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.

Paul Tough Speaks at Harvard: How Children Succeed

One of the highlights of Paul Tough's new book How Children Succeed:  Grit, Curiosity and the Hidden Power of Character comes in the final chapter, when he describes how he and his wife interact with their three-year-old son Ellington to help develop the qualities he spends the rest of the book demonstrating are associated with success.

He describes helping Ellington to calm down after a tantrum or bad scare, providing discipline and rules, and, in addition to lots of hugs and comfort, helping him learn to manage failure. These are exactly the parenting behaviors that research has shown lead to the capacity for emotional regulation, cognitive resourcefulness, resilience, and the ability to adapt to a complex social world.

The thesis of this book, whose primary focus is the education system-Tough is speaking on Thursday September 6th at the Gutman Library of the Harvard School of Education-, is that the conventional wisdom about the key to success has been misguided. Rather than focus on promoting cognitive abilities, our focus should be on development such things as gratitude, curiosity, self-control and grit, all of which are distilled into the word "character."

While Tough does not explicitly make this point, but rather demonstrates it in writing about his son, character develops in relationships.  When a person has a relationship with someone who not only cares about him, but also thinks about him, understands his perspective and unique challenges, helps him calm down in the face of difficult feelings, sets limits on his behavior and trusts him enough to let him fail, he is more likely to develop the "non-cognitive skills" associated with success. He will be able to think clearly and flexibly in the face of stress.

The first chapter offers an excellent overview of the current explosion in research on toxic stress, or stress in the absence of such a secure, safe relationship. Tough refers to the  ACES (Adverse Childhood Experiences) study, a huge longitudinal study that dramatically demonstrated the association between early adversity, including such things as abuse and neglect, parental mental illness and substance abuse, and family discord, with many negative health outcomes including not only mental illness but also chronic illnesses such as diabetes, asthma and heart disease.

Particularly important is the work of Alicia Lieberman, one of the pioneers in the field of infant mental health. Tough writes of Lieberman's collaboration with pediatrician Nadine Burke Harris in an innovative San Francisco based program that applies the ACES study to preventive work with children and families.  Lieberman recognizes that providing a secure attachment relationship "takes a superhuman quality" in the face of poverty, uncertainty and fear. Her model of intervention works with parent and child together.

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.

The rest of Tough's book focuses on interventions for school age children. The implication is that these children have had stressed early relationships, but that interventions in the school setting that focus on character development may mitigate against these early experiences. He writes:

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. 

Tough describes successful school programs that have focused on character development. The Youth Advocate Program, or YAP, in Chicago offers an intensive mentoring program for high-risk teenagers.  At KIPP (Knowledge is Power Program) in the South Bronx, where there is a curriculum designed to teach character, and even a character report card, one student describes how the teachers were devoted to him and his fellow students. " They were like my second family, in essence...that's the vibe we all ended up getting, that we were like a family."

Yet another program is OneGoal in Chicago, run by CEO Jeff Nelson:

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."

Tough shows how relationships can be stressed not only for the very poor, but also the very wealthy.

Riverdale, a private school in a very different part of the Bronx from KIPP, offers an example of wealthy students who are similarly at risk. Referring to the work of psychologist Madeline Levine, he writes:

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. 

Stressed relationships of this kind may have a negative impact on character development. Riverdale's headmaster, Dominic Randolph, is concerned that students are lacking in important character traits.

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.

The book takes an interesting turn when, after focusing on a number of programs that measure their own success in terms of rates of college graduation, Tough reveals that he himself did not graduate from college. Clearly Tough is a highly successful person. This information led me to wish that more of the book had been devoted to exploration of the definition of success.

I thought of how Sigmund Freud defined mental health as the capacity to love and to work. I though about creativity and empathy as two qualities that are intimately tied to success. I found myself remembering Brandon Fisher, the manufacturer of drilling equipment who was recognized by President Obama in the 2011 State of the Union address for his critical role in the rescue of the Chilean miners.

These other aspects of success are mentioned in Tough's book. For example:

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."

A related body of research, coming from the fields of infant mental health and psychoanalysis, supports the notion that the way Tough interacts with Ellington will in fact lead to this broader definition of success. This literature, and in particular the work of leading researcher Peter Fonagy, refers to the central aspect of a secure attachment relationship,  a capacity that is unique to humans, as mentalization, or "holding a child in mind."

John Bowlby, considered the father of attachment theory, writes how in the setting of such a relationship a child becomes, "self-reliant and bold in his exploration of the world, cooperative with others, and also- a very important point-sympathetic and helpful to others in distress." 

Tough is applying his considerable talents as a journalist and writer to a critically important task. The question he asks is not only how children succeed, but also how the answer can inform meaningful social policy. He is bringing this issue to the forefront of public discussion.  I am thrilled to be in the company of Tough, as in my work I have also been asking:  What can we as a society do to promote healthy relationships, that in turn promote both character and success, from infancy through adolescence? Tough writes:

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. 

Tough tackles this issue in his whole body of work, including not only this book, but also his first book,  Whatever it Takes, about Geoffrey Canada and the Harlem Children's Zone, and his New Yorker article The Poverty Clinic about pediatrician Nadine Burke Harris' program.   I am eager to see what he does next.

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.