When I write from my clinical experience as a behavioral pediatrician, I am careful to change identifying information to protect the privacy of my patients. It is rather freeing, therefore, to write about characters in a novel. Left Neglected by Lisa Genova, who is also a neuroscientist (perhaps she took the story from some real cases) offers some important insights into this complex subject.
The story revolves around Sarah, a 37-year-old mother of three young children, who, distracted by her cell phone on her drive to her high-powered job, crashes her car and suffers a traumatic brain injury. In the days just before the accident, she and her husband are called in to see their seven-year-old son's teacher who says, in not so many words, that they should have him evaluated for ADHD and possibly medicated. During the time that Sarah is hospitalized, he is in fact diagnosed and started on Concerta.
But there is another relevant story line. We learn that when she was a child, Sarah's 6-year-old brother accidentally drowned in a neighbor's pool. When Sarah's mother comes to take care of her in the wake of her accident, we gain further insight into the havoc this event wreaked on their relationship. Her mother is holding her hand in the hospital. She writes:
After Nate died, at first she held my hand a little tighter. I'm seven, and my hand is in hers when we cross the street, when she leads me through a crowded parking lot, when she paints my nails. Her hands are confident and safe. And then I'm eight, and my hand must be too awkward to hold along with all that grief, so she just lets go. Now I'm thirty-seven, and my hand is in hers.Sarah acknowledges that her intense drive to succeed has been at least in part powered by this double loss of her mother and brother. In her pre-accident life she is a master multitasker who works very long hours and is rarely home for in time dinner. She clearly adores her kids and is devoted to them, but is usually answering emails while getting them ready for school.
As she and her mother work to heal their relationship, we see a new kind of calm in Sarah (part of this is necessitated by the restrictions on her life imposed by her brain injury.) In a lovely scene where she is helping her son with his homework, she is present with him in a way that she was not in her prior frenetic lifestyle. Together they figure out that he works better standing up. If they cut out the problems, he can do them individually and not be distracted by all of the questions on the page. Both are thrilled by his success.
Jubilant pride skips along every inch of his face. It strikes me that he looks like me.I recognize that these are fictional characters. Yet I think that an assessment, as I do with real patients I see in my practice, can offer some insight into this complex question of the interaction between biology and environment.
There is likely a genetic vulnerability for attention problems in Sarah's family. Her brother's accidental death may have in part been due to an impulsivity that can go along with these traits. Sarah herself may have some attention problems, but her behavior is also in large part fueled by the loss of her brother and her troubled relationship with her mother.
Her son may have this same genetic vulnerability, but his symptoms are also tied to his mother's intense, driven behavior. She may have difficulty being emotionally present with him, particularly as he reaches the age her brother was when he died. As Sarah's relationship with her own mother is healed, in turn she is able to be more fully emotionally present with her son.
My hope for these fictional characters is that Sarah's process of grieving and healing with her mother will in turn help to lessen her son's symptoms of inattention and distractibility, and so support his healthy development.
Grief and loss are frequently present in the family history of children who have been diagnosed with ADHD. But often, as in this story, these losses go unacknowledged for many years, sometimes for generations. They may take the form of "family secrets."
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Controversy is brewing over the recent New York times op ed: A terrifying way to discipline children, in which Bill Lichtenstein describes his five-year-old daughter being held in a seclusion room at a Lexington school when her behavior was out of control. A Globe headline asserts in response: Account of putting pupil in isolation disputed. Of course I do not know what actually happened. However, I do know that a very commonly held belief among parents is that one should leave a child alone, or "ignore" him, when he is having a meltdown. Yet all of the best of developmental science tell us that this approach is completely wrong.
When I work with families who are struggling with a child's out-of-control behavior, I explain that in the middle of a meltdown, a child feels completely helpless. If left alone, he will feel not only frightened, but also abandoned. I explain that at such a moment, the higher cortical centers of the brain responsible for rational thought are not functioning properly.
These types of severe meltdowns are common in children who have experience early trauma, at the time when the higher cortical centers of the brain were not yet fully developed. Stress of a seemingly minor nature can lead the rational brain to in a sense go "off-line." The child will have access only to the lower brain centers that function more instinctively.
I recall working with the parents of a four-year-old child who had been adopted from another country. There he had lived on the street with his mentally ill mother, from whom he had been separated at one year of age and placed in an orphanage. His adoptive parents where both horrified and overwhelmed by what they interpreted as "anger." He would scream at them, spit at them, kick and hit them. Not only would they get angry in return, interpreting his behavior as "defiant," but they would send him to his room, saying, "I'll be back when you can calm down and behave nicely."
