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By Dennis Miller, BHC Senior Writer

“Boys will be boys,” the old saying goes, but have we forgotten today that tumultuous, moody, energetic and occasionally contrary behavior is natural for boys? Are we at risk of turning boyhood itself into a pathological disorder? Author and psychologist Anthony Rao, Ph.D., thinks that in many ways we are. In his new book, The Way With Boys: Raising Healthy Boys In a Challenging and Complex World, Dr. Rao explores what it means to be a boy. He delves into the unique behavioral and developmental characteristics of boyhood, and explains how, in his view, the behavioral health profession, parents and schools may have become too quick to diagnose and medicate for behavior that, while certainly disorderly at times, is not a disorder.

“Boys are diagnosed two, three, sometimes four times more frequently than girls with ADHD, and it has become one of the most common pediatric problems in the United States,” Dr. Rao says. “Those diagnoses have quadrupled over a recent ten-year period, from 1987. Along with that, we’re seeing in more and more boys diagnoses of bipolar disorder, which has increased 4,000 percent in all youth in the United States from 1994 onward. And we’re also looking at more serious medications such as anti-psychotics — a 600-percent increase since 1993.”

Boys are From Mars, Girls Are From Venus

The trend alarms Dr. Rao, who feels that we may be guilty of expecting a standard of behavior from boys that is simply not possible due to the unique nature of their development. “If we look from the very beginning of their lives, there are three really big things that they don’t do as well as girls, and I think it gets them in trouble with early education,” Dr. Rao explains. “One of them is they don’t make as much eye contact. We look at eyes in order to read facial cues, so right there is a problem that later on is going to become very important when they’re asked to sit and look up and pay attention when they get to preschool or kindergarten or first grade. They also don’t hear as well. Girls have better hearing acuity in a range that’s particularly important for speech discrimination. So by the time boys and girls are around 18 months, girls have about twice the vocabulary that boys do. [And] motor activity — boys are just more motorically active. They move more and they explore more. They’re hands-on. So their learning is really quite different.”

While in the past this was considered normal and expected behavior from boys, today, with our earlier emphasis on teaching reading and writing, combined with the educational system’s increasing reliance on standardized testing, boys are being asked to perfect abilities that many simply aren’t capable of at that age — at least not with the same level of proficiency as girls. “When these little guys hit, say, preschool, kindergarten and first grade, they’re already about a year behind in some of their speech and language compared to girls,” he explains. “They’re more visual and spatially oriented. That’s what they are better at. But they’re being asked to sit longer and longer hours and they’re beginning to be tested more and more for early preparation around reading and writing, which is something pretty new in the last few years.”

Quick Results But Longterm Effects

Dr. Rao emphasizes that he is not against medication when warranted, but fears that our healthcare system, with its emphasis on quick results, may have pushed the pendulum too far in that direction, when more traditional behavioral therapies may offer a better chance at resolving issues with fewer long-term side effects or internalized stigmatization. “A pill suggests to a kid that there’s something wrong with your brain. That you have a disorder and this is something that corrects it,” he says. “That message is difficult for a kid who’s growing up and needs to gain confidence to be able to do things on his own later on.”

Additionally, Dr. Rao is concerned that within that message is a suggestion to impressionable young minds that when things get tough in life, drugs are the answer. He feels that’s a dangerous notion at a time when drug abuse is rampant in our society. “There’s something a lot of people don’t know, and that’s that psychostimulants work on everyone. You don’t have to have ADHD or to have a diagnosis in order to see improvement if you were to take the same medication. It works on everybody,” he says. “We now have a longer term consequence of pumping a lot of this medication into the population of the United States. A lot of kids in college, a lot of kids even in high school, are selling these pills to each other or using them recreationally. And they’re very, very dangerous! Grinding up, say, Ritalin or, say, one of these psychostimulants and snorting it is chemically equivalent to cocaine. And it’s something that the DEA now is actually looking at and is very, very worried about.”

In his own practice, Dr. Rao believes in making cognitive behavioral therapy (CBT) his first-line treatment modality in most cases, turning to medication only when necessary to help the therapy along or for patients who are not amenable to CBT. When children are very young, he directs his therapy mostly to parents. “I use behavioral techniques with parents of children who are seven, eight and younger, but those are very simple techniques of, ‘Hey, let’s look at your parenting strategies. Let’s look at how you reward, how you discipline, how consistent you are throughout the day. How do you handle transitions? How do you understand the development of your child?’

