Bad Therapy Review: Privilege

Gently raised in Park Slope

Typical home of average American child. Mikeruggy, CC BY-SA 4.0, via Wikimedia Commons.

[Previously: Fifties Dad Mental Health, Parenting, Surveys]

I.

One of the more telling passages in Bad Therapy, Abigail Shrier’s terrible book about the pediatric mental health system, is the following:

Van der Kolk’s expertise lies in PTSD and battle-worn soldiers who saw the grisliest combat. PTSD exists, and for its sufferers, it may make sense for a therapist to treat them with some of the methods van der Kolk promotes.

But does it make sense to regard all children—children born today, gently raised in Brentwood and Park Slope and Lincoln Park—as if they are likely to have suffered similar shocks?

Park Slope, Lincoln Park, and Brentwood are three of the wealthiest neighborhoods in the United States. Shrier’s argument is of course wrong: a Cadillac in the driveway has no power to protect against child abuse. But the offhanded comment is revealing.

The entire book is like this. Generalizations about the education system in general are made using the anecdotes of parents whose children attend “one of New York’s most prestigious prep schools” or “a posh school in California”. In one case, we draw on the experience of a woman whose job is “consult[ing] to private school parents.” Discovering the existence of this occupation single-handedly convinced me we need to raise the top marginal tax rate to 90%.

If she were asked, Shrier would surely agree that nearly all American children live in neighborhoods with a median household income of less than $150,000 a year. But it hasn’t occurred to her that the parents of these children might be reading her book. When she writes about what “American children” are going through, she means the experiences of a tiny, privileged minority—who are far from those worst affected by the dysfunctions of pediatric mental health system.

Shrier’s concern for only the most privileged children extends beyond wealth. She writes:

Perhaps children who have suffered what the original researchers called “ACEs” [adverse childhood experiences] need special care. Some of them may find it difficult to shake the torment that trails them to school. The question, for such kids, might not be whether they should receive mental health support but what kind.

That is far from the majority of kids, and it is dangerous to conflate those who have suffered years of sexual abuse or been intentionally starved or burnt by the parents who are supposed to love them with those who have faced “adversity.”

I realize that I’m citing an obscure source that is extremely difficult to find, such that it’s unreasonable to expect that Abigail Shrier could have looked at it before writing her Amazon and New York Times bestselling book. But if you look at the CDC’s “Fast Facts: Preventing Adverse Childhood Experiences”, the second Google result for the phrase “adverse childhood experiences”, you’ll discover that 64% of American adults experienced an adverse childhood experience before the age of 18.

Now, I’m not no big-city mathematician, but I think 64% is more than half?

To be sure, many people who technically experience an adverse childhood experience don’t have an especially bad time with it: maybe their parents amicably divorced, or they had a loving yet depressed father, or their mom spent a brief period of time in prison for a misdemeanor.¹ Many other people have horrible childhood experiences that don’t appear on the questionnaire, such as surviving a drive-by shooting or growing up in an ideologically abusive community or even watching their mother beat up their father instead of the other way around. The adverse childhood experiences questionnaire is a rough, first-pass attempt to estimate how common it is to have a shitty childhood—and the answer is “very common.”

But there isn’t anyone with a shitty childhood around Abigail Shrier—at least not anyone who has told her. So they probably don’t exist.

It’s true that it’s a bit silly to talk about trauma-informed education for nonabused children in Park Slope. But the vast majority of educators who take a trauma-informed approach are doing so because their students are abused, are raped, are raised by a mentally ill or addicted parent, have been in foster care, survive on food stamps, have a parent in prison, have drive-by shootings happen on their street, live in fear of deportation, or experience the manifold other ways that children in our society are hurt. In fact—in spite of what the New York Times would lead you to believe—many more children are in this position than live in Park Slope. Traumatic experiences being common doesn’t mean that everything that’s called trauma-informed educational practice is a good idea; often, educators’ ideas are misguided. But they’re trying to solve a problem that only seems made up if, on some level, you don’t think that abused children and children who don’t live in Park Slope really exist.

II.

Abigail Shrier writes about parents who sent their kid, Chloe, to Spence School, an expensive private school in Park Slope. Chloe made an edgy racial joke, in a way developmentally normal for teenagers. The school proceeded to not only discipline Chloe but also to call two different all-school assemblies to publicly accuse her of being racist. As a result, other students at the school isolate and bully Chloe.

