday, March 31st, 2011

1298518811A great crowd last week at Janette Turner Hospital’s course in Columbia, SC, Caught In The Creative Act. Preparing for my talk there led me to think about how any good writing reflects the ways of the human mind: how difficult it is for us to focus, how rarely we can keep our thoughts to one topic, how when we listen to someone we often drift off to think of something else. Or, as the poet Howard Nemerov said,

We think obsessively about sex except
During the act, when our minds tend to wander.

The sad fact of dementia—I’m only guessing here, after watching my father and others with Alzheimer’s—is that patients can’t focus on what they wish to, on any kind of larger picture, on anything that involves language and memory. As that world retreats from them they are locked increasingly in the here and now, yet inevitably struggle with a windshear of confused memories, a drop into confusion.

Meditators want to live in the here and now. Popular psychology holds it up as a kind of ideal. But of that’s all you have, it seems to me a miserable state. I watched my father draw close to living entirely in the moment—and how he suffered.

Most novels and memoirs swing back and forth between two elements: a story unfolding in front of us, and some broader explanations and comments. Narrative and exposition, in literary terms. I imagine this feels natural to us because it’s how our minds work. It’s okay that our minds tend to wander during sex. It may not be best, but from the big laugh I got from that line at my talk in South Carolina, I figured everyone knew what Nemerov was talking about. But if our minds cannot be directed at all, if they cannot wander along some cozy paths with language and memory as handrails, we are in danger of falling off a horrendous cliff. My father fell off it. If he could have lived happily in the here and now, I’d have been much less concerned. But clearly, as I watched him, he felt it as a terrible loss.

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Salt, Eggs and Antioxidants

Wednesday, February 23rd, 2011

morton-saltAbout thirty years ago a girlfriend put her hand on mine at the dinner table and told me I should put down the salt shaker. Salt, she said, was bad for me. I thought she’d slipped a cog. Salt? She had to be kidding.

No, she was quite serious, and quoted some some studies about how too much sodium could lead to high blood pressure. I parried with the fact that my father took salt tablets in hot weather to replace the salt lost in perspiration—and he was in great shape. (Indeed, his heart did pretty well until he developed atrial fibrillation and then congenitive heart disease, in his early nineties.)

In any case, two or three years after that advance notice by my health-conscious girlfriend, I’d joined the big boat of salt avoiders. Today, my GP says I don’t have to worry much about it, because my blood pressure is fine. All things in moderation.

What I’m driving at is how easily we are driven by the winds of dietary and food advice. In particular, the recommendations for Alzheimer’s patients are all over the map. Don’t let him drink coffee, I was told only six years ago—yet today the wisdom seems to be that caffeine is good for those with dementia. Eat a diet rich in antioxidants has been staple advice for decades—but consider a recent article in Newsweek by Sharon Begley, who describes how we’ve long been advised to load up on antioxidants, which help to control the free radicals responisble for aging, cancer and heart disease.

“Not so fast,” says Begley. “First, studies piled up showing that taking antioxidants—even such common and seemingly innocuous ones as beta carotene and vitamins C and E—as supplements was not beneficial to health and might even be dangerous.”

Oxidants, for one thing, are the front-line defense against pathogens and cancer cells—so we may not want to squash them categorically. An assessment of 67 studies with nearly 400,000 participants concluded, “We found no evidence to support antioxidant supplements for primary or secondary prevention, [and] Vitamin A, beta-carotene, and vitamin E may increase mortality.”

Ouch.

You can read the Newsweek article and decide for yourself. My point is that we’re often lead down a path we don’t know that much about. Remember when eggs were the devil incarnate? Now researchers sing a milder tune about them: lots of benefits, as well as the concerns. What I remember, a bit shamefully, was the cogent argument I put up against the dangers of sodium. How convinced I was, and how wrong. Well, that girlfriend was right about almost everything, so I should have known.

