Ritalin for all: the fallacy of simple answers

I've been thinking about the phrase, "the fallacy of simple answers," in preparation for writing about a new book I was asked to review, Pills are Not For Preschoolers (whose cover looks remarkably similar to my book, Keeping Your Child in Mind, that came out a year ago.).  Author Marilyn Wedge gives a clear and compelling argument for the use of family therapy in treatment of behaviorally symptomatic children. Unlike the title suggests, the book is not primarily about preschoolers, but offers multiple examples of her successful work with children ranging from preschool to adolescence.

She contrasts this approach with the current trend of solving complex problems with a prescription for medications. She writes:

What happens, then, if the child's symptoms are treated with medications-say Ritalin or Adderall for the hyperactivity or Zoloft for the depression? The hyperactive boy may indeed calm down and the depressed girl may well cheer up. But, as we will see, if the deeper family issues are not addressed and resolved, unanticipated consequences may emerge, sometimes months or even years later.

Prescribing medication in this way is an example of a simple answer. But I actually heard the above phrase in a completely different context.  I heard it from my father, with whom I am working on a new book about his experience growing up in Nazi Germany. He was telling me that the year of his birth, 1923, was the same year that Hitler was arrested for trying to overthrow the German government. Hitler spent the next year in prison writing Mein Kampf. My father described it as a time characterized by "the fallacy of simple answers." He expressed concern that in this current time of economic hardship, some politicians (particularly those speaking in Tampa this week) offer simple answers to complex problems.

My father was not saying that these politicians are Nazis, and I am not saying that our current approach to child behavior problems has any relation to Nazism. But the phrase resonated for me.  Looking to simple answers to complex problems can have unanticipated, and sometimes dangerous, consequences. In the case of Ritalin prescriptions, one of these is the current epidemic of stimulant abuse in high school.

Unfortunately Wedge's book is also an oversimplification in two important ways. First, many of her cases, while I'm sure they are honestly portrayed, come across as being way too easily resolved. Many of the families I treat in my behavioral pediatrics practice are dealing with serious trauma and loss.  Unlike the families Wedge describes, they have often been struggling with their child's behavior since infancy. Certainly not all families will find that six or seven visits will solve everything.

The biggest oversimplification, however,  is her presentation of the biology/environment, or nature/nurture issue in an either/or model that is not only oversimplified but also outdated. Current research at the intersection of genetics, neuroscience and developmental psychology reveals a complex ongoing interaction between biology and environment.

For example,  families who come to me with concerns about "ADHD" often describe a child who was not only very active in utero, but was also running by 9 months.  Clearly such a child has a biological vulnerability. But even here environmental influences may be at play. A 2006 study at Johns Hopkins showed an association between psychological distress in pregnancy and advanced motor development.

These children often have a family history of ADHD, suggesting a genetic influence. But parents who have themselves struggled with similar problems may bring intense emotional responses to their child's behavior. Genetics and environment are inextricably linked.

In addition, having a child with these challenges, even when they are biologically based, can lead to marital conflict, particularly if one or both parents share these traits. The stress in the household produced by this conflict may in turn exacerbate a child's "problem behavior," or what is more accurately referred to as "symptoms."

The hopeful part of this complexity is that this science tells us that by changing the environment, it is possible to change the biology. We can no longer think in simple dichotomies of drugs or therapy, biology or environment. Supporting relationships, family therapy being one approach, can actually change the brain.

My go-to phrase that I learned from my mentor and colleague Ed Tronick is "embrace complexity." When parents are given the space and time to tell their story to a non-judgemental listener, the multiple origins of their child's behavior, as exemplified by the above view of "ADHD", will become clear. In such an environment of reflection and understanding, a child's development, at the level of gene expression and biochemistry of the brain, can move in a healthy direction

Weathering the storm of a meltdown leads to great rewards

Whether your child is 3, 10 or 16, a meltdown can be among the most stressful parenting moments. Much has been written about this subject; see for example see my recent interview When Your Child is Having a Meltdown on the Mother Company blog. Less attention is paid, however, to the fact that successful navigation of these inevitable moments leads to profound love, intimacy and growth for both parent and child.

Not only does your child see that you understand him, but also that you love him enough to hang in there with him when he is at his absolute worst.  He sees that you will help protect him by setting limits, and, perhaps most important, that he can survive the intensity of his own emotions. Repeated experiences of being held in this way teach children the essential skill of emotional regulation.

An example from my book, Keeping Your Child in Mind, was actually based on an experience with my then three-year-old son. Now 14, and a talented actor/musician, he prides himself on having been one of my greatest teachers, and has given me permission to write about him.

