Every parent who has ever raised a young child knows that many days, it seems there is little to praise. Toys left strewn, water running, disgusting messes, unused lights left on, spontaneous, defiant outbursts, toothpaste swallowed, and bedtime shenanigans are just a few on the infinite list of things that seem to make the day go long. Even the best of parenting intentions and interventions at times fall flat. Gains appear minimal at best and non-existent at worst, although some days aren’t that bad. Part of the challenge stems from not knowing what is next and part of it comes in the energy that it requires to engage it all. But somewhere in that day, often at unexpected times, quietness and compliance emerges unexpectedly. However brief it may be, even beyond the actions that teeter on hilarious and hellacious, he responds in a positive, compliant way. He offers to share. He goes up to his room when asked to get his blanket. He picks up the books on the floor. And then just as quickly, it is gone, and he resumes his defiant charge. It is at these moments that positivity is there for the reinforcing if only we are as in tune as when the problems began.
As a parent of a young child, these times can be stressful. Increasingly, parents who feel overwhelmed are seeking out psychiatric support in many different ways. One of these ways is medication. Detailed in a Pediatrics article entitled, “National Trends in Psychotropic Medication Use in Young Children: 1994–2009” (Chirdkiatgumchai, 2013), medication usage for children (treated in an outpatient setting) ages 2-5 continued to climb from 1994, and peaked from 2002-2005, before gradually declining to about 1994-1997 rates until 2009.
But amidst this reported leveling in medication usage among young children, a disturbing side trend has emerged. Antipsychotic medication use in preschoolers has soared over the past decade, to the upwards tale of a two- to five- fold increase despite lack of FDA approval in almost all of these medications for this age group (Harrison, 2012) and little to no information about long-term side effects. In addition, researchers have noted that most antipsychotic medications were being used off-label, and increasingly for the treatment of behavioral issues that many argue are both developmentally inherent and often a product of significant environmental dysfunction. Despite little knowledge regarding long-term implications, no debate exists about the potential myriad short-term concerns that led the FDA in 2003 to require that all second generation antipsychotic agents include warning labels highlighting a significant risk of “diabetes mellitus, hyperglycemia, and severe hyperglycemia associated with ketoacidosis, hyperosmolar coma, or death.”
Authors of the Journal of Pediatric Health Care article noted a number of plausible reasons for possible increased usage. They include societal acceptance, more awareness and availability, increased prescribing in vulnerable populations, and limited time for practitioners to exercise other options, in addition to other plausible explanations. Although not clearly illuminated in the article, there is little doubt about the role that widespread advertising, physician influence (especially upon at-risk populations), and limited options play in this trend. This must continue to be exposed.
But as a parent, what struck me the most was the following heading: Demand for Quick and Affordable Treatments. Imbedded within this paragraph was the following sentence: “Parent training and cognitive-behavioral therapy can be costly for families without adequate insurance and may seem too time-consuming for families in desperate need of a ‘quick fix’ . . . for treatments that often require 12 or more sessions to attain full benefit.” All of us understand that financial issues may be at play, although I wonder just how much the average household spends on mobile devices and electronic entertainment in a year. But in regards to the “quick fix”, it seems that the biggest problem may not be the child after all, but our perception of what those first five years are about. They are anything but conducive to a “quick fix”, especially given that even the best of preschoolers are only compliant 70% of the time. In many ways, it unfortunately fits with our American culture, which not surprisingly consumes psychotropic medication at 1.5 to 3 times greater (see same article) than our Western European counterparts. As my colleague aptly noted, too, “Twelve weeks in the life of your child seems like a relatively quick fix” even though we both understood there is no such thing.
In 1996, Dr. Rex Forehand published a book entitled, Parenting the Strong Willed Child, designed for caregivers of children ages two through six, which is now in its 3rd Edition. Based on early applied behavioral analysis (ABA) and authoritative parenting research, it emphasized the importance of timeout, ignoring, and punishment as critical to teaching emotional regulation and impulse control at a young age. But unlike much advice on discipline, it began with a focus on providing a basis for positive interaction. The first skill, attending, focuses on using a set time (e.g., ten minutes a day) to encourage parents in the techniques of imitation and describing. For example, if a child is building a tower of blocks, parents may say “That is a really tall tower” or “My tower leans like yours.” On the contrary, parents are told not to ask questions or give directives, which typically entail much of what goes on all day. The purpose is simple, but critical—teach children that they can get your attention through positive means just as they can through negative ways. Forehand goes on to teach the next step: Giving rewards. The focus here is on distinguishing between different types of rewards (social and nonsocial) and techniques to increase the likelihood the reward will work. Namely, working to make the reward as immediate, concrete, and specific as possible. Young children like to hear they did good. But without telling them exactly how they did well (picked up your clothes off the floor) right after they did well, there is little chance this praise will lead to future good behaviors.
