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?”

Sibling conflict: untangling the complexities

A number of years ago I was asked to see six-year old Sam for a second opinion after a local "ADHD expert" had diagnosed that disorder and written a prescription for Ritalin based on one visit with Sam and his mother.   My first visit had been with Sam, his four-year-old brother Jake, and their mother. At that time I learned that Sam's "behavior problems" occurred mostly in the form of conflict with his younger brother. Sam was "impossible," always provoking Jake, who had to follow along when family activities were disrupted by Sam's "difficult" behavior.

I was immediately struck, when I met with his parents together, at Sam's father's close physical resemblance.  Like Sam, he had a full head of curly red hair. He was silent and sullen for the first part of the visit while his wife unleashed a torrent of complaints about Sam. Interestingly, she looked like Jake, who was a handsome blond boy.

As I shifted my focus to Dad, and expressed interest in his experience of Sam's behavior, it immediately became clear that he was an unwilling partner in this evaluation. He had no concerns about Sam. "I was just like him as a kid" he said. Then things began to get complicated. I learned that Sam's father was temperamentally not only very much like Sam, but also shared many qualities with the maternal grandfather, with whom Sam's mother had a difficult relationship. The sibling conflict was actually a symptom of difficulties in the marriage, which were in turn related to relationships from the parent's past.

In almost every child I see for behavior problems, there is a similarly complex story in the background. Lest I feel tangled in an impossible web of multigenerational conflict, it is important to step back and focus on the task at hand, namely to evaluate this child, Sam.

My aim is simple. It is to help these parents to recognize Sam's "true self," to quote D. W. Winnicott. My task is to, in a sense, clear the brush of this complex tangle of relationships to enable parents to see Sam for who he is.

When qualities are placed in a child that actually belong to some other relationship, it is often out of parent's awareness, or to use the psychoanalytic term, "unconscious." When I participated in at a Parenting conference at Austen Riggs last weekend, I learned that most of the adult patients there, who struggle with serious mental illness, feel that they were born to play a role, in a sense robbing them of their own unique identity. It occurred to me at the conference, where I spoke about the Newborn Behavioral Observation system as a way to bring out a baby's unique characteristics at birth, that this intervention might offer a tool to prevent such a dynamic from being played out.

The beauty of working with young children is that it is possible set things in a better direction by clearing conflicts belonging to other relationships off the child.  Parents need to be given the space and time to tell their story to a nonjudgmental listener. This process may allow unspoken and even unconscious feelings to be brought to light. Once his caregivers recognize a child's true self,  he is free to develop in a healthy way.

In the case of Sam and Jake, once the conflict was put in its proper place, Sam's "difficult" behavior decreased. Interestingly, when his parents were less stressed by his behavior, tension in the marriage lessened, setting in place a positive cascade of change. Sam was, to use another therapy term, the "identified patient" in a larger family dynamic. If he had been medicated for his behavior symptoms, however, the full story might never have been brought to light.

Pediatrics and Psychoanalysis: An Essential Partnership

D.W Winnicott, pediatrician turned psychoanalyst, has been among the most important influences on my work. Unlike him, however, I have been determined, in my professional life, not to "defect" from pediatrics to become a psychoanalyst. I have always felt it was important to bring the wealth of deeply meaningful ideas coming from the discipline of psychoanalysis to the practice of pediatrics.

For example, in my current position as a behavioral pediatrician at Newton-Wellesley Hospital I teach the pediatric residents and  medical students about colic by starting with Winnnicott's notion of "primary maternal preoccupation." I read to them from my book: Keeping Your Child in Mind, itself an effort to bring psychoanalytic ideas to a general audience:

Winnicott described the first weeks to months of motherhood as a period deserving of a name, a psychological state, which for both a newborn and mother is not only healthy but highly adaptive. The name Winnicott gave this state was “primary maternal preoccupation.” He referred to a mother who is preoccupied in this way with her baby as an “ordinary devoted mother.” This way of being in tune with the baby happens naturally and does not look like anything particularly dramatic. A mother knows what her baby feels through her intense identification with him. He is a part of her. Though her role is in this sense “ordinary,” it is in fact hugely important. Winnicott writes: “It will be observed that though at first we were talking about very simple things, we were also talking about matters that have vital importance, matters that concern the laying down of the foundations for mental health.”

Rather than asking "what to do" to "manage" colic, I encourage them to think about the meaning of the behavior within the context of this intense infant-parent relationship. Similarly, when parents come to see me about how to "manage" their child's "behavior problem," I help them to recognize that they are engaged in a kind of "dance of dysregulation" with their child, and that they both need to learn a new way to dance that is calm and coordinated.

This weekend, however, I get to do exactly the opposite, namely bring my knowledge as a pediatrician to a group of psychoanalysts.  Just as psychoanalysts are experts in relationships, so pediatricians (and all professionals who provide primary care to children) are experts in babies.  We are immersed in child development in a way that is unlike any other profession.

I am speaking at a conference at the Austen Riggs Center, co-sponsored by the Yale Child Study Center: Development of the Parent as a Person: Psychological, Biological and Genetic Contributions. Within minutes of looking at the proposed lineup of presentations, I knew exactly what I had to add. My talk is titled: "The Development of the Parent: the Child's Contribution."