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A Book on End-of-Life Care

Tuesday, January 25th, 2011

martensen-life-worth-livingI’ve been busy, and this blog has been quiescent because of it. First I spent a month at the Vermont Studio Center, working night and day on my next project, a novel about the Cuban Revolutionary hero Camilo Cienfuegos and a woman somewhat like my mother. I drove to Denver for a Christmas with my son and his family, then flew to Havana from Miami with a literary research group.

On the flights home I read a book by an Emergency Room physician and bioethicist named Robert Martensen, A Life Worth Living. I recommend it. The subtitle is “A Doctor’s Reflections on Illness in a High-Tech Era.” In other words, it’s about care toward the end of life, especially when the medical care extends lives that to many of us (perhaps from a safe distance) seem hardly worth living.

The best parts of the book, to me, were the stories of individuals facing a difficult end. Not knowing, of course, when death would come, but dealing with it and making crucial decisions about how much care they wanted.

We’ve all thought about this, haven’t we? At one end of the spectrum is that misleading line, “If I get to that state, just shoot me.” No one, as I’ve written before, is going to shoot us. At the other end of the spectrum is the bad fall we might take one day when we are deep into our own dementia. A telephone call is made by whoever is looking after us, the squad arrives and swings into their normal, predestined mode: Take care of the patient.

Martensen imagines how the death of his own father might have been prolonged (for better or worse) if the paramedics had arrived to find him unresponsive and not breathing. “Whether or not [his wife] told them of his Do Not Resuscitate status, the paramedics would likely have put in an artificial airway—an endotracheal tube—and begun ventilating him. They would have done so because he possessed vital signs—a pulse and blood pressure—and emergency field protocols specify ventilatory support when they are present, regardless of the circumstances.”

You can have your DNR tattooed on your forehead, but this will not necessarily change the paramedic practices. Then, in the ER, you will almost certainly be put on a ventilator, and admitted to the Internal Care Unit. Once the ventilator is installed, it’s not easy to get it taken out—and so the patient finds himself, if conscious of his own condition, in a state that he worked hard to avoid. Living wills and notarized DNR documents to the contrary, it’s easy to wind up in an ICU with machines extending one’s life in a way the patient had tried to prevent, back when he was hale and articulate.

Among the penetrating stories in the book is one of a doctor who is diagnosed with cancer in his forties, and who eventually withdraws from all medical treatment, feeling stronger because he has withdrawn from “the system.” He gives up Phase II cancer drug trials, he gives up repeated CAT scans to follow the progress of the cancer. The added months of life such treatment might give him—or perhaps it would only be days, or perhaps no time at all—are not worth as much to him as his own sense of empowerment and freedom.

The author cites studies that support his personal view that when it comes to late-life care, “more usually means less. Specifically, sick elderly people who endure the aggressive treatments that our “best” medical centers routinely administer near the end of their lives tend not to survive any longer than those who avoid such treatments.”

If I were diagnosed tomorrow with cancer, I’m sure I’d head straight for an oncologist and whatever treatments she recommended. But I imagine that somewhere closer to the end I’d give it up and accept my coming demise, and try to avoid the extensive, futile medical endeavors designed to keep me living another few days or weeks.

But I’m also aware that many have thought this and later changed their minds. I might too. Who can say what we’re going to do when we’re actually looking death in the eye?

A good book: Robert Martensen’s A Life Worth Living.

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Miami Valley Alzheimer’s Symposium

Tuesday, November 16th, 2010

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I had a busy couple of days at the Miami Valley Alzheimer’s Association Symposium, along with hundreds of family members and professionals in the field.

Sold fifty books, which was great. And sold them to the best of readers, those who are wrapped up in the disease, both its devastations and cure.

Above all, beyond my own talks, I heard story after story. The ones that come back to me now, a few days later, are about family troubles. About the caregivers, for example, who have left their own lives to move in with their parents. Or the woman with four siblings: “Two of them say there’s nothing wrong with my mother, and two of them fight me every step of the way.”

