October 17, 2009

Defusing the Explosive Child and the Demise of Discipline

Along with death and taxes there have always been problem children and experts who have offered advice to concerned, suffering parents and teachers. A visit these days to any large bookstore will reveal rack upon rack of parenting advice books covering virtually any problem or angle of child rearing imaginable, a testament to an enduring and insatiable belief in self-improvement/help especially true of the American parent. The majority of these books focus in one way or another on the behavior of children, especially over limit setting and discipline. The range of books and answers strongly suggest there is no single approach that works for all children and all families.

In my twenty three years practicing behavioral pediatrics I've seen a number of these books come and go as markers of popular thinking about child rearing in America. In the 1980s, The Explosive Child by Stanley Turecki popularized the workings of childhood temperament and fit in a sensible and practical manner. In the early 1990s, Mary Kurcinka's euphemistically titled, The Spirited Child, anticipated the boom in the attention deficit/hyperactivity disorder (ADHD) diagnosis and reflected the ethos of the now waning self-esteem movement in child psychology.

The late 1990s brought us The Explosive Child by child psychologist, Ross W. Greene. If titles discern a trend I think we can soon expect the publication of The Lethal Child (a primer to avoid raising a school shooter) and perhaps by the end of this decade, The Thermonuclear Child (describing a youngster capable of wiping out an entire community). This progression of titles and ideas, strikes me as extremely worrisome and disturbing.

Discipline has been eroding in this country for 150 years since families began leaving the farm for the factories of the city. The development of public compulsory education a little over one hundred years ago played a role in decreasing the power of parents. In the 1920s the routine attendance of high school, which brought teens together for the first time separate from their families, especially empowered youth at their parents' expense. The mid-century power of Child Guidance movement further diminished the cultural legitimacy of discipline espoused by behaviorist and religious leaders. It also shifted expertness from grandmothers and clergy to child psychiatrists, psychologists and pediatricians.

In the 1960s and 1970s child abuse and spousal abuse were brought out of the closet and were rallying cries for both child advocates and feminists. The aforementioned self-esteem movement which became prominent in the 1980s, along with self-help and 12-step ideology, gave any adult conflict with children a negative spin. Books that ostensibly taught parents to talk to your kids so they will listen implied that if you used these approaches one could successfully avoid arguing with children. The response to the excesses of the child sexual abuse hysteria of the early 1990s epitomized by the McMartin day care fiasco was only a temporary balancing check to an otherwise continuing relaxation of limits and expectations in the name of protecting children. By the late 1990s, American psychiatry has medicalized (disorder of the month) most coping behavior. With Ritalin and Prozac, America appears more ready to address children's bad behavior with a pill rather than a swat.

Indeed, Ross Greene happens to head the psychotherapy arm of treatment at the Clinical and Research Program in Pediatric Psychopharmacology of Harvard's Massachusetts General Hospital, the leading child psychiatric drug research center in the country. Its director, Joseph Biederman, a child psychiatrist, is arguably the nation's most influential pediatric psychopharmacologist and a vigorous promoter of using psychiatric medications in children. Dr. Greene openly acknowledges that most of the children he treats are taking one or more psychiatric medications. He feels they are necessary in order just to allow his approaches to begin to work.

Controversy rages nationally about the possible over diagnosis of entities like ADHD or bipolar disorder in children. Dr. Biederman and colleagues find that nearly a quarter of the children evaluated at his clinic with ADHD also meet the criteria for bipolar disorder, the new name for manic-depression, once thought quite rare in children. This very high rate of co-morbidity has led other doctors to question how typical these patients are compared to the general community. Critics have challenged the clinic's diagnostic threshholds - it may be easier to be diagnosed with bipolar disorder of childhood in Boston than anywhere else in the world.

It has been said that ADHD diagnosis and Ritalin are for irritable and irritating children while bipolar disorder and the drugs commonly prescribed to treat it -- lithium, Depakote (an anticonvulsant) or Risperdal (an anti-psychotic) -- are for very irritable and very irritating children. Children with the bipolar diagnosis have most often failed to improve with conventional psychotherapeutic interventions such as play therapy or parent effectiveness training. Drugs like Ritalin, Adderall or Prozac have either been insufficient or completely ineffective in controlling symptoms.