Three-year-old Evan and his friend Robbie were collecting sticks to roast marshmallows. Evan and Robbie’s mothers were best friends, and this marshmallow roast was a highly anticipated part of their regular visit together. But when Evan, who was a very bright but inflexible and easily frustrated child, started poking Robbie with a stick, things began to fall apart. When Evan ignored her request to stop, Dana, Evan’s mother, could anticipate what would happen next. She knew Evan would have a hard time when she had to take the stick away. However, she felt calm and confident, despite the wild, screaming protests of her son when she told him he couldn’t have any more sticks. She felt the supportive presence of her friend, who she was sure would respect her decision to be firm with Evan despite the disruption it would cause to their afternoon.

Dana took Evan indoors, repeating softly through his cries that she couldn’t let him hurt anyone. She reflected his disappointment and acknowledged his excitement about getting together with Robbie. She held him through his escalating screams, feeling a bit embarrassed to have this scene witnessed by her friend, but still able, in the face of these feelings, to focus her full attention on her son’s emotional state. She stayed with him for what felt to her like a long time, while his crying gradually slowed to a whimper. Then together they were able to figure out a plan to still have fun that afternoon without using the sticks. They went outside and rejoined their friends.

Certainly things don't always go so smoothly, particularly when a parent is stressed, usually about something that has nothing to do with the child. I've had many such moments with my now teenager children. I hope that, for the most part, I have recognized that things have not gone well and attempted to repair the disruption.

But when things go well,  I am able to be calm and respectful of the feelings behind the behavior, which in the case of teenagers usually has to do with anxiety about school, love relationships, or simply finding someone to sit with at lunch.  When the meltdown ends, there is a powerful feeling of love and closeness.

D.W. Winnicott referred, an idea less well known than those I have described in previous posts, to an "ego orgasm." Lest people feel uncomfortable with that word being included in a column about parenting, it is not about sex. He described it occurring in a child's play, friendships and even going to the theater, when a play speaks to a person's experience in a profound way.  It can be understood as a rush of intense warmth and intimacy. The notion is aptly applied to a tantrum, as when it is over, there is also the release of built-up tension that occurs in the eye of the storm.

So, you see, the rewards are great. A parent experiences a feeling of competence and positive self-esteem. A child moves another step closer to development of a healthy sense of self.  Life, not just childhood, is full of disappointments.  The good-enough mother, another Winnicott term, does not insulate and protect her child from life's struggles.  Again quoting from my book:

She reflects their experience and contains their distress in a manner appropriate to their level of development. She holds them in mind through the difficult times. In doing so she gives her children the tools of empathy, flexibility, and resilience, a secure base from which to become an effective adult.

A perfect community moment: holding a mother so she can hold her baby

I am a devoted fan of Zumba, specifically as it is taught by my wonderful teacher, who has a dedicated following. She has been out for the past month, home with a newborn and two year old. Last week, she came with her baby to try to take the class, now being taught by a substitute, also a regular member of her class.

"I need this for my mental heath, " she confided as we walked together in the parking lot. A mother of a teenager who was also taking the class greeted us at the door.  Without hesitation, she offered to take the baby to a nearby park with her other two kids. "I'll bring him back when he needs the breast, " she said, and was off.

About 20 minutes in to the class, we heard the insistent cry of newborn hunger. His mom stopped her dancing and sat on the side nursing the baby, cheering the rest of us on through the new routines. A few minutes later, she was back in action, the other mom taking the baby again. My teacher was able to get a couple more numbers in before her baby demanded the second breast. Again she stopped, and settled in with him on the floor of the dance studio, where the two of them remained through the end of the class. We all wished them well as we filed out of the class.

It was a beautiful example of both  "the holding environment," and "primary maternal preoccupation," two ideas central to the work of D. W.Winnicott, pediatrician turned psychoanalyst.

Being home full time with a toddler and newborn is among the most difficult jobs there is. Taking care of your mental health is essential. This little scene included two important elements: physical activity that is calming, Zumba being a great example, and a community of supportive caring people.  In an ideal world, every mother would have access to such a "holding environment." When  a mother is struggling with perinatal emotional complications, such as depression or anxiety, this is particularly important. In such an environment, a mother is free to provide the "maternal preoccupation," that my teacher demonstrated with her unhesitating attention to her baby's needs.

Human infants, unlike some other species,  are completely helpless and dependent for the first 8 to 12  weeks of life.   Beyond these early weeks, babies begin to have the ability to comfort themselves, for example bring a thumb to their mouth. The need for this kind of preoccupation lessens. In fact, as they grow and develop, learning self regulation by not having their every need met becomes increasingly important. But in these first few months, being highly attuned and  attentive to a baby's needs, or "preoccupied," while it can be exhausting,  is essential for healthy development. It lays the groundwork for self-regulation and a healthy sense of self.