Or the woman whose brother was suing her to get back everything she had spent on their mother’s care. He wanted his inheritance.

Or the woman whose father abandoned her mother when she became forgetful and confused. He took all the money, went to live elsewhere, doesn’t visit, doesn’t want anything to do with his wife of many years. The daughter struggles to keep her mother at home, but doesn’t know how long she can go on, emotionally or financially.

Behind so many of these stories: the money. Caregiving takes money, whether you’re doing it yourself or paying some assisted living center or nursing home to do most of it. (Nursing Home, incidentally, is now something of a pejorative description. The facilities are all leaving it behind in favor of more hopeful terms such as Health Campus.) Care facilities are big business—and as my mother was fond of saying, “All it takes is cash.”

Actually, what is most needed is human will. We need both: money and the desire to help. And in some 350 people at the Dayton symposium, I found plenty of human will and drive. No wonder: everyone there had seen Alzheimer’s up close, and knew its devastations. It was a powerful and effective symposium, their 19th annual, and perfectly organized.

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Deluge of Information

Monday, October 18th, 2010

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Alzheimer’s is an industry. Every day I receive notices of panels, commissions, double-blind drug studies, memory walks, research into tau and amyloid-b plaques. From the White House, Preparing the Nation to Better Address The Challenge of Alzheimer’s. From eurekalert, New Findings on Iron and Alzheimer’s. From reutershealth, Mental Acuity Not Linked to Calcium, Vitamin D. From USAgainstAlzheimer’s, Voters Want Congress to Make Alzheimer’s a Priority. From UCLA, Neuroscience Research May Help Patients Recover from Brain Injury.

All those, and several others, came from a single day’s reports at Alzheimer’s Daily News.

I’m glad of the seemingly-vast research being done on this disease. Even more is needed, I’m sure. As Maria Shriver and the Alzhehimer’s Foundation reported last week, “With the baby boomers entering their mid-60s, an Alzheimer’s tsunami is about to hit, with the number of people with Alzheimer’s disease expected to triple, reaching as many as 16 million by 2050.”

The devastation of the disease is vast, and so is its medical complexity. The debate rages about causes and possible cures—and every day more people tumble into the hole of memory loss, language loss and the loss of the self. And tumbling beside them are their caregivers, and they suffer as well.

Since the time I was living with my father and taking care of him, I’m sure a thousand medical studies have been done on Alzheimer’s and other dementias. Even at the time there was plenty to read on the Web—but for most hours of those days, seven days a week, I was busy with my dad. When I could, I read books. I read David Shenk’s great biography of Alzheimer’s, The Forgetting. I read pieces of the meaty, practical advice in The 36-Hour Day. I read only a little about the drug research, the trials and animal studies.

What I had to read were the personal stories of people who had been through the chaos and disaster that was engulfing both my father and me. It was memoirs I wanted. Well-written, poorly written, I tracked them down and read every one I could find.

Today there are more of them. Hundreds, perhaps thousands, now that self-publishing is so common. But those early memoirs saved my life, or so it felt. Eleanor Cooney’s Death in Slow Motion was the first, and it brought me to my knees. Then John Bayley’s exquisitely-written Iris, An Elegy. And the the most adroit of them all, with insights on every page, Aaron Alterra’s not-very-widely-known The Caregiver.

It was my response to those books that made me think I had to write my own memoir. I read and read, then I wrote and wrote.

Under Other Alzheimer’s Memoirs on the sidebar, you’ll find two dozen reviews of the books that moved me.

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A Death in the Family

Monday, September 13th, 2010

You wake up one day in mid-September, and it’s fall. It’s beautiful, the morning is crisp, the sun soon rises and pours down into the valley, lighting up the sycamores and maples and buckeyes, the yellow ragweed and the last of the ironweed. You could not ask for a more perfect day.

But it’s autumn. The tide of hot weather is going out, and like my father, I despair of it. I love the days of early fall but hate the thought of the winter to come. Lhude sing goddamn, as Pound wrote. Already I’m nostalgic for summer!