To his credit Greene avoids the whole controversy over psychiatric diagnosis in children. But Greene feels these problems are, nevertheless, inherently biological. He invokes child temperament. Personality qualities that could be described neutrally as intense, determined, persistent or coping poorly with transitions - in The Explosive Child become inflexible, stubborn and explosive - coincidentally core descriptors of bipolar child behavior. Environmental experience in this schema has little to do with the development of these problems. Parents and schools are absolved from responsibility for the problems - a welcome relief to be sure for parents who generally continue to feel responsible and some guilt no matter what benevolent theories are offered.

Nevertheless, Greene correctly starts out by telling parents they will have to be the agents of change in how they deal with their kid's behavior. Greene, like many other child oriented experts, has found the old Freudian based models of play therapy, which were meant to allow children to express themselves safely in order to resolve inner conflicts, simply do not work in helping children learn to self-control. Most family therapists have known this for years but treating children only with play continues in most community mental health practices with hopeless regularity.

By the time parents have reached the Harvard Clinic, no doubt they feel that they've tried everything. Many of them feel like they've tried behavioral modification programs yet their children continue to exhibit tantrums and outrageous behavior over trivialities. Greene tells them behavior modification will not work with these children because the kids' brains makes them incapable of responding to normal rewards and punishments. The children quickly move into a vapor lock sense of inchoate rage which makes not only reasoning but time out a useless learning exercise.

Greene's descriptions of the inner thoughts of these intense and persistent children are accurate. He does a lovely job of elucidating the thinking of a seven years old girl who goes bananas simply because her mother wants to prepare the remaining waffles for her younger brother. This little girl believes with all her heart that these two waffles have her name on them. They belong to her even though she's told no one about her convictions. She simply screams, yells and kicks when her mother insists that since the girl has already had her waffles it's only fair to give the last two to her brother.

But Greene would have this mother capitulate or negotiate with this child's otherwise outrageous demands in order to avoid having the girl melt down. He feels the melt down - the frequent rages and temper tantrums - are in of themselves the most destructive aspects of the explosive child for both the family and the children themselves. These episodes lead to increasing feelings of despair and desperation for all the parties involved. Greene's goal is somehow to have the parents keep the child hanging onto reason.

He proposes dividing all conflictual challenges into three baskets. In reverse order, basket C has the parents deciding that the waffles aren't worth fighting about at all. Okay honey I won't prepare them for your brother if it's that big a deal to you. He feels most conflicts parents take on with their kids can actually be put into basket C without too much ill effects. Basket B is for issues that are not easily dropped but call for negotiating, distraction, rationalization, anything to keep the kid involved in talking and not flaming out. Since you've already eaten your waffles this morning what if we went out and bought some more right after school? How would that be? The idea here is that our little lady is mollified by the offer and that by 3 PM she likely has forgotten how important they were to her in the morning. Good sense otherwise would have her then say That's okay mom, you don't have to get them until you go shopping over the weekend.

Greene spends most of the book teaching parents how to work with items in basket B. He offers a variety of stratagems and linguistic pyrotechnics for keeping the kids involved. Parents must show amazing commitment to the approach in the face of continuing outrages expressed by their kids. There were passages in The Explosive Child of kids' behavior and parents' acquiescence that made my stomach queasy and my chest tight. Four letter words, personal insults and epithets, negotiating with unreasonable three and four year olds are all accepted in the service of the higher goal of keeping the kid cool.

Behavior placed in basket A results in a limit. Greene does believe there are some infractions, primarily physical attacks and destruction of property that should be stopped. However, he gives parents little instruction or advice in how they might accomplish this. He believes if most behaviors are tossed into baskets B and C there should be far fewer episodes of rage that call for a firm unyielding limit.

