Tears ran down Elena's cheeks as she described being so overwhelmed and full of rage that she forcefully held her fully clothed 4-year-old son, James, under the shower when he wouldn't go to bed. Later in the same 50-minute visit she revealed that she had suffered years of physical and emotional abuse as a child. As is typical of visits to my behavioral pediatrics practice, she had brought James because he was "defiant." "Something must be wrong with him," was followed by, "Tell me what to do to make him listen." James' preschool teachers, who were having trouble managing his behavior, had suggested that he might have attention deficit hyperactivity disorder (ADHD.) They recommended to Elena that medication be considered. They knew nothing of this history. My wish in listening to this story is not to judge, but rather to understand the experience of both mother and child.
A great tragedy of 2011 was the sudden death of Elizabeth Young-Bruehl a month before the publication of her book, Childism: Confronting Prejudice Against Children, released January 10th. Not only was this the loss of a great mind, but also the opportunity for her to represent her very important ideas, ones that are likely to cause some controversy, in public discussion.
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."
Elena's story offers a microscopic view of the macroscopic phenomenon Young-Breuhl so brilliantly articulates. Following the history of the field of Child Abuse and Neglect (CAN) studies, she finds that "from the start [this field] took attention away from abusers and their motivations; and it implied that children could be helped without their abusers being helped." Furthermore, 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.
While Young-Breuhl does not write about ADHD, such as James is believed by his teachers to have, 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."
I wonder if Young-Breuhl would have considered the new American Academy of Pediatrics (AAP) guidelines recommending the diagnosis of ADHD in children under age 6 (in contrast to the previous guidelines that covered age 6-12) to be a manifestation of childism.
According to the new AAP guidelines, if a child in this age group meets diagnostic criteria for ADHD, he is first treated with "behavior management techniques" and if these fail, medication is prescribed. The guidelines do not call for exploration of the meaning, or motivations, of behavior, which is often due to a combination of biological vulnerability and environmental stress. One could argue that inherent in this approach is the phenomenon of childism; the idea that children are property of adults, who have the right to control them for their own self-interest.
Rather than blaming individual parents, my aim, as Young-Breuhl does, is to call attention to the way we as a society approach problems involving children and families. For childism is a societal phenomenon. Most individual parents, given the opportunity to be heard and supported, are not childist. They long to help their children, not merely control them.
Elena, once she had the chance to tell her story, was eager to address her own trauma. She wanted to learn to regulate her emotions and help her son to manage his. She did not want to medicate away his symptoms. But getting such help is not easy. There is a severe shortage of quality mental health care services. Pediatricians are under enormous time pressures in the current system of health care, in which a practice must accommodate demands of multiple different insurance carriers. Visits are on average 10 minutes in length, not offering a chance for a clinician to listen to a story like Elena's.
The problem of improving access to care is a political one. Young-Breuhl describes an attempt in 1970 to pass the Comprehensive Child Development Act. Its creators were accused of being "anti-family." Young-Breuhl writes, "To this kind of childism, in which trying to ensure that parents were responsive to their children's developmental needs was seen as anti-family, the framers and supporters of the act could not reply, "this is childism." They lacked the concept of childism to address the root of the controversy and so remained on the defensive, trying to win a "disinformation" propaganda war. A futile project." Current efforts to provide services for young children and families similarly come up against "family values" propaganda.
Young-Bruehl compares the situation in our country with that of comparably 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."
Young-Breuhl wisely recognizes that "children whose development is not being supported cannot be protected." She proposes a new Comprehensive Child Development Act. I think she would be heartened by the recent policy statement of the AAP: Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health. This policy statement seeks to use the explosion of research at the interface of neuroscience, genetics and developmental psychology to support early parent-child relationships. It is a preventive model designed to promote healthy development.
Access to care is a significant obstacle to implementation. I believe Young- Bruehl would say that childism is the reason why pediatric primary care clinicians and mental health care workers are among the lowest paid professionals. She would point to childism to explain why the health insurance industry and pharmaceutical industry have together been able to create a system where children are more likely to be medicated than listened to. She would say that medicating James (or even using "behavior management") without addressing either his mother's history of abuse or his experience of her out-of-control behavior would be a manifestation of childism.
Atthe time of her death, Young-Breuhl was in the process of editing the complete works of D.W.Winnicott, pediatrician turned psychoanalyst. His notion of the need to recognize a child's "true self" to facilitate healthy development fits seamlessly with her ideas.
Pediatrician T. Berry Brazelton, whose work is featured as an antidote to childism, endorses the 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."