My father was exactly the same. He put up with winter, but loved the hot days of summer, the life of summer evenings. He died on November 22nd, and I think in part it was because he didn’t want to go through another winter.

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My father worked at Time when James Agee wrote for Fortune, and knew him a little. Dad didn’t read much fiction, but had great respect for Agee’s novel, A Death in the Family. I have his copy of the book, a first edition, published in 1957 after Agee’s death, and last night something pulled me across the room to my bookshelf. I had to read again, as I read every year, its prologue, titled Knoxville: Summer 1915. This was not actually part of the novel, but was added by Agee’s editors, who say they “would certainly have urged him to include it in the final draft.” It begins, famously, “We are talking now of summer evenings in Knoxville in the time that I lived there so successfully disguised to myself as a child.”

It’s a slow, evocative piece, and builds to this close:

“It has become that time of evening when people sit on their porches, rocking gently and talking gently and watching the street and the standing up into their sphere of possession of the tress, of birds’ hung havens, hangars. People go by; things go by. A horse, drawing a buggy, breaking his hollow iron music on the asphalt: a loud auto: a quiet auto: people in pairs, not in a hurry, scuffling, switching their weight of aestival body, talking casually, the taste hovering over them of vanilla, strawberry, pasteboard, and starched milk, the image upon them of lovers and horsemen, squared with clowns in hueless amber…

“Now is the night one blue dew, my father has drained, he has coiled the hose…

“On the rough wet grass of the back yard my father and mother have spread quilts. We all lie there, my mother, my father, my uncle, my aunt, and I too am lying there…. They are not talking much, and the talk is quiet, of nothing particular, of nothing at all in particular, of nothing at all. The stars are wide and alive, they seem each like a smile of great sweetness, and they seem very near. All my people are larger bodies than mine…with voices gentle and meaningless like the voices of sleeping birds. One is an artist, he is living at home. One is a musician, she is living at home. One is my mother who is good to me. By some chance, here they are, all on this earth; and who shall ever tell the sorrow of being on this earth lying on quilts, on the grass, in a summer evening, among the sounds of the night. May God bless my people, my uncle, my aunt, my mother, my good father, oh, remember them kindly in their time of trouble; and in the of hour of their taking away.

“After a little I am taken in and put to bed. Sleep, soft smiling, draws me unto her; and those receive me, who quietly treat me, as one familiar and well-beloved in that home; but will not, oh, will not, not now, not ever; but will not ever tell me who I am.”

Now is the night one blue dew, my father has coiled, he has drained the hose. What is it in this line, this single perfect line, that makes me weep? I don’t cry easiily. I wish I could, but I don’t. But I come to this line and I break into tears, I cry and cry. Who shall ever tell the sorrow, indeed. Because that boy’s father, or the father like him in the novel, is going to die. The summer will die, our fathers will die, we will no longer sit together on quilts on the rough wet grass of the back yard. Everything will be lost. Our youth, our parents, our lives. My father.

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Atul Gawande in The New Yorker

Monday, August 16th, 2010

new-yorker-cover-aug-2-2010I’ve read a hundred articles and books about dying. The best of them all is Atul Gawande’s piece in the August 2nd New Yorker, “Letting Go,” in which he writes about the choice that must sometimes be made between fighting to stay alive (or keep a patient alive), and accepting an approaching death.

Gawande is brilliant. I called up his father here in Athens, Ohio (Ram Gawande was my urologist before he retired) to tell him I think his son is a genius, and to ask how Atul managed to write one fascinating article after another for the New Yorker, even as he carried on a full surgical practice in Boston. “He’s very busy,” Ram said.

Busy and focused and the best medical writer we have. “Letting Go,” subtitled “What should medicine do when it can’t save your life?”, is subtle and painful. At the heart of it is that meeting (if it ever occurs), in which a doctor tells a patient that there is nothing that can be done to help or cure his disease. That almost no hope remains.