For older children, Dr. Rao finds that CBT techniques are often effective at creating long-lasting change without drugs. “If we look at kids that are older — maybe ten, eleven, twelve and up — we’re able to do more one-on-one, more of what is called cognitive therapy. Which is, ‘Let’s look at how you see the world, how you see yourself.’ The ability to stop and say, ‘Hmm, maybe I’m not making the best choices for myself,’ or, “I tend to distort how I see things this way and that makes me feel depressed or less likely to engage socially with my peers.’ So, in the office, we’ll do some activities around that and we’ll even practice with kids, for example, who have anxiety or phobias, on how to address those fears directly. We find that when people expose themselves to the things they’re afraid of, in safe, stepped and very careful ways, they end up proving to their own brain that there’s nothing to be afraid of.”

Diagnosing for Dollars

If we truly do have a problem with over-diagnosing, over-medicating, and essentially over-pathologizing natural childhood behavior, particularly for boys, Dr. Rao feels the nature of our contemporary healthcare system, with managed care’s emphasis on quick results, may have a lot to do with it. In particular, he cites the very nature of our healthcare reimbursement system, where in order to be considered for payment, claims have to include a diagnosis code. “We all know that we need to give a diagnosis every time. Otherwise, there’s no reimbursement,” he says of behavioral healthcare professionals. “So we’re forced into categories. But if every kid who goes for help, even if to rule something out, ends up with a psychiatric diagnosis, to me that’s not good. That’s more about bureaucracy, not the accuracy of trying to figure out what’s best for that kid or that parent or that school.”

To listen to this fascinating conversation with Dr. Rao and learn more about why he feels we may be over-pathologizing and over-medicating boys today and what the behavioral healthcare profession can do about it, click on the audio icon above. Or, keep reading for a complete, edited transcript.

BHC: Tell us a bit about the book and why you wrote it.

AR: I have, for many, many years, seen what has been an increase in the number of boys — and younger and younger boys — coming to my clinic and also into some of the clinics and hospitals where I’ve trained and supervised, in larger numbers, already diagnosed and medicated. [I became] curious about those trends, realizing that there were alternatives to diagnosing first, and curious as to why this kind of phenomenon was happening.

So really the basis of the book is looking at: What has changed in the United States? What are the trends that in particular saddle very young boys in larger and larger numbers with psychiatric diagnoses, when it occurs to me that a lot of times it may just be development. And how boys are different developmentally is really important for the population to know. Parents need to understand that boys — young boys — develop quite differently than girls, look very different than girls and often they can get caught into some of these diagnoses.

BHC: You’ve described what you call a “crisis in American boyhood.” Can you expand on that a bit?

AR: Absolutely. One of the shocking statistics among many is [that of] the number-one group of children being expelled from schools in the United States. One would think that might be high school kids and probably boys because they tend to act out more. It turns out that the largest group of children who are expelled from school are preschoolers — and four and a half more times likely, they’re going to be boys.

That’s one trend that’s really shocking on the home front of education, but in our medical communities, what we’re also seeing is that pediatricians are also very busy with questions around ADHD. Boys are diagnosed two, three, sometimes four-times more frequently than girls with ADHD, and it has become one of the most common pediatric problems in the United States.

Those diagnoses have quadrupled over a recent ten-year period, from 1987. Along with that, we’re seeing in more and more boys diagnoses of bipolar disorder, which have increased 4,000 percent in all youth in the United States from 1994 onward. And we’re also looking at more serious medications such as anti-psychotics — a 600-percent increase since 1993. [These are] medications and certain types of diagnoses that we might not have ever considered, at least when I first started about 20-24 years ago.

BHC: What makes boys different from girls in their behavior and development as they grow?

AR: We have to look first at infancy, and in the book, I talk about how boys are different from day one — not just infancy, but also toddlerhood. But if we look from the very beginning of their lives, there are three really big things that they don’t do as well as girls and I think it gets them in trouble with early education.

One of them is they don’t make as much eye contact. They just don’t look at their Moms from day one as much. We look at eyes in order to read facial cues, so right there is a problem that later on is going to become very important when they’re asked to sit and look up and attend when they get to preschool or kindergarten or first grade.