When I explained that during a meltdown he was developmentally more like a newborn than a four- year-old, their approach to him completely changed. Rather than react in anger, they would ask calmly, "Do you need a hug?" Or they would try to hold him. If he were too out-of-control to allow physical contact, they would take him to a place where he was physically safe, and speak to him reassuringly until he began to calm down. Not only did the tantrums subside, but his parents began to learn to recognize when he was about to descend into what they now understood as a lower center of brain function. They would try to engage him when the thinking part of his brain was still working.
Similar mechanisms are at play in a child who has not had this kind of severe trauma. Frequent meltdowns are common in the setting of sensory processing problems and developmental problems such as speech and language delay (as apparently was the case for Rose, the child described the New York Times piece.) When a child is repeatedly abandoned both physically and emotionally in the middle of a meltdown, that experience in itself may be traumatic. In such a situation frequency and intensity of meltdowns often worsens.
I had the privilege of speaking with Paul Tough on the very day that his new book How Children Succeed: Grit, Curiosity and the Hidden Power of Character was released. In the middle a massive publicity tour, including NPR interviews and major speaking engagements (he is speaking September 6th at Harvard), his publicist arranged for him to speak on the phone with me. Despite being under what I imagine to be intense pressure, he was very gracious and thoughtful.
It was really more of a conversation than an interview, as my hope was to introduce some ideas that were not addressed in his book. It was understandably relatively brief, and I am using my blog to elaborate on what we discussed. I am thrilled that his book is receiving the attention it is. In presenting his thesis that character, rather than cognitive skill, is the key to success, he brings some very important research to the forefront of public discussion.
Extensive research has shown that in the setting of a safe secure caregiving relationship, children develop the capacity for emotional regulation, cognitive resourcefulness, resilience and the capacity for social adaptation. He uses somewhat different words-including grit, curiosity, self-control, and gratitude, and refers to these traits as a whole as "character."
From my view as a pediatrician and scholar of developmental theory, I see significant obstacles to promoting character development in the way he is advocating for. I wonder if, in addition to funding programs that promote character, or funding research to study these programs, as Tough effectively argues we should be doing, we need to understand the nature of these obstacles.
With that in mind, I asked Tough about three interrelated issues. These are; our society's undervaluing of primary healthcare, overreliance on psychiatric medication, and childism.
Consider the following scenario, variations of which are exceedingly common. It starts with a mother who is under significant stress in pregnancy. Then she has a baby who "cries all the time." Stress in pregnancy is associated with this kind of behavioral "dysregulation" in the newborn. She may struggle with postpartum depression(PPD). The combination of depression and a fussy baby makes providing the kind of attuned relationship a newborn needs extremely difficult. But in the absence of an effective PPD screening and treatment program, the pair may not get help. There is severe sleep deprivation, marital stress and many other factors that make it difficult to be responsive in the way that supports character development.
By age three, the child has significant trouble with emotional regulation. His pediatrician, under the time constraint of the 10-15 minute visit, likely will offer behavior management advice about such things as time out. She likely will not have the opportunity to hear about the stressed marriage or the mother's depression, much less to take the time necessary to make an appropriate referral.
At age four, the child is disruptive in preschool. An ADHD evaluation is recommended by his teachers. He meets diagnostic criteria as defined by DSM. He is started on stimulant medication and immediately his behaviour improves. But soon the problems resurface as the underlying issues have not been addressed. The dose is increased. The medication is changed. This continues throughout the rest of his childhood. When he gets to high school and confronts the barrage of tests Tough writes about in his book, he starts abusing his stimulants.
I'm a clinician, not a policy person, but I do have some thoughts about what needs to happen to get children off this path and on to one where relationships and character development are supported.
1) Transform education of health care professionals, who are on the front lines with young children and families, to focus on relationships as the 4th vital sign. The American Academy of Pediatrics Early Brain and Child Development Initiative is an important step in the right direction.
6) Address the overreliance on psychiatric medication use. There is a severe shortage of qualified mental health care professionals, related in large part to low reimbursement rates for treatments other than medication.
Just before I spoke with Tough, I read the following from an interview with him in the Hechinger Report:
Is part of the problem in higher-education and K-12 policy circles that we’re myopic—and that it takes longer than we’re willing to wait to determine if something is working?