Of course there is always some hope. Miracles have happened, and we’ve all heard stories about them. The problem is that in pursuing yet another chemotherapy regimen or series of radiation treatments, we sometimes overwhelm the patient, keep her in the hospital when she might be at home with her family, make her last days a nightmare of mechanical ventilators, electrical defibrillations and feeding tubes. As Gawande writes:

“Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or ‘It’s O.K.’ or ‘I’m sorry’ or ‘I love you.’”

You can read the full article here.

Most affecting in Gawande’s writing are the stories of his own insecurity, the awkwardness of having that painful discussion with a terminally ill patient. When he does what we might consider the “right” thing, it may not work. From a transcript of questions readers asked of him about the article, I found this additional story, in which Gawande admits that discussions about death don’t always work out well:

“I broke the bad news of an incurable and rapidly aggressive cancer to a patient of mine recently. I tried to think about the best ways to frame it. I said, the clear option to give her a chance of a lottery ticket, of actually controlling the cancer, would be chemotherapy and radiation. But then I said the hard thing, which was [that it is] rare for people to live more than a year or so. If she proved to be one of them, we would dance in my office. But we also needed to think about what was most important to her if she wasn’t one of them.

“When I talked to her a day later, she was angry with me. She told me she read on the internet about people who were cured and they said not to listen to the doctors.

“I didn’t sleep very well that night. I had hurt the trust she had in me. And suppose I was wrong? But then a week later, when we talked again, she was grateful. She pushed ahead with further opinions and then treatment, but I think we are also beginning to think about the limits of what she wants to take as this goes along.”

This is surely one reason that doctors don’t want to tell the truth: it takes hope away from patients, and it can anger them. But to sugar-coat the facts, or simply not report them, and to let terminally-ill patients believe there is much greater hope than science can allow, might result in another patient withering in an ICU instead of making his peace at home with death and his family.

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My own father died without ever talking about his death. But then, that was his choice—compounded by a dementia which left him unable to say anything near the end. My girlfriend, Jan, who died three summers ago, didn’t want to talk about death either. Not to me, and not, that I heard, to anyone else. The result was that she was taken to the hospital one day with a failing kidney, suffered some small strokes (they showed up later on either a CT scan or an MRI), and was unable to say more than a few words in the last week of her life. Her family and friends gathered, a world was created around her hospital bed, she underwent test after test. Her brother and I made a move, at the very end, to get her into a hospice center in Columbus, but by then it was too late.

I’m sure many caregivers feel the way I did with both Jan and my father: unsure about pressing someone else to talk about their own death. But I’m also sure of this: I wish everyone would read Atul Gawande’s article, which is a huge step toward an open discussion of how we want to spend our last days and hours.

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Pinned Like A Bug

Sunday, August 8th, 2010

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I’m back at my dad’s house, sleeping in the same little room where I lived for the last year of his life. Things have changed, of course. My family is here (or most of us), and off we go to the beach, we go kayaking, we play badminton and cook dinners on the grill.

But in this house my father is never far from my mind. This is the place of Alzheimer’s. Here is the lift chair he sat in, the bed he lay in. Here is where he retreated from the world.

I can take, at times, a somewhat-cheerful stance on Alzheimer’s. I can think about the true connection I made with my father in that last year. But here in his house, what I most remember is how he retreated from life, how it defeated him, how he lost interest in everything.

Talking to a woman from the local paper, I hear the same story about her grandmother. This is the story I’m always alert to: of an Alzheimer’s patient, once lively and inquisitive, who no longer wants to do anything, who now just sits in a chair, who resists all efforts to keep her involved with other people and the world. Perhaps it’s because I’m alert to it that I hear this story so often—but it’s the story I can’t escape, the one that pins me like a bug to a cork board.