They also don’t hear as well. Girls have better hearing acuity in a range that’s particularly important for speech discrimination. So by the time boys and girls are around 18 months, girls have about twice the vocabulary that boys do. So their hearing, and some of their attention therefore, is also not as sharp as girls.

Motor activity — boys are just more motorically active. They move more and they explore more; they’re hands-on. So their learning is really quite different.

Now, fast forward to what it’s like for these little guys when they hit, say, preschool, kindergarten, first grade. They’re already about a year behind in some of their speech and language compared to girls. They’re more visual and spatially oriented — that’s what they are better at. But they’re being asked to sit longer and longer hours and they’re beginning to be tested more and more for early preparation around reading and writing, which is something pretty new in the last few years. We never usually before, say, first grade or certainly kindergarten cared too much about reading, writing and all that more academic-type material that we would expect certainly starting in first grade up, but we’re pushing more and more.

Also, boys as a group aren’t as good with social and cooperative skills. Girls tend to do better with that and if you put boys in a more crowded or busy kind of classroom, their response to that type of stress is going to be more assertive and aggressive. Girls however are going to be able to utilize more of their social and cooperative skills and run under the radar, if you will, of getting tagged as having a behavioral or emotional issue that occurs in those environments where they’re stressed.

BHC: Let’s talk about parents a bit. Why do you think it is that parents — if this is true — are so quick to accept a diagnosis of a pathological disorder instead of just accepting that much of what they may perceive as unruly behavior is simply what makes boys boys?

AR: The majority of parents that I know and have worked with over all these years don’t want to see it that way. But you have to remember that they’re relying on us the professionals and that includes teachers as well as mental health professionals. And all of us have gotten the message for the last 20 to 25 years that disorders such as ADHD and bipolar are real disorders that we can see in children at younger and younger ages. And if we can do something earlier, we can stop the progression of these disorders.

With that kind of thinking, it only makes sense that you’d want, as a parent who loves their child, to do as much as you possibly could to be able to arrest and stop the progression of something that could be really serious and interfere with their ability to function and do well in school.

So, in a lot of ways we’ve had, I believe, somewhat the wrong message. The latest research is showing that, at least for ADHD, this is more of a difference in a trait, if you will, versus a disorder, where the brains of particularly these boys — again, because it’s about two to three times more likely to be in boys than girls to be diagnosed — that what we’re seeing is that their brains are just like the brains of other kids. That they’re not fundamentally different. You can’t use a brain scan and say, “This kid has this disorder or not.”

Now remember, there’s no objective test for any of these disorders. We don’t have blood tests; we don’t have MRIs; we don’t have CAT scans; we don’t have x-rays. So it’s based upon people reporting behavior. Now, teachers are on to this and they are aware of the criteria over these last couple of decades and teachers are on the front line of seeing kids under more stressful circumstances — boys in particular, who aren’t a good fit for the early years — and they’re more likely to report these to parents who then bring it to pediatricians or other professionals who can prescribe.

And don’t forget, there’s another piece here we need to talk about, which is that because we have very, very rushed medical appointments due to managed care, parents are lucky to get — what? — 15 or 20 minutes in front of their pediatrician. So, judgments are made fast. Not a lot of data is collected.

In the book, I talk at length about how a parent can really tease apart in very, very simple ways what is a symptom, what isn’t, what are the things to worry about, and what is just good old plain development.

So, as I’ve been talking and lecturing around the nation, I am finding more and more groups of parents really stepping up and wanting to hear the message, because it fits with their experience of their sons. It’s not something that they haven’t been thinking about, but they’ve been following our lead, the professionals, and we’re doing the best job that we can. This is very, very difficult to try to diagnose these types of disorders, and I think we’re getting better at it, but we still rely on a lot of very vague and general criteria that I think increases the error rate.

BHC: How frequently do you estimate disorders are being diagnosed inaccurately?

AR: Well, there’s some good research on this as regards general medical diagnosing. So, imagine a scenario where you’re seeing your physician or specialist. They’re very well trained and you’re curious about something that is more of a real medical issue. Maybe a blood test is run, maybe a PET scan, MRI, CAT scan — something like that. In scenarios where all that is done and it seems to be done correctly, we’re looking at one in five medical diagnoses being incorrect. That’s 20 percent. That’s a lot.

