Letters

Read the story.

It's a shame that Dr. Lawrence Diller appears to have completely missed the point of my book, "The Explosive Child." In his recent article, "Defusing the Explosive Child," Dr. Diller writes, "prescribing drugs, not discipline, will only escalate conflict, lead to more difficult kids, and weaken our already-lax culture of parenting." Dr. Diller continues, "Less a strategy than a means of surrender, ["The Explosive Child"] is a 326-page letter of permission to follow the path of least resistance -- even if it frequently involves prescription drugs and constant cajoling."

While he gets an A+ for sensationalism, Dr. Diller gets an F for comprehension and accuracy. But sensationalism won't cut it on this topic: There are children and families at stake here. We lose a lot of children in this country because of unenlightened, oversimplified views of their difficulties. It's easy to advocate for "good discipline" (whatever that means) and to characterize as "lax" any approach that attempts to lend greater sophistication to the discussion. Understanding and fixing the problem is a lot harder.

One can't help but wonder whether Dr. Diller actually read the entirety of my book. Only one chapter in "The Explosive Child" is devoted to medications sometimes useful in the treatment of explosive/noncompliant children. In no way does the book suggest that medication is the treatment of first choice for such children. It does suggest that medication might be an effective form of treatment for some of the factors underlying explosive/noncompliant behavior and that, in some children, medication is an indispensable component of treatment.

More the pity that Dr. Diller can do no better than to characterize the strategies contained in "The Explosive Child" as "constant cajoling." In the book, I suggest that explosive/noncompliant behavior might be best conceived as a form of learning disability. In other words, explosive/noncompliant children lack important skills related to managing frustration and handling demands for flexibility and adaptability. The goal of intervention flowing from this conceptualization is to teach these skills. Not by cajoling, but by having adults engage the child in a process by which important problem solving and conflict resolution skills -- thinking of good solutions, anticipating problems before they arise, taking others' needs into account -- are taught. Such an approach still requires that adults be authority figures; but rather than use their authority to "teach the child who's boss," adults instead teach the child crucial thinking skills. Naturally, such teaching can only occur once a clear understanding of the factors fueling each child's difficulties has been achieved. Because he wasn't specific, it's not clear whether or how Dr. Diller's concept of "good discipline" would accomplish such teaching. Indeed, it's my experience that what most folks mean by "good discipline" actually exacerbates the difficulties of many of the children with whom I work.

Dr. Diller also writes that "The Explosive Child" "overpathologizes" difficult children. Perhaps difficult children are more complicated than Dr. Diller is aware. Our research at Massachusetts General Hospital shows that noncompliant children almost always meet criteria for at least one other psychiatric condition, including attention-deficit/hyperactivity disorder (ADHD), depression, bipolar disorder, anxiety disorders, nonverbal learning disability, language processing disorders, Tourette's disorder and Asperger's disorder. Our research at Mass. General also documents that the approach described in "The Explosive Child" is highly effective at reducing explosive outbursts, reducing adult-child conflict and, yes, improving a child's compliance. On many measures of treatment response, this form of intervention is significantly more effective than approaches to "good discipline" emphasizing rewards and punishments. Rather than encouraging a "lax culture of parenting," "The Explosive Child" aims to encourage a "sophisticated culture of parenting." Parenting a difficult child in the manner recommended in the book is very hard work. The parents with whom I work have done nothing approximating "surrender," nor have they "followed the path of least resistance." What they have done is aggressively pursue a better understanding of and relationship with their children in a society that instinctively and often erroneously judges them incompetent disciplinarians.

I invite Dr. Diller to come to our clinic, see our work, meet our children and families, and read our research. Pediatricians are often the first to hear parents' concerns about their children's behavior. If pediatricians like Dr. Diller continue to respond to such concerns with the lack of sophistication conveyed in his article, more children, parents and families will have been done an enormous disservice.

-- Ross W. Greene, Ph.D.
Associate professor of psychology
Harvard Medical School