Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Wednesday, September 5, 2012

A Conversation with Paul Tough: How Children (Don't) Succeed

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.

2) Educate all professionals who work with children and families about practical application of contemporary developmental science  (I actually wrote my book Keeping Your Child in Mind, for this purpose)

3) Change the system of reimbursement so that primary care clinicians are among the highest rather than the lowest paid

4) Value time as a clinical intervention

5) Offer comprehensive screening and treatment for postpartum depression and other perinatal emotional complications. Representative Ellen Story working to implement just such a program in MA

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.

1 comment:

  1. There's much to like in your post, but there's enough in it to undermine it's analytical thrust.

    The locus of the undermining point pertains to your comments regarding a child's response to the initiation of stimulants in the wake of an ADHD diagnosis. You note that the child's parents may see a return of pre-medication behaviors after a period of remediation. To be blunt, such a turn of events a should be anticipated if not expected.

    As you point out, providing pharmacotherapy for a child patient does not resolve environmental or contextual issues (e.g.: undiagnosed parental issues, martial issues, school/schooling issues, ...). Nor does this course of treatment remediate any of the comorbid disorders that are extraordinarily common to ADHD. Various studies provide solid evidence that CD, ODD, chronic or major depression, AD and other disorders present in children diagnosed with ADHD (especially the combined sub-type) at at rates of 40-80% of the diagnosed population (by disorder). To be concrete, the cohort of children diagnosed with ADHD-C are likely to also have ODD (65%), ASPD (>55%), MDD or dysthymia (70%), AD (65%) or substance abuse disorder as they approach their teen years.

    Treating ADHD with age appropriate psychotherapy and pharmacotherapy delivers resilient improvements in the vast majority of instances. It also opens the door to therapists, parents and 3rd party care-givers/educators to begin to identify and, as needed, disaggregate the comorbid disorders that are more often than not lurking behind - and fueling - the more acute expressions of behaviors that can appear to be solely ADHD symptomatic.

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