All this sounds a lot like the old sensible parenting advice of picking and choosing your battles. But Greene's emphasis on Baskets B and C is misplaced and potentially damaging. If in fact the parents are effectively setting limits for certain Basket A behaviors why not encourage them to expand their demands on their children's performance over time. If hitting mommy in anger sends Johnny to time out, parental immediacy and consistency should in time cause Johnny to think twice about such actions. Once parents see improvement in less hitting, why not begin to include swearing as another time out offense.

This is not rocket science but it is also not easy to do with difficult persistent children. And no one approach works all the time for all children. Sometimes, the most useful thing parents can do with their wailing whining six year olds is hold them close and whisper sweet nothings into their ears. Parenting these children is like playing an antique violin. Bow too softly and you hear nothing. Bow too hard and it squeaks. Finding just right amount of pressure to make the violin sing sweetly requires much skill, practice and often some instruction for playing difficult instruments.

Greene admits there is no published data supporting his approaches at this time. However, I suspect we will be seeing such studies in the future if only because Greene works with the most prolific group of pediatric psychiatric researchers in the country. No matter how his results are spun I worry deeply that Greene's approaches will be applied by the hungry hoards of desperate parents struggling with setting limits for their tantrumming preschoolers and school age children.

There is a place for calmness and negotiation in child rearing. Many of the parent caricatures in The Explosive Child are themselves rigid and explosive. They have unrealistic expectations that their young children can think and act like adults and threaten them unrealistically with being grounded until their 21st birthday. Some negotiation with teens make sense by virtue of their physical size, ostensible emotional maturity and rights afforded them by an more ever permissive society. Few angry teens can be safely hauled off to a time out by their parents. If these kids haven't learned to go on their own by then, the cops will likely to have to be called in to physically intervene. But how will these kids learn to self-control when their parents have been giving in to them since their toddler days?

That's my biggest worry about The Explosive Child. This is not the approach I'd recommend for the average family with a difficult or even very difficult two to twelve year old child. Of course Greene would say these kids are beyond even very difficult. They and their families haven't responded to the standard behavioral advice. Yes, but how many of the parents I see feel like they've already tried everything by the time they've gotten to my office. They feel like they've tried to reward and punish without success. An approach that promises relief to the pressures of children and their tantrums will beguile these worn out, hopeless parents.

Yet so many of these families who come to see me succeed once they've been given permission and support to become more immediate and tangible with their discipline. With less ambivalence interfering with their demands and follow through, parents often wind up using the same approaches that previously failed but now succeed when they are applied consistently and immediately. Rewards also have a role in shaping behavior but they too should be immediate and tangible: stickers, stars and small toys for younger kids; money and extended privileges for the older ones. Rarely, though are rewards alone an effective substitute for limits and discipline.

Some children who are especially hyperactive and impulsive will be helped with drugs like Ritalin or Adderall. And some children will continue to rage and tantrum. No one approach solves all problems. Undoubtedly a few children will never receive the degree of immediacy and consistency required to meet their behavioral challenges within their own homes. That doesn't mean they are unresponsive to rewards and punishments. All animals (and probably some plants too) respond to these behavioral inducements. But for these kids, their current environment doesn't meet their needs.

This is not parent blaming. Some of these children have been very difficult from birth (which in itself doesn't fully exonerate their family and school from influence on their behavior). At some point though, the choices for these families become very difficult. Find another environment that can meet the kids' needs - another relative's home, a different class or school. If it's warring spouses perhaps the parents should separate or the child should live with one parent exclusively for a while. All these situations are common with very difficult children in part caused by having to raise them. More medications are often added to the child's chemical balance to restore some living balance. Or the environment changes.

Somewhere in the mix for these very extreme cases there might be a place for the approaches espoused by The Explosive Child. I'm not sure whether the approach works for the kids in Greene's clinic or simply the medications they are taking sufficiently address or sedate them. But for the many other families struggling with very difficult children, premature adoption of these techniques will have the ironic effect of creating more explosive children -- good perhaps for sales of books and medications but tragic for a society that's lost its balance between the dual needs of children: loving nurturance and effective discipline.

An edited version of this review first appeared in salon.com on July 18, 2001.

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