On the heels of Perfect Madness, Judith Warner's widely discussed 2005 book about motherhood and parenting in the age of overwork, the author, reporter, and New York Times columnist began to formulate the germ of the idea for her next book. In it, she would explore the notion -- which was gaining increasing currency -- that childhood in 21st-century America was becoming heavily mediated by behavior-modifying drugs. Parents everywhere, it seemed, were using prescriptions like Adderall and Ritalin to boost teenage SAT scores or turn B students into A students, and to tame the natural, anarchic energy of boys and girls to fit into a carefully regulated, career-competitive vision of life.
But what Warner soon found was quite a different story – in many ways the opposite of what she had been sure she'd document. Her research included not only a survey of the most current research about children and mental health, but conversations with parents and psychiatrists trying desperately to help children and teens afflicted with serious cognitive and emotional problems. We’ve Got Issues documents her journey to the realization that, far from being a misguided "Ritalin Nation," we are on the verge of a potentially transformative new era of treatment and resolution for mental illness in kids – if we can only focus on that goal. In a conversation via email earlier this month, Judith Warner talked with us about her journey to a changed mind, her insights for our national discussion, and her soul-searching along the way. – Bill Tipper
The Barnes & Noble Review: We've Got Issues reads at times like a kind of mystery story -- you’re the investigator, trying to track down where these ideas about medicated kids come from. But there prove to be many layers: the popular myth of the doped-up child, the real issues that parents of mentally ill children are facing, the questions of psychiatric ethics and pharmaceutical money. At points you convey the sense of a difficult problem that has no center --was that your experience as you researched and wrote this book?
Judith Warner: This was a very difficult book to write. The image that always came to mind, as I grappled with it, was of quicksand. I kept trying to get a handle on the book – what it was really about, what I did and didn’t know, and each time I thought I had a new formula for moving forward, it would collapse under and around me. My certainties were so solid at the very beginning. I sold the idea of a book on “affluent parents and neurotic kids,”and the way forward seemed clear: : we lived in an anxious time; parents were pushy and competitive; children were undisciplined and badly-behaved generally, all that bad behavior was being called sickness. It made sense to me that children’s purported “issues” were just side-effects of living in our anxious, competitive times. It suited my way of thinking – habits of mind developed back in college that were only semi-conscious – to “read” children’s symptoms as signs of cultural malaise. It suited my prejudices (again, only semi-conscious) to basically discount the beliefs of modern psychiatry; to see biological psychiatry as anti-humanist, to feel that our culture was pushing to fit children into a box and that those who didn’t fit into it were being diagnosed as sick.
The problem came, first, when I began speaking to (or more precisely, listening to) parents of children with mental health issues. There was an objective reality to the difficulties they were witnessing and experiencing that didn’t at all fit with my idea of children’s-mental-illness-as-mirage. There is a “center,” as you put it, to the topic of children’s mental health issues: there is the experience of children and their parents. When you get at the reality of this experience – that children suffer, that their parents suffer along with them, and do everything in their power to help them (when they have the means and general wherewithal to do so), it changes everything about how you view the issue. The important questions then become: what are the best treatments available for children today? What is the state of the science? Are children getting the best possible care? And if not, why not? These became the central questions of the book once I put children -- real children, not symbolic representations of whatever social ill I was attacking -- at the center of my thinking.
BNR: In the chapter “Stuck in the Cuckoo’s Nest” -- one of the most thought-provoking sections of the book -- you quote Gerald R. Klerman on the prevalence of a “pharmacological Calvinism” that sees all drug therapies as inherently pernicious, crutches for a kind of mental laxity. Do you see the contemporary furor over pharmaceuticals and childhood as something having a theological dimension?
JW: That chapter --- as perhaps you sensed – is my favorite part of the book, as it looks at the intellectual underpinnings of contemporary American anti-psychiatry. Yes, I think that the debate over children and meds does have a theological dimension, if you define “religion” a bit abstractly, as I did in Perfect Madness, when talking about the “motherhood religion” that reigns in our time. I meant that, in America, we have a tendency to raise all kinds of opinions (about motherhood, about breast-feeding, about stroller choices … here, about kids and meds) to the level of religious doctrine. People’s beliefs become black-and-white and unshakeable, and there’s all kinds of moralizing that gets attached to them. Much of the talk about children and medication is really about criticizing today’s parents: children have problems because their parents have raised them badly; they end up on medication because their parents are drawn to “quick-fix” solutions. Once again, this has little to do about real parents and real children with mental health issues, and everything to do with how we view the general state of parenthood and childhood in our time. There is an investment in these beliefs about parenthood and childhood that is over-strong, not entirely rational. It expresses itself in the rabidity with which people talk about kids and psychotropic medication – and in the fact that people’s negative beliefs about children and medication often exist without any basis in truth.