Life at its best is filled with will power, with drive and curiosity and excitement. Instead of this, what overcomes so many Alzheimer’s patients is a kind of endemic, untreatable depression. Prozac or other SSRIs might lift an edge of the blanket, but in my father’s case the loss of interest in the world seemed vast and incurable. To forget names and people, to lose track of his own history was painful to him. But what it led to was worse: the time he spent with what seemed a determined will to do nothing. He didn’t want to be roused. He wanted only to sink. It was terrible for him, hence terrible for me—and it’s the story I hear from one caregiver after the next.

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The Other Life, The One We Long to See

Monday, April 19th, 2010

“There are really two kinds of life. There is, as Viri says, the one people believe you are living, and there is the other. It is this other which causes the trouble, this other we long to see.” ––James Salter, in Light Years.

I think this is what I find so electrifying about Alzheimer’s memoirs. Dementia is in a sense a dreary topic, all decline and desperation. But down in the trough we see that other life Salter talks about, the one people hide, the one they don’t want to show—and the one I long to see. Because of course some kind of breakdown is never far from any of us. It could be an oldman who turns difficult, cantankerous, even violent, as Alzheimer’s strips him—though never entirely—of his old graces.

Or the breakdown could be taking place at the other end of the ladder. With my grandson, for example. Consider the following scene, so close in spirit to the stubborn resistance and fierce will of the ninety-year-old professor mentioned above:

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I was in Denver ten days ago, visiting my son and his family. Twenty-seven-month-old Max was sitting at the table, ready for dinner, which was on the stove but not quite done. Max, who is not that interested in things that will happen ten or fifteen minutes later, wanted his food now. To hold him at bay, his mother, LL, set him up with a piece of paper and a felt marker, so he could draw or scribble. But Max wasn’t interested in drawing, and quite deliberately, when we were all watching, threw the pen on the floor.

Not allowed, of course, and it drew a reprimand from both his parents. At which Max, using the back of his hand, with his eyes leveled on his mother’s, slowly pushed his plastic dinner plate off the table.

It fell with a clatter. LL lifted him onto the floor and asked him to pick it up. He would not.

“Then you can’t eat dinner. Not until you pick up the plate.”

The lines were set. I won’t describe the prolonged battle in detail: every outburst, every crumple to the floor, every claim that he had to use the potty, that he had hurt himself, that he was desperate for food. Affection was not withheld. Both Janir and LL picked him up several times and hugged him and told him they loved him—but he had to pick up the plate. Which was the one thing he absolutely would not do.

A timeout on the stairs wouldn’t work. They knew from experience that he would simply climb down. They could have locked him in his room and let him bang his head against the door, resoundingly—but their interest was to have him pick up the plate. One simple act. Not of contrition, just the pure act of picking up the plate he had brushed off the table.

He wouldn’t do it. The strength, the depth of his refusal was epic. It went on for an hour, during which the meal was served and the adults ate. I’d say that overall, Max was winning. We were all still talking about the plate, rather repeatedly, and he was not picking it up.

Invention. It’s no less important for parents (or for the caregiver of someone with Alzheimer’s) than it is for a Picasso or Flaubert. Or so it seems to me. A truly creative person is the one who can find a way out of a knock-down, drag-out battle with a two-year-old. And that night the one who saved us was Janir, who finally suggested, like a general avoiding an outright rout, “Max, how about we go up and take a bath?”

Ten minutes later I went up to see them, and Max was his usual happy self in the tub, playing with his toys and splashing around.

When they came down, with Max in his nightsuit, there came the awkward moment. Dinner was ready for Max, but first—and here Janir squatted down with him on the floor, making it as easy as possible—he had to pick up the plate. There was a terrible hesitation. Would he dive back into his apocalyptic refusal? Instead he bent, picked up the plate and gave it to his father. The adults all applauded him and told him how happy we were—and so ended another near-Armageddon.

Oh yes, that other life, the one we long to see. Often we have the ideal, gorgeous child, laughing and entertaining himself. And sometimes we have this other, the one that causes the trouble.

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