But for parents who do need more intensive assistance to deal with significant emotional and behavioral issues, effective treatments do exist, and research indicates that they work well if an investment is made. One of these is Parent Child Interaction Therapy (PCIT), which was originally developed by Dr. Sheila Eyberg. Further information is available at http://pcit.ucdavis.edu/about-us/. PCIT is designed for children ages 2-7 and involves parents working directly with the clinician in session (using instantaneous feedback devices, such as a “bug in the ear”) for the explicit purpose of reducing negative behaviors and improving prosocial responding. Similar to Forehand’s approach, PCIT focuses on relationship building skills characterized by the acronym PRIDE: Praise, Reflection, Imitation, Description, and Enthusiasm. Treatment generally lasts 12-20 weeks (one hour per week) with booster sessions to follow during the next year.
For children with autism spectrum disorders (ASD) or severe developmental delays, ABA techniques have been shown to significantly improve long-term social, behavioral, emotional, and vocational functioning. The following link provides brief one page introductions for its use in addressing negative behaviors and teaching conceptual skills: http://www.stmarys.org/related-links. Further information about all empirically supported treatments for young children can be found at the following link: www.effectivechildtherapy.com. Although the criticism is valid that practitioners can be difficult to find, there are a significant number of resources available to parents through many outlets for those who become committed to finding non-medication methods to address early challenging behaviors. But we must invest in this pursuit with the same zealousness and commitment as we do in other ventures we consider worthwhile.
Coursing through all of this is the message that positive reinforcement is critical. But many times we find ourselves feeling that our children should just do what they are told, because well, they should. And sometimes this is the case. Too much praise and reward, used too lavishly and liberally, can create an expectation that they must always get something in return. As Forehand notes, any reward that is nonsocial (e.g., treat) should always be paired with a social reward, so that the treat can be pulled and the behavior will still continue. Likewise for the praise itself because sometimes everyone, even young kids, just have to do our part so one person doesn’t have to do it all.
But if we pan outward, there is a lifespan issue at play that most will not consider when their child is three. Assuming all goes well, this little boy will become a man someday and there is a good chance he will take on a role as a father and a significant other. The quality of his relationships with his significant other and his children will largely be associated with one thing: his degree of positivity. If he tends to have an argumentative demeanor early in life, there is a reasonable chance he may maintain a strong-willed disposition later on. That being the case, it suggests even more of a reason that we as parents of these kids must find ways to teach positivity from a young age. Sometimes it may feel like teaching a brick to be soft. But research on relationships suggests it is absolutely necessary.
John Gottman and his wife, Julie, have been studying relationships for almost four decades. Much of their research has included observing and coding couples’ interactions in the laboratory to see which factors are most likely to lead to the success or demise of a marriage. Over time, they found that they could predict divorce with a remarkable certainty simply based on the degree of positive moments versus negative moments they observed in a fifteen minute interaction. As quoted in the book Why Marriages Succeed or Fail, Gottman stated “Amazingly, we have found that it all comes down to a simple mathematical formula: no matter what style your marriage follows, you must have at least five times as many positive as negative moments together if your marriage is to be stable.” Those relationships on the demise generally average 1:1.
All of us also fall short of the ratio of positive to negative moments on certain days. But as I watch the shenanigans unfold, I have to remind myself that this little boy stands where I did years ago. It is easy to show love when love is shown. But it gets hard to be positive when those close to you leave a trail of destruction and debauchery. But as with every challenge, it presents opportunities – one of which is providing clarity for what is great, good, okay, bad, awful, and in between. With clarity comes growth, and the chance to seek out clear ways to unite and avoid clear ways to divide. And for us, it presents a chance to increase our capacity to love – not just the boy leaving a mess, but the spouse doing the same. In seeing others’ weaknesses and strengths more clearly, we become privy to our own. Then the process of growth can begin—accepting consequences for what we did wrong and asking others to do the same. Hope only exists when we can see the positive in life. Before we ask this of another, we must do the same. As Albert Einstein once said, “In the middle of every difficulty lies opportunity.” Maybe these struggles are chances to turn the tide in a more positive way.
Chirdkiatgumchai, V., Xiao, H., Fredstrom, B., Adams, R.; National Trends in Psychotropic Medication Use in Young Children: 1994–2009. Pediatrics. Online September 30, 2013. doi: 10.1542/peds.2013-1546
Harrison, J, Cluxton-Keller F, Gross D.; Antipsychotic Medication Prescribing Trends in Children and Adolescents. Journal of Pediatr Health Care. March 2012, 26(2):139-45. doi: 10.1016/j.pedhc.2011.10.009)
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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