 After more than 20 years of listening to countless parents and seeing thousands of babies, I have no doubt that babies come in to the world with their own unique set of qualities and characteristics, that from the first moment have a significant impact on the development of the parent. Almost every parent who is struggling with their child's challenging behavior has shared some variation of, "we saw this from the moment he was born."

I will use the photographs from Kevin Nugent's book: Your Baby is Speaking to You, that so beautifully captures the way babies are engaged in complex communication from the start. I have a video clip of a baby at three days of age having a conversation with me. I will introduce the Newborn Behavioral Observation system, a clinical tool designed to bring out these qualities in the baby, and promote healthy relationships from the start.

A number of years ago I attended a conference entitled "Pediatrics and Child Psychiatry: an Essential Partnership." I was hopeful, but sadly it ended up being primarily about prescribing medication, with a little bit about "parent training" thrown in. The word "relationship" was not mentioned once.

Here we have two parallel relationships: the parent-child relationship, and the pediatrics-psychoanalysis relationship. In each pair, one has the opportunity to have a profound and positive effect on the development of the other.

A necessary mourning

I heard the phrase, "I don't want to live in the past" three times last week. The first was from Dr.Ruth Westheimer, famous sex therapist and Holocaust survivor. Her interviewer pointed out the inconsistency of that statement and the fact that she was in town to see a play about the story of her life. The second was a mother who wept in my office as she spoke of her troubles dealing with her young daughter's behavior. She recognized how her own issues got in the way, but wished to "live life forward."  The third was from my father.  We are working together to find a way to tell his remarkable story of his life in Nazi Germany, his escape to America, and his subsequent rescue of his parents from Theresienstadt when he returned as a soldier with the US army. His ambivalence is powerful-one day he will be eager to tell more stories about his life, and the next day he will shut it down. 

I find myself thinking-do these stories, often associated with very difficult and painful memories- need to be told? Virtually every person who hears my father's story says it must be told. But why?

I think there are two answers. The first is about history. History is essentially about telling stories from the past. Our hope is to make sense of things and so to better understand the present and future. But it may be difficult for the individual person who experienced the trauma directly to carry this burden. Perhaps history needs to be written by those who can study it from a distance.

The second answer is more personal.   It is about the hold that unprocessed grief can have on an individual, and on subsequent generations. When speaking with a friend about how little I knew about my father's life until very recently, she said, "Can you imagine how much energy it takes to hold all of that in?"

When loss on the magnitude of the Holocaust has occurred, it is very difficult to wrap one's mind around the effect of unprocessed mourning. In my work with parents and young children, however, its effect can be immediate and vivid. Here is an example from my pediatric practice.

Emily brought her son Michael to see me when he was 3 and 1/2 months old. He had been born one month premature, but it was clear from a first glance that he was doing well. I remember noticing that his mother was so close, physically close. She hovered over his carriage, reluctant to let me pick him up. She stood inches from him while I examined him.

He was robust little boy who gave a big smile as he intently followed his mother's face. Emily felt he was doing well. So well, in fact, that she was attributing qualities to him for which he seemed to young. "It's good for him to comfort himself, right? I should let him cry, right?" She seemed very anxious.

About a year earlier, Emily had lost a baby, Christopher she called him, in her ninth month of pregnancy, when she was in a car accident. She conceived again almost immediately. And here was this miracle baby. I watched Michael sleeping in his blue jumper. He seemed so small and vulnerable. 

"He's doing great," I said. Emily continued to wear that uncertain look as I tried to reassure her. She asked about sleep. "Is it OK if he is still in our bed? Is it good for bonding?" she asked. I was puzzled by this question and paused, asking her to tell me what she meant.

"Is he bonded to me?" she asked. I started to attempt an answer when she interrupted me. "Can you bond in utero? I mean I bonded to Christopher, but he died. I didn't let myself bond to Michael when I was carrying him."

I felt a tingling in my arms and a clutching in my chest. Tears came to my eyes as I watched them run freely down her cheeks. We sat this way for a while, living in the unbearable pain of her loss.

With Emily I wondered aloud if getting pregnant so quickly had prevented her from doing the difficult work of grieving the loss of her first child. She said to me, "I feel like I can't give all of myself to Michael. I have to hold back to protect myself." 

At that visit with me, perhaps fortified by our moment of connection, of true empathy, she found the courage to face this task of grieving. She recognized it was critically important not only for herself, but for her relationship with her infant son.

 Sometimes there is urgency to telling these stories, to protect the next generation from the effects of unprocessed grief by enabling parents to be fully emotionally present with their children. In the case of war or massive social trauma, the work of mourning may need to be done generations later, when people are safe and comfortable and do not fear for their lives.

The French psychoanalysts I refer to in my previous post on this subject make the distinction between "big history," and individual family history, noting that the second can sometimes be a reverberation of the first. Gerard Fromm, in his book Lost in Transmission: Studies of Trauma Across Generations, elaborates on this notion through case histories from his work at the Austen Riggs Center.

A friend who knew I was writing about this subject recommended that I watch the first scene of the film Angels in America. It is the funeral of an elderly Jewish woman. The old rabbi looks out at his audience of adult children and grandchildren and, speaking of this woman's life, hardship and coming to America, says, "that ocean crossing lives in you." When they are spoke of or not, these stories live in subsequent generations, and demand to be told.