In terms of Gerald Klerman’s quote on “pharmacological Calvinism;” he wrote this phrase in 1972, at a time when there was spreading concern about American drug use, both legal (tranquilizers) and illegal (marijuana, heroin, etc.) The notion that strong people tough it out, weak, self-indulgent people give in to seeking chemical salve for life’s blows, persists among many Americans today, however. You hear it all the time in criticisms of Americans’ antidepressant use: the idea that we’ve become a medicated nation, unable to bear any sort of adversity. Once again, this kind of moralizing shows little concern for reality – the lived reality of people who do suffer from depression – and a sort of blind adherence to dogma.
BNR: Near the close of Perfect Madness you argued that in the culture wars over modern motherhood, the focus by progressives on “elite” women’s achievements was a mistake in emphasis that harmfully re-defined the challenges facing women, in terms that only apply to the few. Is a parallel mistake in labels, or narratives, at stake in our cultural dialogue about children, drugs, and mental illness?
JW: Absolutely. There has been a great deal of coverage, over the past decade, of parents in wealthy communities who try to work the system to secure their kids every possible advantage. These parents push doctors to give their kids stimulants so that they’ll get As instead of Bs; try to get their kids diagnosed with learning disabilities so that the children can have extra time on the SAT (something the college board has made much harder to do in recent years); they try to get school districts to reimburse therapies like horseback riding or to pay private school tuitions that they are perfectly capable of paying on their own. They, essentially, try to use our tax dollars to give their kids a competitive edge, the story goes. Not only is that story untrue (in that it has been greatly exaggerated; the actions of the few generalized into the pathology of the many), it also hides a bigger, more important story: that most children in our country who really do have learning disabilities or other mental health issues get no care at all. Those who do get care more often than not receive woefully substandard care. This is true not only of poor children – who are greatly underdiagnosed with conditions like autism, which can respond so greatly to top-quality early intervention – but of middle class children whose parents have to contend with the limitations of their health insurance or the paucity of specialists available to them in a given geographical area. The real story about children’s mental health care in America isn’t that it’s excessive, but that it’s pretty bad. This is inexcusable, and fixable. But there can be no productive conversations about how to improve it while we’re all caught up in sterile debates about “drugging kids.”
BNR: If , as you say, most American kids with these problems have no opportunity to get treatment, to what extent does that make this about economics? And if it is so strongly influenced by household income, is that why we have such difficulty talking about it – because to do so would suggest an economic solution?
JW: There is a large degree to which it is about economics -- parents with means can access wonderful care for their kids. It's not entirely about economics, because parents with means often get caught up in treatments that are not helpful -- all kinds of alternative treatments that they can afford but that can be largely a waste of time ("I think they’re maybe titrating their own anxiety," Eileen Costello, a prominent Boston-area pediatrician with a specialty in autism spectrum disorders told me of those parents recently). Still -- the differences in care, and thus in opportunities for life improvement that I saw between well-off parents and simply middle class parents in my research was striking. And that's not even taking into account the poor -- who, of course, get the worst care of all. It's as much about economics as it is about education level. You probably saw the recent headlines for the study that showed that the biggest environmental factor linked to higher autism rates was the education level of parents. (It wasn't that highly educated parents were at risk for having autistic kids; it's that these parents have the savvy to get their kids quickly diagnosed and into treatment.)
We do talk about the economics of this in some ways. There's the "the-rich-are-trying-to-rip-you-off" narrative (about how people with means are trying to use public money to pay for their kids' care and to give their kids a competitive edge), and then there are the stories about how children on Medicaid are being overmedicated -- given atypical antipsychotics, in particular, at a rate that far outpaces that of better-off children. These stories are true, and of very serious importance, but they tend to stop with expressions of outrage about the medications, and without raising the issue of why a population of kids that's particularly vulnerable to having mental health issues isn't getting more comprehensive, better quality care.
At base, that's about economics: it would cost a fortune to give these kids the kind of care that wealthy kids can get. But the fact that journalists don't take the story to that point isn't about money. I think it's just that the drug-stuffed-child narrative dominates their thinking, and their skepticism about the reality of children's mental disorders is so great.
BNR: Early in the book you note that you employ the phrase “Ritalin Wars” as a shorthand for the furor over these issues. That phrase stands out as a potential marker for the way in which pharmaceuticals of all stripes take such prominence in our collective mind these days. One of the central arguments of the book is perhaps its subtlest: our obsession with drugs – their apparent ubiquity, their potential for seemingly miraculous effects twinned with a potential to do harm – overwhelms what would be a more productive concern with mental illness. Can we separate our conversations about kids and mental illness from our conversations about pharmaceuticals? Should we?