In the book, I talk about, “If that were true, what would it be like for psychiatric diagnosing, let alone in children?” Well, we’ve got a study that shows about 25 percent of people given a diagnosis of major depression —a quarter of those people — it turns out just have natural normal grieving. Again, it’s very hard in psychiatry to be able to diagnose, because it’s either through self-report or it’s all based upon the reports of behaviors or emotions — again, no objective testing.

Now, think about children. Children don’t report their own symptoms — young ones certainly don’t. We usually get the information secondhand. I call that ‘by proxy’ — we’re getting it from a teacher, we’re getting it from a parent. Again, more likely that error gets entered into diagnosing. And in the book I’m proposing about as much as 30 percent (maybe even higher) of some of these diagnoses (because remember they all have very general criteria) could be wrong in kids, particularly very young kids, and particularly boys, whose development tends to be a little bit erratic, not in nice steps and stages when they’re younger.

BHC: What are some of the long-term risks you think in being a little too quick to diagnose and medicate, both for the boys themselves and the adults they will one day grow into? And then, on the larger scale, for our society as a whole?

AR: In my practice, I am seeing a number of boys, who even though, I believe, they’re at a point where even if they had a reliable ADHD diagnosis and had used medication — in addition to some other good behavioral therapy, other help at school — they get to an age (usually in their very early teens) where they don’t want to try — without either using medication — that is stay in school. They don’t want to go off the medication when the medication may not be necessary any more in some of those cases. Or they believe they have a lifelong disorder or disability that impedes their ability to do tasks like be able to prepare for tests or do papers.

There’s a lot of sort of excusing oneself ahead of time and not having the confidence to try. I think that is an unintended consequence of, early on, trying to help a kid, but not knowing when the right time is to begin to fade out with medications. Remember, a pill suggests to a kid that there’s something wrong with your brain. That you have a disorder and this is something that corrects it. That message is difficult for a kid who’s growing up and needs to gain confidence to be able to do things on his own later on. So, I come across that quite a bit.

So, I educate parents and kids and say, “Look, chances are your brain is now more mature and it’s probably functioning like every other kid.” I’ve seen studies that show that 90 percent of these kids who are diagnosed with ADHD don’t carry a lot of the symptoms into their adulthood, so we don’t need to think that this is a lifelong progressive issue in all cases. So I see it at that level.

The more immediate concern that I have is the effects of medication, particularly the stimulant medication. When it’s used as a first-and-only approach, there are side effects. There are lots of things that can really be difficult on a kid, and in about a quarter of these cases where kids are experiencing side effects, about a quarter of those parents don’t really listen that well to the complaints of their kids. That’s what one study shows. They believe in the medicine. It does the trick and they just want to move forward.

And, unfortunately, there’s something a lot of people don’t know. It’s that psychostimulants work on everyone. You don’t have to have ADHD or to have a diagnosis in order to see improvement if you were to take the same medication. It works on everybody. In part, we now have a longer term consequence of pumping a lot of this medication into the population of the United States. A lot of kids in college, a lot of kids even in high school, are selling these pills to each other or using them recreationally. And they’re very, very dangerous! Grinding up, say, Ritalin or, say, one of these psychostimulants and snorting it is chemically equivalent to cocaine. And it’s something that the DEA now is actually looking at and is very, very worried about.

BHC: Are we a bit too hung up as a society on this idea of normalcy? Or do we perhaps have a misguided definition of what that means?

AR: It’s a great question. I think that we struggle with what’s normal and we also struggle with trying to be fair and equal to everybody. And I think those two things get us into problems, particularly when we are assessing how children are doing when they are very, very young.

It seems to me — and this is just my view of the world working with these kids over so many years — that a lot of schools, and even a lot of parents; a lot of our society is looking for more of a one-size-fits-all program or plan to bring a child from, say, the early grades on up, narrowing what are the skill sets that we think kids have to have at certain ages in a very factory-like way. And in doing that, we’re ignoring all the really amazing diversity, the incredible broad range of expression in children that we see.

Boys don’t come into the world in one way. Some are very hunter/warrior-like, more active, hands-on, take risks. Some are quieter — they stay to the side. They watch. They’re thinkers. They might be more interested in mechanical objects. They may be interested in maps. They may be interested in exploring but not, again, in a very sort of rush-out-there kind of way.