In general, yes. I think any time you’re talking about child development and public policy, there’s that problem, which is that any intervention is going to take a long time. There’s a good case to be made that the most effective interventions are early interventions, and quite literally you’re not going to see the payoff for years and years—and our political system is not set up to fund those sorts of things.So we have all this evidence of the importance of promoting healthy relationships in early childhood, as well as compelling evidence from University of Chicago professor James Heckman that investing in early childhood is economically very wise, and still we are so short-sighted and impatient? I asked Tough if perhaps this was a manifestation of childism.
Childism: Confronting Prejudice Against Children is a brilliant book by Elisabeth Young-Bruehl who tragically died suddenly just before the book was released, depriving us of the opportunity to learn about her work through the kind of publicity tour that Tough is now having. I describe it in detail in a previous post, that I will summarize here.
Young-Breuhl, an analyst, political theorist and biographer, calls attention to the way human rights of children are threatened. Childism is defined as “a prejudice against children on the ground of a belief that they are property and can (or even should) be controlled, enslaved, or removed to serve adult needs.”Young-Breuhl provides ample evidence for her assertions, including a detailed history of the field of child abuse and neglect.
She describes Child Protective Services (CPS) as a “rescue service-a child saving service-not a family service supporting child development generally and helping parents…” Rather than setting up a system of treatment, CPS became "an investigative service...a situation in which bad families suspected of making their children bad will be invaded and infiltrated." Young- Breuhl has empathy for both parent and child, arguing that failure to support families is a manifestation of childism.Overreliance on psychiatric medication is in her view is example of childism:
She writes of “a childism of the sort that is now fueling an epidemic of diagnoses of bipolar II disorder and the prescription of medications to children who are, in effect, being doped into acquiescence."Young-Breuhl compares the situation in our country with comparable developed countries that have lower rates of child abuse and neglect.
There, “children have a range of preventative and development-oriented services: universal health care, health services, and parent support services in homes after the birth of a child; maternal and parental leaves for infant care; developmental preschool programs; after-school programs; and economic supports of various kinds.”I don't claim to have the answer to the problem of childism, but I do think that if we are going to be able to make use of Tough's very important book to implement meaningful change, it a least needs to be acknowledged.
Pediatrician T. Berry Brazelton, whose work is featured as an antidote to childism, endorses [Young- Breuhl's] book, recommending that all who are involved with children and families should read it. This book has helped me, like nothing else I've read, to understand why it is so hard to get the kind of help for children that all the best science of our time is telling us they need. I hope everyone reads it. As Young-Breuhl states, “prejudice has to be recognized in order to be overcome.
Lieberman's treatment is relatively intensive, administered in weekly sessions that can continue for as long as one year. But the principle behind it-improving children's outcomes by promoting stronger relationships between children and their parents-is increasingly in use across the country in a wide variety of interventions. And the results, when the interventions are evaluated, are often powerful.
It is hard to argue with the science behind early intervention. Those first few years matter so much in the healthy development of a child's brain; they represent a unique opportunity to make a difference in a child's future. But one of the most promising facts about programs that target emotional and psychological and neurological pathways is that they can be quite effective later on in childhood too-much more so than cognitive interventions.
Nelson's belief is that underperforming high-school students can relatively quickly transform themselves into highly successful college students- but that it is almost impossible for them to make that transition without the help of a highly effective teacher. OneGoal has signed a unique partnership deal with the Chicago public schools that lets the organization work directly with individual teachers...the teacher sticks with the same class for three years...And when the students are freshmen in college the teacher keeps in close touch with them...providing support and advice."
Wealthy parents today, she argues, are more likely than others to be emotionally distant from their children while at the same time insisting on high levels of achievement, a potentially toxic blend of influence that can create "intense feelings of shame and hopelessness" in affluent children.
Traditionally the purpose of a school like Riverdale is not to raise the ceiling on a child's potential achievement in life but to raise the floor. What Riverdale offers parents, above all else, is a high probability of nonfailure...The problem, as Randolph has realized, is that the best way for a young person to build character is for him to attempt something where there is a real and serious possibility of failure.
At KIPP, teacher Mike Witter explains to a parent, "The categories [of character traits] we ended up putting together represent qualities that have been studied and determined to be indicators of success. They mean you're more likely to to go to college. More likely to find a good job. Even surprising things, like they mean you are going to get married, or more likely to have a family."
Parents are an excellent vehicle for those interventions, but they are not the only vehicle. Transformative help also comes regularly from social workers, teachers, clergy members, pediatricians, and neighbors.