The parents continued to send Chloe to Spence School.

Friends, Spence School costs $63,000 a year. The fuck are you sending your kid to a $63,000/year school where the administrators are bullying your child? There is no shortage of excellent schools in New York City, many of which are far less expensive. If an administrator called an all-school assembly to call my teenage child a racist, I would place two phone calls, and neither of them would be to Abigail Shrier: one to the school immediately pulling my child out, and one to my lawyer to find out if I can sue for emotional damages.

Abigail Shrier talks about this incident like it says something deep about American culture. It doesn’t. The only people batshit this way are the administrators of private schools with yearly tuition that are the same as the U.S. median household income, and the parents who send their children to same. The ultra-wealthy have long had a passionate desire to abuse their children in novel and innovative ways—just look at Victorian British boarding schools. But none of this has anything to do with the parenting, schooling, or mental-healthcare experiences of normal people.

III.

A word that never appears in Bad Therapy is “antipsychotic.”

It’s a striking omission. When I list off the reasons that the pediatric mental health care system needs to be burned down and the ashes salted so nothing can grow there again, the first item is inappropriate prescription of antipsychotics.

I know numerous people, often nonpsychotic, who were prescribed antipsychotics in adolescence. In every case, their lives were ruined for as long as they took the medication; often, the effects continued long into adulthood.² While of course adults are also given antipsychotics inappropriately or nonconsensually, generally this only happens to severely mentally ill people. In the pediatric mental health care system, inappropriate antipsychotic prescription occurs because someone is black or Hispanic, or poor, or disruptive in class, or just unlucky.

Also entirely absent from Bad Therapy: applied behavior analysis, the controversial treatment for autism. Children undergoing ABA sometimes attend therapy for as much as 40 hours a week. ABA often focuses on making autistic children look normal, as opposed to teaching them life skills. As discussed in the link, more than a third of ABA experts would consider using “sensory punishment”, such as “bad smells, foul-tasting substances or loud or harsh sounds”, on autistic children. Even purely reward-based therapy can feel like punishment to the child: for example, if the child is only ever permitted to engage in a special interest in brief periods as a reward for good behavior. All this for a therapy that has never shown to be effective in a well-conducted randomized controlled trial.

ABA is often the only therapy for autistic children that’s covered by insurance. Parents are left to choose between taking their child to a potentially abusive therapy, leaving a child whose autism is making them miserable without any support in developing coping mechanisms, and finding a clinician who’s willing to do a little light insurance fraud. But Abigail Shrier has nothing to say about ABA.

A third treatment that goes unmentioned in Bad Therapy: troubled teen camps. Troubled teen camps are actually particularly good for Abigail Shrier’s case. Maia Szalavitz writes in Help At Any Cost: How The Troubled-Teen Industry Cons Parents and Hurts Kids:

Research shows that there are effective methods for coping with ordinary teen rebellion, marijuana use, and drinking without residential care. For one, the evidence is clear that with no professional intervention at all beyond simple parental care, most kids simply grow out of these behaviors. Even among the worst “stoners” and “burnouts”, the majority become productive workers and family members by their mid-twenties. Those with less severe problems are even more likely to get better rapidly without invasive treatment.

However, parents feel like they have to do something—that their child’s misbehavior is in their control as a parent and they have to be able to fix it. And they trust the mental health care system more than they should, including when exploitative providers say that without a troubled-teen camp their child will wind up in prison or dead. So they pay an enormous amount of money for abusive treatment that traumatizes their children and sometimes costs them their lives.

This is the exact dynamic that Abigail Shrier is talking about—the pediatric mental health care system overtreats behaviors the child would grow out of on their own, which leads to iatrogenic harm. The people who send their children to troubled teen camps are even middle-class or rich! But Abigail Shrier never mentions troubled teen camps. Maybe she just doesn’t care about “bad” kids, addicts and petty criminals; maybe troubled teen camps would provide an inconvenient argument against tough love. I don’t know, I’m not her. But it nowhere appears in the book.

A race or class analysis only briefly surfaces in Bad Therapy.³ The oversight is glaring, because iatrogenic harms and psychiatric abuse very disproportionately affect poor children and children of color.

