Defusing the explosive child

Prescribing drugs, not discipline, will only escalate conflict, lead to more difficult kids and weaken our already-lax culture of parenting.


Lawrence H. Diller
July 18, 2001 11:10PM (UTC)

In my 23 years practicing behavioral pediatrics, I've seen dozens of parenting manuals come and go, their titles the checkpoints of popular thinking about child rearing in America. In the '80s, "The Difficult Child" by Stanley Turecki popularized the workings of childhood "temperament and fit" in a sensible and practical manner. In the early '90s, 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.

Now we have "The Explosive Child" by child psychologist Ross W. Greene. Originally published in 1998 and released this year in paperback, the book offers, as its subtitle suggests, "a new approach for understanding and parenting easily frustrated, chronically inflexible children." While Greene's approach may be valid for some extreme cases, "The Explosive Child" overpathologizes difficult children and is likely to have a pernicious effect on our already-lax culture of parenting. (Expect the publication next year of "The Lethal Child" and perhaps by the end of this decade "The Thermonuclear Child.")

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The weary parents of extremely difficult kids deserve our compassion, but Dr. Greene's book does them no favors. Less a strategy than a means of surrender, it is a 326-page letter of permission to follow the path of least resistance -- even if it frequently involves prescription drugs and constant cajoling.

It is true that, in the last two decades, I have witnessed a rise in the level of children's problems (younger children referred with more serious behavioral and emotional issues). And I, like many other doctors and practitioners, have responded more frequently with a strategy that involves, among other approaches, the prescription of medicines like Ritalin.

But I have also seen an attendant plunge in the confidence and competence of the parents of very difficult children -- and an equally disturbing trend on the part of caregivers to reflexively regard drugs as the remedy of first choice. While it is important to recognize the plight of these mothers and fathers, it is dangerous to suggest that -- except in the most extreme cases -- they will do themselves or their children any good by opting for psychotropic drugs and negotiation as a substitute for discipline, rewards and spending enough time with their kids. And yet, even with the best of intentions, this is what Greene, and a growing number of colleagues, have begun to advise.

The discipline of children has been eroding in this country for 150 years, starting with the departure of families from the farm for the factories of the city. The development of public compulsory education -- about 100 years ago -- played a role in decreasing the power of parents. By the '20s, routine attendance of high school brought teens together for the first time separate from their families, and specifically empowered youth at their parents' expense. The midcentury power of the "child guidance" movement further diminished the cultural legitimacy of discipline espoused by behaviorists and religious leaders. It also shifted "expertness" from grandmothers and clergy to child psychiatrists, psychologists and pediatricians.

In the '60s and '70s, child abuse and spousal abuse were brought out of the closet and informed the rallying cries of both children's rights advocates and feminists. The aforementioned self-esteem movement, which became prominent in the '80s, 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 you could successfully avoid arguments with your children.

The response to the excesses of the child sexual abuse hysteria of the early '90s, epitomized by the McMartin day care fiasco, was only a temporary break in the continuing relaxation of limits and expectations in the name of protecting children. By the late '90s, American psychiatry had medicalized most coping behavior. And with Ritalin and Prozac in the mix, American doctors and parents appear more ready to address children's bad behavior with a pill rather than a swat. "The Explosive Child" is the latest manifestation of this trend.

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"Explosive Child" author Greene heads 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, child psychiatrist Joseph Biederman, is arguably the nation's most influential pediatric psychopharmacologist and a vigorous promoter of using psychiatric medications in children.

Controversially, Dr. Biederman and his colleagues find that nearly a quarter of the children with ADHD who are evaluated at their clinic also meet their criteria for bipolar disorder, the new name for manic-depression, once thought quite rare in children. The bipolar diagnosis carries with it the implications of a lifelong disabling pyschiatric disorder requiring perpetual drug treatment with medications like lithium, Depakote (an anticonvulsant) and Risperdal (an antipsychotic drug). The Harvard clinic's very high rate of diagnosis has led other doctors to question how typical these patients are compared to the general community. Critics have challenged the diagnostic thresholds of Biederman and his partners, alleging that it may be easier to be diagnosed with bipolar disorder of childhood in Boston than anywhere else in the world.

To be sure, the art of psychiatric diagnosis in children remains a very inexact science and in practice most doctors follow an algorithm of treatment using the safest drugs first. Children with the bipolar diagnosis have most often failed to improve with conventional psychotherapeutic interventions such as play therapy or parent effectiveness training. Drugs with relatively safer side effect profiles like Ritalin, Adderall or Prozac have either been insufficient or completely ineffective in controlling symptoms of these very difficult children. In fact these kids at the Boston clinic are often taking two, three and even four psychiatric drugs at the same time.

Greene openly acknowledges in his book that most of the children he treats are taking one or more psychiatric medications. He feels the medications are necessary just to allow his approaches to begin to work. The behavioral problems of children he treats, says Greene, are biological in nature, stemming from the children themselves. He believes the children's poor behavior is the result of their genetically derived temperaments -- behavior that is felt to be inherent to the children themselves and not the result of environment or experience.