So we see boys in all different ways, and yet, most education is working at standardizing things to tests, creating programs, and I think that’s a very, very, very bad thing, particularly for boys, again, who developmentally don’t fit into those early years of education.

BHC: Well, you touched on the topic of this next question before a little bit and that is how much has managed care and the drive to see quick results, as well as the requirements that clinicians have to report a diagnosis before they’ll be paid for treatment — how much has all that been behind you think this trend towards over-diagnosing and over-medicating?

AR: It has a lot to do with it. It’s definitely a contributing factor. When I do talks in front of medical professionals — other psychologists, psychiatrists, pediatricians, whoever I speak with — one of the questions I will ask is, “In your clinics, in your medical practice, how many people come in and don’t get a medical diagnosis?” Particularly in psychiatry one could ask a question, “How many people in, say, your bipolar clinic or your ADHD clinic, don’t get a psychiatric diagnosis?” And they look at each other — there’s some mumblings, there’s often laughter and some head nods. We all know that we need to give a diagnosis every time. Otherwise, there’s no reimbursement.

So we’re forced into categories. And again, if we treat it that way and we say, “Fine, this is how we use these categories. They’re just to get reimbursed. We’re going to rule out these things as well as rule them in,” that would be fine. But if every kid who goes for help — even if to rule something out — ends up with a psychiatric diagnosis, to me that’s not good. And again, that’s more about bureaucracy, and that’s not about the accuracy of trying to figure out what’s best for that kid or that parent or that school.

BHC: In terms of the treatment limits that have been in place for behavioral healthcare, do you think that parity might begin to perhaps tip the scales back in the other direction? That when a clinician isn’t limited to just 10 or 15 or 20 visits, they’ll feel freer to employ therapy that might take a little longer and see how that works before turning to meds?

AR: Absolutely. Because we know the long-term research all shows that behavioral therapy, cognitive therapy, some other therapies, work as effectively as medications. They work a little bit more in the long run, but they do tend to keep skills in place and people do better in the longer term. In the short run, the medication seems to work very well, but people have a hard time tolerating being on medicine for the long haul. They tend to just drop out. It would make more sense if we could allow a range that’s broader to allow people to have more connection with their mental health providers or their physicians, that they would be able to have other therapies that involved skills, goals being set, and those are tools those people can take and move forward.

I’m not against using pills at all. I think when they are warranted they can be a lifesaver. I think, though, they shouldn’t be a first-and-only approach, which is what’s happened mainly under managed care systems.

BHC: Are pharmaceutical companies and the drive to develop and market profitable products to blame here as well, in their drive to create a need for their product?

AR: They have to take some responsibility, because these are very well funded, very powerful organizations that are for-profit. I think that’s all up and above board. They’re clear about that. They certainly want to sell more of their product. They certainly believe that what they are doing is the right thing. But one can’t help but dismiss — when we’re looking at figures like $2.3 billion a year being spent by pharmaceutical companies to advertise to all of us to go back to our doctors and tell them about medicines that we’ve seen on television or in magazines or on the radio. When that has happened, research shows those physicians are about two to three times more likely to prescribe that medication than they would have, had the patient not even mentioned it.

So in other words, they know that if they can (it’s called drilling down) get us to maybe think that there’s maybe something of a symptom and if they can get us to bring a particular drug or drug classification to our appointment, we’re more than likely to end up being given a prescription. So they definitely are involved that way.

They also, in my opinion, overfund the research. Most of the research on the effectiveness of these medications are funded by drug companies. They’re terrific researchers at great institutions who have to apply for these grants and be able to conduct this research. But again, it’s a little bit disingenuous to believe that there’s no way that all this money or speaking engagement fees or money given to universities and medical schools wouldn’t in some way influence the outcome of either the research or how it’s presented.

So, there’s a lot of money and there’s a lot of feel of lobbying in this so it’s hard to say that there’s no influence whatsoever. I think it’s a pretty big influence.

BHC: Dr. Rao, some have argued that insisting on trying some form of conventional talking therapy first may be taking the long route to solve a problem that medications, perhaps in combination with therapy, may be able to resolve far more quickly. How do you respond to that argument?

AR: I like to think of the more individualized approach. There are people that don’t fit into the kind of therapy I would like to provide, which would be more of a short-term, behavioral or cognitive, goal-oriented therapy. First session: Let’s do our evaluation. Let’s talk about what you need changed. I need an active participant in this. I need you to do some homework for me, come back, let’s see if it changed.