JW: Yes. We have collapsed the two. We have allowed the drug companies to create our understanding of what mental illness is via their advertising and marketing schemes. And then we rail against overdiagnosis and the banalization of disorders – as though the reality created in pharmaceutical ads on TV or in magazines were the reality of what goes on between a doctor and patient in the consulting room. This is a very naïve way of thinking about mental illness. It would be as if we drew serious conclusions about family life -- the reality as opposed to the representation of family life -- from looking at the way families interact or are portrayed in print ads or commercials. Everyone is smart enough not to do that. But we lose some ability for critical thinking when it comes to the subject of kids and medication.
BNR: You cite a statistic that leaps off the page with some prominence – “At least 25 percent of American adults in any given year suffer to some degree from a mental disorder.” The commonality of our experience with mental illness is a key point – but it seems likely that for many, if not most Americans, that figure would seem provocative. Are our issues, perhaps, with the acceptance idea of mental illness as a widespread health problem?
JW: You are right to bring this up. That figure really only has meaning if you look at the two sentences in the book that follow it: “About half of those people are severely affected enough to need treatment. Six percent are so impaired that they attempt suicide or have substantial limitations to their daily functioning.” The really big figures that are often used, particularly by mental health advocates, to make the case that mental illness is an extremely widespread problem do turn people off intellectually and make them cynical about the debate. It’s important to have a sense of the intensity of symptoms some people suffer from. If six percent are suicidal or otherwise stuck in their lives because of mental illness, that’s not such an eye-catching number, but it’s still a lot of people, and a lot of broken lives.
I look similarly in the book at the numbers that are cited to talk about how prevalent mental health issues are in children and make a similar argument – that when you see big numbers – numbers saying that 25 or even 30 percent of kids have “issues” – you really have to take a hard look to see what those numbers represent. A much lower percentage of kids – more like five percent – are very seriously impaired. It’s important to be aware of this, because the idea that there’s an “epidemic” of mental health issues in kids today, which is very widespread, and is bolstered by things like those 25 or 30 percent numbers, is very unhelpful. There’s no epidemic. But that doesn’t mean that there aren’t serious questions to discuss about the kids who desperately need help and aren’t getting it.
BNR: You’ve reflected at length in the opening chapters of this book about how your column in the New York Times took part in the public conversation about these issues – and what you experienced when you published your “Second Thoughts” there. Has the experience changed your view of how reporting and commenting on these cultural battlegrounds should be carried out? Or do we even presume too much by deciding to frame them as such?
JW: The media coverage of children’s mental health issues varies enormously. Overall, journalists belong to the culture they write about. They share its prejudices -- until something happens to open their eyes and make them see differently. Even then, it’s hard to shake institutional prejudices -- I have seen newspaper articles on the issue of children and medication headlined in ways that support the received wisdom, while the stories themselves are written with insight and sensitivity. It’s the headlines that stick in people’s minds, however. When people come to a topic with very strong preconceptions, it’s very hard to change their views, no matter what facts you present.
I rarely had the sense, reading the responses to the columns I wrote on this issue, that I was changing any minds. People were either happy to see their experiences validated or angry when I challenged their beliefs. That hasn’t, however, been my experience in talking to people face to face. I’ve had the sense that when I share with people my own personal journey on this issue: how I began thinking the way most people think, how talking to parents and to doctors, reading the research, and exploring the roots of my beliefs changed my point of view, they listen and are receptive. If their minds don’t change on the spot, I still can see that they are willing to at least question their views. The key, I think, is in making people see that children with mental health issues aren’t exactly like children without them: their problems with focus or mood or making friends or learning aren’t the typical hiccups of difficulty that all children experience growing up or in school. It’s very hard for people to understand something that’s outside of their realm of experience; this was certainly true of me in the past. What I hope is that this book will make the experiences of parents of children with mental health issues real for the wider community of parents. I hope that this will increase empathy and understanding and, ideally, help us start a more productive conversation about how to better serve these vulnerable parents – and their children – in the future.
BNR: Is the confrontation with suffering itself – the experience of pain both physical and psychological –the ultimate missing factor in these ongoing cultural battles? Is it accurate to say that this is as much a problem of our commitment to empathize with one another as it is any public policy prescription?
JW: Absolutely. I am constantly amazed by the way depression, in particular, is written about. Much of the concern with overdiagnosis seems to rest on the idea that depression is, in some way, good for you, that to take depression away, particularly with medication, is to make a person less human. To be of this opinion you really have to have never suffered from depression or to have never loved someone who did. There is no nobility, no higher, sacred form of humanness to be found in mental illness.
BNR: What are you planning on working on next? Do you have another book-sized project in mind?
JW: I am currently shifting gears after the end of “Domestic Disturbances” in December. I do have another book project in mind, one that will build on some of the wonderful conversations I had with readers on nytimes.com. I don’t want to jinx it by saying too much now.
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