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Greene specifically avoids the debate over the psychiatric diagnosis of bipolar disorder in these children, which, given the controversy, is probably wise. But he puts a particularly negative spin on personality qualities that could be described neutrally as intense, determined, persistent or coping poorly with transitions. In "The Explosive Child" these qualities are defined as inflexible, stubborn and explosive -- coincidentally core descriptors of bipolar child behavior.

In Greene's analysis, parenting and school experience have little to do with the development of these children's problems. Greene absolves parents of causing the problems: a welcome relief for parents who generally feel guilty and responsible no matter what benevolent theories are offered for their children's behavior. Nevertheless, Greene correctly starts out by telling parents they will have to be the agents of change in improving their kid's behavior whether or not the child is taking medication (he or she usually is).

(Like many other child-oriented experts, Greene has found that 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.)

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

Greene nicely captures the inner thoughts of these intense and persistent children. He does a lovely job of elucidating the thinking of an 11-year-old girl who goes bananas simply because her mother wants to prepare waffles for the girl's younger brother. This little girl believes with all her heart that these waffles have her name on them. They belong to her even though she's told no one about her convictions. She argues, screams and knocks down chairs while her mother pleads that since the girl has already had her waffles, it's only fair to give the last two to her brother.

Most doctors would recommend ending this kind of exchange early before it escalates -- if necessary, with the immediate loss of some privilege or going to timeout. But Greene asks the mother to capitulate or negotiate with her daughter's otherwise outrageous demands in order to avoid having the girl "melt down." He feels the meltdown -- the frequent rages and temper tantrums -- constitutes the most destructive aspect of the explosive child for both the family and the children themselves. He says that 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 even though -- to me -- it appears to be "rewarding" outrageous behavior.

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Greene proposes that parents divide 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. "OK, 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 many ill effects.

Basket B is for issues that are not easily dropped but call for negotiating, distraction, rationalization -- anything to keep the kid 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 the child will eventually be mollified by the offer and that by the time school is out, she will have forgotten how important the waffles were to her in the morning.

Greene spends most of the book teaching parents how to work with items in basket B. He offers a variety of stratagems and linguistic gymnastics for keeping the kids involved and out of tantrum mode. Greene demands amazing commitment to the approach from the parents in the face of continuing outrages expressed by their kids. Indeed, there were passages about kids' behavior and parents' acquiescence in "The Explosive Child" that made my stomach queasy and my chest tight. Greene asks parents to accept four-letter words, personal insults and epithets in negotiating with unreasonable 3- and 4-year-olds -- all in the service of the higher goal of keeping the kid cool.

Only 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 on how they might accomplish this. He believes that 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 and, for some reason, declines to be specific about how to set that firm unyielding limit.

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Much of this sounds a lot like the old sensible parenting advice: "Pick 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 timeout, 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 timeout offense?

This is not rocket science, but it is also not easy to achieve with difficult and 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 6-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 the right amount of pressure to make the violin sing sweetly requires much skill, practice and often some instruction in mastering a difficult and beloved instrument.

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. But no matter how his results are spun, I fear that Greene's approaches will be grabbed by the hungry hordes of desperate, uncertain parents struggling over setting limits and hoping to avoid the unpleasantness of dealing with their tantrummy preschool and school-age children. However, avoiding the unpleasantness of conflict with their kids will ironically lead to more and escalating conflict and more "explosive" bipolar children.

Keeping one's cool as a parent is quite important in child rearing. There's even a place for negotiating. Some negotiation with teens makes sense by virtue of their physical size, ostensible emotional maturity and "rights" afforded them by an ever more permissive society. Few angry teens can be safely hauled off to a timeout by their parents. If these kids haven't learned to go on their own by then, the cops might 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?

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That's my biggest worry about "The Explosive Child." Greene's approaches, as articulated in this book, are not approaches that I would recommend for the average family with a difficult or even very difficult 2- to 12-year-old child. Of course Greene would say these kids are beyond even very difficult. And that may well be true. On the other hand, I see many parents who feel as if they've already tried everything by the time they've gotten to my office. They feel as if they've tried to reward and punish without success. Yet so many of these families actually succeed once they've been given the 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 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 older ones.

Rarely, though, are rewards alone an effective substitute for limits and discipline. Kids also need some time with their parents doing something together that is not merely shuttling from music lesson to soccer practice, a ritual that seems to pass for quality time among suburbanites and affluent city dwellers. And, of course, kids need affection and warmth from their parents too. However, I find in the families I see that showing love is not the parents' problem as long as their kids' difficult behaviors are under control.

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 throw tantrums. No one approach solves all problems. Undoubtedly, a few children will never receive the degree of immediacy and consistency required to meet 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.

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I am not blaming parents. Some of these children have been extremely 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. They may have to find another environment that can meet the kids' needs -- a relative's home, a different class or school.

If warring spouses aggravate the challenges, perhaps the parents should separate or the child should live with one parent exclusively for a while. Perhaps the next time the kid acts out the cops should be called. These types of painful decisions for parents make alternatives like more medication for the child or Greene's approaches to discipline attractive.

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


Lawrence H. Diller

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