There are people who don’t do well in that. They do need to talk about things in a longer time kind of model, in a more in-depth kind of model. Those people do better in a longer term, more dynamic or psychodynamic kind of therapy. There are some people who’d do better in a couples therapy. Some would do better in family therapy, where all the members of the family that’s having issues are all participating in the process.

Other people want a very, very quick fix, and don’t buy into any of the talking. And for those reasons, just want a pill only. So, in a lot of ways it’s sort of matching it to the right person. That, however, doesn’t excuse the fact that the vast majority of children and adolescents who have problems with depression or anxiety or attentional issues or learning issues, developmental problems — whatever — do tend to get medicated or diagnosed with psychiatric diagnoses first and then medicated first.

And I’ve seen studies that show almost up to a third or a half of, say, adolescents with anxiety or depression aren’t getting offered other supportive therapies. They are getting a few visits that are shortened down to maybe 15, 20 or 30 minutes with a psychiatrist. Maybe they’re doing talking therapy during that, but that’s not really what I would consider a good, longer term, more full-range experience of therapy.

BHC: What would be on your action list of things that we need to do as society and as a profession to begin to reverse this trend of over-pathologizing and over-medicating for what may simply be normal human behavior?

AR: The first step is getting to preschool teachers, getting to school systems and getting to young parents. That’s who I’m targeting in a lot of my talks. I was just at a maternity talk the other night, and the moms are incredibly excited to get this information. They know they’re having a boy or they just had a boy and they know that this is going to be a very different experience than they’d have if they had a little girl. And they want this information and they want it early. Kindergarten teachers, preschool teachers, first grade teachers — we’ve got to get the information out that the development of boys, when they’re young, is different than girls. And that that matters in our fast-paced kind of hectic society.

There’s another thing we need to do which is, we need all of us to be outdoors more. We’re a sedentary society. I mean, all of us — look at the obesity rates to realize that. We have a lot of bad habits, and what we find is, if we can get outdoors and be more active and physical, we do better psychologically. Emotionally, we’re going to feel healthier. We’re going to be more motivated. We’re going to be able to push to the side the anxiety and depression that sometimes we all have to deal with if we are more active and engaged, particularly in going outdoors. We find that young boys, in particular, when they go outdoors and they get good physical activity, when they come in, a lot of their ADHD symptoms can disappear for a few hours.

So, there’s a lot that we can do in schools, a lot that we can do in educating young moms and people who are educating young children.

BHC: Tell us a little bit about your practice and the techniques and therapies you use to help foster positive growth and development without using drugs unnecessarily.

AR: I hinted at that a little bit earlier and it’s really one where I want an active participant. Now, that might be a parent who’s bringing a child in who’s say three, four, or five years old. Certainly I’m not going to sit and talk a lot with that child. Let me do a little bit of play work to engage them, find out a little bit of how their development looks, and do a brief assessment in the office, but for the most part, I use behavioral techniques with parents of children who are seven, eight and younger — sometimes even older — but those are very simple techniques of, “Hey, let’s look at your parenting strategies. Let’s look at how you reward, how you discipline, how consistent you are throughout the day. How do you handle transitions? How do you understand the development of your child?”

So there’s a lot of education, a lot of coaching them through and modeling in the office on how to improve their interactions with their child and decrease the behaviors that they find difficult or a problem, as well as being aware that the environment and how we relate to children has a lot to do with the behaviors that we see and accidentally then label as a disorder.

Now, if we look at kids that are older — maybe ten, eleven, twelve and up — we’re maybe able to do more one-on-one, more of what is called cognitive therapy. Which is, “Let’s look at how you see the world, how you see yourself.” The ability to stop and say, “Hmm, maybe I’m not making the best choices for myself,” or, “I tend to distort how I see things this way and that makes me feel depressed or less likely to engage socially with my peers.”

So, in the office, we’ll do some activities around that and we’ll even practice with kids, for example, who have anxiety or phobias, how to address those fears directly. We find that when people expose themselves to the things they’re afraid of, in safe, stepped and very careful ways, they end up proving to their own brain that there’s nothing to be afraid of.

