Commentary on the Child Case

This is the case of a very touching and sad little boy whose level of self-development is still quite primitive. As Anne Alvarez describes him, he is at best borderline, at times psychotic, and somewhat, in her words, “Asperger-ish.” While differential diagnosis is always difficult with children like Sam, there are many indicators that he is not simply neurotic, although at times of higher functioning it can seem that he is. And again, although he has severe narcissistic issues, his self-development has not reached the level of cohesiveness that one can expect of a child with a predominantly narcissistic personality.

Sam's sense of self exists as a fragmented self, in bits and pieces; at one moment he is the Kid, at another, the Big Guy, and at other times he is the “stupid” external object in his world. The difficulty in treating children with such fluctuating ego states is that the self, which lacks a stable core, switches from fragment to fragment so rapidly that it is hard for the therapist to know whom she is relating to at any particular moment. As Anne Alvarez expresses it, “who he is in the here and now.” The therapist is on a roller coaster, clearly working very hard to stay with her patient in the here and now, at times succeeding and at other times losing him.

The concept of developmental levels of the self (as discussed by Linda Mayes and Anne Alvarez earlier in this volume) is applicable to the case of Sam. When the therapist was in tune with the level of the child, a closeness in their relationship was palpable, even though the child immediately undertook to smash that connection—for that is where he is living, in his smashed relationships.

How do we work with a child, given such rapidly fluctuating ego states (Pine 1974)? How do we react to the ever-shifting changes, one moment a 6-week-old baby, who cannot make or sustain eye contact with mother, and at another moment an anal child, who wants complete control over the