Consider oppositional defiant disorder. Abigail Shrier inexplicably seems to believe that oppositional defiant disorder is diagnosed in order to keep badly behaved children from experiencing the punishment they deserve. In reality, oppositional defiant disorder (and conduct disorder, a related condition) are diagnosed in a profoundly racist and classist way. Black and Hispanic children are disproportionately likely to get a diagnosis of oppositional defiant disorder, while white children are more likely to get other diagnoses, especially ADHD. In one study, more than 90% of adolescents diagnosed only with conduct disorder met criteria for PTSD, major depression, generalized anxiety disorder, or past history of mania or panic attacks.

How does this happen? A child is too frightened to talk to his teacher; if he’s rich and white, he’s diagnosed with social anxiety, but if he’s poor and black, he is seen as defying authority and is diagnosed with oppositional defiant disorder. A child can’t concentrate in class and keeps getting up and walking around; if he’s rich and white, he’s diagnosed with ADHD, but if he’s poor and black, he is seen as a chronic rulebreaker and is diagnosed with oppositional defiant disorder. A child is gifted and keeps misbehaving in class out of boredom and correcting the teacher; if he’s rich and white, he’s put into a more difficult class, but if he’s poor and black, he’s seen as angry and vindictive and diagnosed with oppositional defiant disorder.⁴

In part, overdiagnosis of oppositional defiant disorder occurs because teachers and clinicians interpret children’s behavior in a racist and classist way, such as seeing identical behavior as more aggressive if it comes from a black child. In part, overdiagnosis occurs because poor, black, and Hispanic children are more likely to attend terrible schools without the resources, teacher skill, or even willingness to provide a good education to neurodivergent, gifted, or traumatized children.

In part, overdiagnosis occurs because parents who are black, Hispanic, poor, or a combination can struggle to advocate for their children’s needs. They may work long hours and stress about finances and not have money, time or energy to advocate for their children. They might struggle with navigating bureaucracies that are designed for people who know how to codeswitch into white and middle-class social norms. They might have a sense of learned helplessness about bureaucracies giving them a reasonable outcome. They might be too poor to hire a lawyer or pay for a private school if the public school is absolutely failing to educate the child. And advocacy can backfire, especially if teachers and clinicians have racist or classist stereotypes about the parents or the parents don’t know how to communicate in a middle-class-acceptable way: the parents can be seen as “in denial” of their child’s oppositional defiant disorder, which leaves their child worse off.

Overdiagnosis of oppositional defiant disorder is a serious problem, because oppositional defiant disorder is a highly stigmatized condition. Many teachers and clinicians see children with oppositional defiant disorder as cruel, disobedient, bullies, or future criminals. Conduct disorder, in particular, is stigmatized because meeting criteria for conduct disorder in childhood is required for an adult diagnosis of antisocial personality disorder (sociopathy). An oppositional defiant disorder diagnosis can be a self-fulfilling prophecy, cementing in the minds of those around the child that he’s Just A Bad Kid—which means no one tries to meet the child’s legitimate needs or teach him skills.

It’s not an accident that Abigail Shrier is leaving out all the most serious harms of the pediatric mental health care system. As you might expect, the pediatric mental health care system disproportionately harms the worst-off children: poor children, traumatized children, intellectually and developmentally disabled children, children of color, children whose parents don’t know how to work the system, children whose needs and behavior are inconvenient to adults. And Abigail Shrier is uninterested in any of those groups.

Antipsychotic overprescription, applied behavioral analysis, troubled teen camps, and oppositional defiant disorder overdiagnosis don’t affect children who are really real. Parents making incomprehensible choices in expensive private schools do. Because the vast majority of children who are really real don’t have any adverse childhood experiences, and all really real children were gently raised in Park Slope. No one else reads books.

1. I love that word “intentionally” Abigail Shrier sneaks in there. If it isn’t your parents’ fault that you don’t have enough to eat, apparently it’s fine!

2. Rob Nostalgebraist writes eloquently about his experiences.

3. The only two times I noticed were Shrier (1) saying that cutting foster-care children slack is the soft bigotry of low expectations and (2) lamenting that concern about the school-to-prison pipeline was keeping schools from harshly disciplining children of color.

4. Giftedness is massively underrecognized in black and Hispanic children. Studies of universal screening for giftedness suggest that the education system misses as many as half of all black and Hispanic gifted children.