Thinking about this scene led me to reflect on a post written by Kara Baskin, one of my fellow Boston Globe bloggers, about Yahoo CEO Marissa Mayer's plans to take only a few weeks maternity leave. She writes:

I’m sure Mayer will make the situation work for her however she can, whether that means hiring an army of nannies or installing some kind of high-tech baby-cam from which she can run meetings while playing virtual peek-a-boo or, you know, trying to work flexible hours.

Baskin wonders how realistic this is considering how emotionally drained and physically exhausted a new mom can feel.  This is an important point. But at the risk of accusations of anti-feminism, I think Mayer's idea is selfish. Recently I spoke with a very experienced maternity nurse. She observed that, more than in previous generations, for today's new Mom the pregnancy is "all about them."

Well, the hard reality, and also the great joy, is that it is not all about them.  At the end of the nine months, this baby needs someone to offer the kind of primary preoccupation that I described above. It doesn't necessarily need to be the mother. It could be a father, grandparent or other relative. If it is a nanny, which in my opinion is not ideal, then it must be recognized that when that nanny leaves, it will be a significant loss for the child that will need to be processed and grieved.

Our society needs to recognize the value of those first two to three months. We need to provide a holding environment for new Moms. We need to let them know that taking time to devote to preoccupation with their newborn is among the most important things they can do. It's not that much time. But in terms of the health of future generations, it will go a long way.

Addressing the question: Is something wrong with my child?

In the setting of my behavioral pediatrics practice, this can be a loaded question. One would assume that parents are hoping very much for the answer to be "no." But they wouldn't be in my office if there weren't something wrong. Therefore if I say "no," parents may be left feeling there is something wrong with them.  At moments like this, I turn to the growing discipline known as "infant mental health." (Here infant refers to children under age five.) Charles Zeanah, MD, in the Handbook of Infant Mental Health writes: 

The relational focus of infant mental health has been the sine qua non of this field from the beginning. It is not the infant who is the target of intervention but rather the infant-parent relationship. . . . Instead of the problem or disturbance being understood as within the child or within the parent, the problem may be understood as between the child and caregiver.

The child brings his or her own qualities to the relationship, qualities referred to as "biological vulnerabilities." These may include difficulties with sensory processing and inflexibility. The parent brings his or her own issues, which include not only biological vulnerabilities, that in adult life may manifest as actual mental illness, but a whole history of relationships and experience.

"Infant mental health" can be a confusing term, as it may imply that there is such a thing as "infant mental illness." As those who read my blog know, I am very much opposed to diagnosing mental illness in young children.  Rather, infant mental health is about understanding and supporting the young child's ability to experience, regulate and express emotions, form close relationships, and explore the environment and learn.

Many forces, including the education system and health insurance industry, push parents in the direction of answering the above question in the form of a diagnosis. On a purely emotional level, during the time it takes to  address the problems in the relationship (and it does take time, but for a young child, not that much time) it can be hard to hold on to the complexity. The need to answer this question with a definitive "yes" or "no" may be put aside, only to resurface at a later time.

Daphne Merkin, in last week's New York Times piece Is Depression Inherited? tackles this challenging issue. Merkin, who has had a lifelong struggle with depression, looks at the question from her perspective as mother to a now 22-year-old daughter. She writes:

Probably the most basic error we make is in trying to frame the puzzle of how human character evolves in stark oppositional terms — nature or nurture — rather than seeing it as an inextricable mix of things.

Her most important point comes in a parenthetical statement. In considering how to use the current information available to guide parenting, she writes:

Until more compelling genetic information becomes available, it seems that the best we can do is to keep our children’s predispositions in mind while focusing on the pieces of the developmental puzzle over which we can exert control. (This includes being attuned to your child’s nature, especially when it differs from your own.)

 This last concept of "being attuned to your child's nature, especially when it differs from your own,"  is the essence of healthy parenting. She is describing a parent's recognition of what D. W, Winnicott termed the child's "true self." It involves recognizing a child as a person with thoughts and feelings that are his own. It is an excellent goal to work towards, though not always easy.   Issues that get in the way of recognizing the child's true self, including stresses in a parent's life and other relationships, may need to be addressed.

When viewed from this perspective, the question becomes not "is there something wrong with my child?" but rather "Who is this child, and how is he or she both alike and different from me?"

As I write in my book Keeping Your Child in Mind, where I explore this issue in much more depth:

It is my hope that we can move from an emphasis on diagnosis and labeling to an emphasis on prevention. We need to ask not “what is the disorder?” but rather, “what is the experience of this particular child and family?” and “what can we do to move things in a better direction?”