substance use

By: Nancy Roosa, Psy.D.
Pediatric Neuropsychologist, NESCA

I recently evaluated a 15-year-old boy, who we’ll call Sam, whose parents brought him in due to some concerning new behaviors, including failing classes, disobeying his parents’ rules – particularly around curfew and technology use – and smoking marijuana on a daily basis. When meeting Sam, I was amazed at how engaging, polite and good-natured he was. It was hard to imagine this young man disobeying his parents and staying out all night, which he was also doing frequently.

Sam had grown up in an affluent and supportive family, the third of four children. The other three were, like their parents, easy-going, adaptable and successful – academically, socially and athletically. They were on the path to becoming independent and successful adults. Sam had always been a bit different. He was the child who had colic as an infant, sleep disturbances throughout childhood, separation anxiety at preschool, and extreme sensitivity to sensory stimuli. His parents cut tags out of his clothes, bought him loose-fitting pants, and avoided birthday parties at Chuck E. Cheese’s – or almost anywhere there would be crowds of loud children, as these situations could reduce Sam to tears.

When evaluating Sam, I was impressed by his intelligence, quick reasoning and solid academic skills.  There was nothing obvious that standard neuropsychology tests uncovered. But Sam was also open and articulate about his difficulties. He explained that he was easily overwhelmed – “jangled,” he called it – in social situations, in a fast-paced classroom or on an athletic field. When he started ninth grade in a challenging parochial school, he was faced with more stressful situations, academically and socially. He became extremely anxious about tests and lengthy homework assignments, so he fell behind academically and developed pretty serious school anxiety. Given his sensitive nature, he was particularly likely to struggle in a class where the teacher was, in his words, “too strict,” or even “mean.” He wasn’t successful enough socially or athletically to sustain his self-esteem in these areas, particularly compared to his talented siblings. He found himself becoming angry and anxious, and he started using marijuana to calm himself. As he described it, getting high was the only time he felt happy and relaxed.

Sam was clearly struggling, easily meeting criteria for an anxiety disorder and a substance use disorder.  But I wanted to explain some of the “why” behind his struggles, so, in talking to his parents, I relied on the explanation put forth by Dr. W. Thomas Boyce, in his book, Orchids and Dandelions: Why Some Children Struggle and How All Can Thrive. He explains that most children are like dandelions, born with sturdy, resilient temperaments so that they, like dandelions, grow and thrive wherever they land –  assuming there’s some minimal level of appropriate conditions. But about 20% of children are more like orchids. They are born with a very sensitive nervous system, which is highly attuned to all the stimulation in the world around them. Dr. Boyce found that for these children, lower levels of stress precipitated a full-fledged anxiety response, involving the release of stress hormones that create a Fight, Flight or Freeze response – an appropriate response for a life-threatening situation, but not much help when facing, say, a strict teacher or a hard test. These children are therefore much more likely to develop full-blown anxiety disorders. On the positive side, their high level of sensitivity to the world around them means they are typically very empathic and emotionally attuned. Like an orchid with careful nurturing, they will develop into exceptional adults.

Fortunately, many orchids do naturally gain resilience as they grow, according to Elaine Arons, Ph.D. In her book The Sensitive Child, she cites studies that find most children who are shy as preschoolers – suffering social and separation anxiety – will develop coping strategies and not appear shy by the time they reach school age. These orchids gain resilience without losing their sensitivity.

But this positive evolution requires good parenting. While dandelions do fine with the average “good-enough” mother, as famously defined by psychologist Donald Winnicott, orchids need parents to be just a bit better.

How does one do this? How can a well-meaning, good-enough parent help these orchids become better able to manage the squalls, large and small, that occur in any one’s life?

Fortunately, there is a wealth of research – contained in books and articles – on building resilience in children. Most emphasize that we need to allow children to struggle with challenges, even to the point of sometimes failing, so they learn that they can cope and succeed in the face of adversity. This message is clear from the title of several such books: e.g. The Blessing of the Skinned Knee: Using Timeless Teachings to Raise Self-Reliant Children, by Wendy Mogel and The Gift of Failure: How the Best Parents Learn to Let Go So Their Children Can Succeed by Jessica Lahey.

We also have a neurobiological explanation for this process. We know that continued exposure to a stressful situation allows the body to habituate and the terrible feelings – such as fear and panic – that accompany a stress response gradually recede. As this happens, the previously scary situation becomes routine, and the child’s self-confidence and willingness to tackle new risks grows. Every preschool teacher knows this. The crying child who is being left by his parents in an unfamiliar preschool will eventually calm down and start to enjoy himself. The process goes more quickly if parents calmly and confidently reassure the child, then leave. The parent who is also anxious, who hovers over the child, attempting to sooth his fears, only increases the child’s anxiety by sending the message that this IS a scary situation. This phenomenon was dramatically illustrated in a study by Susan Crockenberg and Esther Leerkes (Development and Psychopathology, 2006). They found that 6-month-old children had different levels of reactivity – or startle – in response to unfamiliar stimuli. These infants also showed differences in how much they tried to avoid the situation, versus distracting themselves while staying in the presence of the stimuli. Children with high reactivity and a tendency to withdraw from novel stimuli, along with parents who were less sensitive, were more likely to show high anxiety at 2.5 years of age. Exposure to challenge causes the body to habituate and builds resilience. Trying to avoid stressful situations only exacerbates fears.

However, this can be counterintuitive for parents of very sensitive children. In fact, the more attuned a parent is to his/her child’s sensitivity, the harder it becomes. Sam’s parents had always coddled him a bit more than their other children. Knowing that he didn’t like loud birthday parties, his mother tended to decline these invitations. When he became upset and started to cry at a soccer game, his father felt so sorry for him that he didn’t insist that Sam return the next week. This avoidance did not allow Sam to grow and master new situations, but instead narrowed his world.

This is not to say that Sam’s parents should have been less emotionally attuned. Rather, it’s important for parents of children like Sam to walk a fine line between exposing the child to moderate challenges that he can manage but do not overwhelm him. It’s also important that they stay calm themselves, empathizing with the child’s fears but reassuring him at the same time. Not an easy task.

Fortunately, Sam has many strengths, not the least of which are his sensitivity and his intelligence, as well as great artistic gifts. He also has a solid relationship with his parents, even though it has been quite strained of late. After our evaluation, Sam and his parents decided to place him in a therapeutic wilderness program so he could withdraw from daily pot use in a safe place and learn skills from therapists there, as well as learn from peers who were going through similar struggles. This coming year, he will not return to the challenging parochial school he attended for ninth grade and will instead start at an independent school that offers some academic supports and a flourishing arts program. Sam’s roots are well-established, and with a bit more awareness of the gifts and challenges inherent in his sensitive nature, he is expected to grow into a self-confident and resilient young man.

About the Author: 

Dr. Roosa has been engaged in providing neuropsychological evaluations for children since 1997. She enjoys working with a range of children, particularly those with autism spectrum disorders, as well as children with attentional issues, executive function deficits, anxiety disorders, learning disabilities, or other social, emotional or behavioral problems. Her evaluations are particularly appropriate for children with complex profiles and those whose presentations do not fit neatly into any one diagnostic box. As part of this process, Dr. Roosa is frequently engaged in school visits, IEP Team Meetings, home observations and phone consultations with collateral providers. Dr. Roosa has also consulted with several area schools, either about individual children or about programmatic concerns. She speaks to parent or school groups, upon request.

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton and Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.