With people who are depressed, who are distorting how bad things are, we find that if we can slowly get them to see how things aren’t as bad as they might believe they are, or were once, they in fact begin to feel less depressed. As we work on sleep issues, we work on all sorts of behavioral and developmental issues, again in a very short-term model.

BHC: Can you mention maybe a case study, if you will, or an example from your practice, of a young patient who was dealing with a certain issue that perhaps in the hands of someone else might have resulted in taking medication, but that you were able to solve through talking therapy?

AR: When I was working at one of the major hospitals in Boston, we would get a fair number of kids who had been say attacked by a dog. And maybe they had come in through the emergency room or a physician would refer them in. And after a bad dog bite, often the kids — particularly if they were younger — were afraid to go outside or began to develop a phobia of open places.

One girl that I worked with, for example, had been bitten when she was about seven or eight, and it was pretty serious. It was on her leg, and it was well taken care of medically — a few stitches, she was okay. But slowly, she became very reticent to be able to go outside. She wanted first her mom or dad to accompany her even just into the backyard. She didn’t want to go off to first grade. I mean, things that just popped up a little bit out of the blue. Again, a very common reaction for many children who’ve had a traumatic experience like that. In most cases, it goes away on it’s own. In this case the girl developed a real phobia — first of dogs, then of open places (particularly parks where those dogs might be).

So, instead of using medication, which is what the first-line treatment would have been — something to quiet her system down and make her feel more relaxed — rather than that, I did what was just a simple desensitization program. So, in the office, I had her come up with an idea in her head — maybe a few scenarios of imagining what it would be like if a dog was, say, very far away, but in a cage and would never hurt you. And then she would think through maybe two or three steps ahead where somebody would unlock the cage door, but then the dog would come out and the dog wouldn’t be hostile. Just using her imagination, we developed a series of scenarios where she could actually begin to see herself petting the dog. And over time, we got her brain used to, just using imagination and images, that that was okay. Meanwhile, I’m relaxing her, keeping her calm, trying actually to have some fun with it.

We then had her practice that at home and in the office a few times, and then we did it a real-life desensitization, where the parents were able to arrange a neighbor’s dog to slowly approach her while she kept calm. Little by little, she got to the point where she could then actually pet the dog. Now, at this point a lot of anxiety drops. The brain now has information that there’s nothing truly to be afraid of and at this point all the other fears — open places, parks — can just vanish.

We have to continue over another couple of weeks thereafter rehearsing and rehearsing, because sometimes, people jump back to their baseline and fears have a way of knocking back on the door again and just popping up out of the blue. But with, again, some more rehearsal, it worked. It worked really well. And, again, it was an example of where a very simple kind of approach could be used instead of medication.

Jumping into the future, I later learned that this girl who got in contact with me many, many years later wanted me to know that she did something very special. She went on a particular camp experience outside the state and actually worked with wolves that were in captivity that they were going to be releasing. And I thought to myself, “What an incredible leap that is, that when she was little, she had a terrible dog phobia and yet, at some point, she was interested in actually wanting to work with wolves.”

So, again, it’s the kind of thing where medication might have suppressed anxiety symptoms when she was seven, eight and nine, but they wouldn’t have done anything to prove to her that in fact she didn’t need to be afraid. Only real-life experience and graded safe steps could prove that to her.

BHC: Fascinating. Dr. Rao, I really want to thank you for joining us today. Any thoughts in closing?

AR: Just that if people are interested in The Way of Boys, I want them to know that in addition to outlining the problems we have with over-medication and over diagnosing in boys, it’s really a book that’s more like a manual of how to raise these really fun and often adventurous young guys. A lot of chapters are devoted to really fun things about why they like war play and how to handle difficulties with time-aways and time-outs when they challenge you, when they’re having problems socially. How to handle schools and teachers when you feel they just don’t get your son.

So I do encourage people to take a look at it. Particularly the last chapter I am very proud of, which is a group of kids that I have followed for several years that I re-interviewed. Four boys in particular who had all sorts of challenging issues early on. Some used medicines, some didn’t, but most importantly, they worked through their problems and you’ll see at the end of the book how they turn out and they turn out really well.

BHC: And you have a website where people can get more information about the book?

AR: Yes, and in addition, I’m asking people if they want to leave an email address there, it’s very clear when they come on to anthonyrao.com and I’m sending out a monthly newsletter of articles or interesting information if people want to sign up.
 

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