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Pathology in the Hundred Acre Wood: a neurodevelopmental perspective on
A.A. Milne Sarah E. Shea, Kevin Gordon, Ann Hawkins, Janet Kawchuk and
Donna Smith Sarah-the-Shea, Ann-the-Hawkins, Janet-the-Kawchuk and
Donna-the-Smith are with the Division of Developmental Pediatrics and
Kevin-the-Gordon is with the Division of Neurology, Department of
Pediatrics, Dalhousie University, Halifax, NS.
Abstract
Somewhere at the top of the Hundred Acre Wood a little boy and his bear
play. On the surface it is an innocent world, but on closer examination by
our group of experts we find a forest where neurodevelopmental and
psychosocial problems go unrecognized and untreated.
--------------------------------------------------------------------------------
On the surface it is an innocent world: Christopher Robin, living in a
beautiful forest surrounded by his loyal animal friends. Generations of
readers of A.A. Milne's Winnie-the-Pooh stories have enjoyed these
seemingly benign tales.1,2 However, perspectives change with time, and it
is clear to our group of modern neurodevelopmentalists that these are in
fact stories of Seriously Troubled Individuals, many of whom meet DSM-IV3
criteria for significant disorders (Table 1). We have done an exhaustive
review of the works of A.A. Milne and offer our conclusions about the
inhabitants of the Hundred Acre Wood in hopes that our observations will
help the medical community understand that there is a Dark Underside to
this world.
We begin with Pooh. This unfortunate bear embodies the concept of
comorbidity. Most striking is his Attention Deficit Hyperactivity Disorder
(ADHD), inattentive subtype. As clinicians, we had some debate about
whether Pooh might also demonstrate significant impulsivity, as witnessed,
for example, by his poorly thought out attempt to get honey by disguising
himself as a rain cloud. We concluded, however, that this reflected more on
his comorbid cognitive impairment, further aggravated by an obsessive
fixation on honey. The latter, of course, has also contributed to his
significant obesity. Pooh's perseveration on food and his repetitive
counting behaviours raise the diagnostic possibility of Obsessive
Compulsive Disorder (OCD). Given his coexisting ADHD and OCD, we question
whether Pooh may over time present with Tourette's syndrome. Pooh is also
clearly described as having Very Little Brain. We could not confidently
diagnose microcephaly, however, as we do not know whether standards exist
for the head circumference of the brown bear. The cause of Pooh's poor
brain growth may be found in the stories themselves. Early on we see Pooh
being dragged downstairs bump, bump, bump, on the back of his head. Could
his later cognitive struggles be the result of a type of Shaken Bear
Syndrome?
Pooh needs intervention. We feel drugs are in order. We cannot but wonder
how much richer Pooh's life might be were he to have a trial of low-dose
stimulant medication. With the right supports, including methylphenidate,
Pooh might be fitter and more functional and perhaps produce (and remember)
more poems.
I take a PILL-tiddley pom It keeps me STILL-tiddley pom, It keeps me
STILL-tiddley pom Not fiddling.
And what of little Piglet? Poor, anxious, blushing, flustered little
Piglet. He clearly suffers from a Generalized Anxiety Disorder. Had he been
appropriately assessed and his condition diagnosed when he was young, he
might have been placed on an antipanic agent, such as paroxetine, and been
saved from the emotional trauma he experienced while attempting to trap
heffalumps.
Pooh and Piglet are at risk for additional self-esteem injury because of
the chronic dysthymia of their neighbour, Eeyore. What a sad life that
donkey lives. We do not have sufficient history to diagnose this as an
inherited, endogenous depression or to know whether some early trauma
contributed to his chronic negativism, low energy and anhe(haw)donia.
Eeyore would benefit greatly from an antidepressant, perhaps combined with
individual therapy. Maybe with a little fluoxetine, Eeyore might see the
humour in the whole tail-losing episode. Even if a patch of St. John's wort
grew near his thistles, the forest could ring with a braying laugh.
Our neurodevelopmental group agrees about poor Owl: obviously bright, but
dyslexic. His poignant attempts to cover up for his phonological deficits
are similar to what we see day in and day out in others so afflicted. If
only his condition had been identified early and he received more intensive
support!
We especially worry about baby Roo. It is not his impulsivity or
hyperactivity that concerns us, as we feel that those are probably age
appropriate. We worry about the environment in which he is developing. Roo
is growing up in a single-parent household, which puts him at high risk for
Poorer Outcome. We predict we will someday see a delinquent, jaded,
adolescent Roo hanging out late at night at the top of the forest, the
ground littered with broken bottles of extract of malt and the butts of
smoked thistles. We think that this will be Roo's reality, in part because
of a second issue. Roo's closest friend is Tigger, who is not a good Role
Model. Peer influences strongly affect outcome.
We acknowledge that Tigger is gregarious and affectionate, but he has a
recurrent pattern of risk-taking behaviours. Look, for example, at his
impulsive sampling of unknown substances when he first comes to the Hundred
Acre Wood. With the mildest of provocation he tries honey, haycorns and
even thistles. Tigger has no knowledge of the potential outcome of his
experimentation. Later we find him climbing tall trees and acting in a way
that can only be described as socially intrusive. He leads Roo into danger.
Our clinical group has had its own debate about what the best medication
might be for Tigger. Some of us have argued that his behaviours, occurring
in a context of obvious hyperactivity and impulsivity, would suggest the
need for a stimulant medication. Others have wondered whether clonidine
might be helpful, or perhaps a combination of the two. Unfortunately we
could not answer the question as scientifically as we would have liked
because we could find only human studies in the literature.
Even if we were able to help Tigger, we would still have the problem of
Roo's growing up with a single parent. Kanga is noted to be somewhat
overprotective. Could her possessiveness of Roo relate to a previous run-in
with social services? And where will Kanga be in the future? It is highly
likely that she will end up older, blowsier, struggling to look after
several joeys conceived in casual relationships with different fathers,
stuck at a dead end with inadequate financial resources. But perhaps we are
being too gloomy. Kanga may prove to be one of those exceptional single
mothers who show a natural resilience — an ability, if we may say so, to
bounce back. Maybe Kanga will pass her high school equivalency test, earn a
university degree and maybe even get an MBA. Perhaps some day Kanga will
buy the Hundred Acre Wood and develop it into a gated community of $500 000
homes. But that is not likely to happen, particularly in a social context
that does not appear to value education and provides no strong female
leadership.
What leadership there is in the Hundred Acre Wood is simply that offered by
one small boy, Christopher Robin. Our group believes that Christopher Robin
has not exhibited any diagnosable condition as yet, but we are concerned
about several issues. There is the obvious problem of a complete absence of
parental supervision, not to mention the fact that this child is spending
his time talking to animals. We also noted in the stories early signs of
difficulty with academics and felt that E.H. Shepard's illustrations
suggest possible future gender identity issues for this child. The more
psychoanalytical member in our group indicated that there could be some
Freudian meaning to his peculiar naming of his bear as Winnie-the-Pooh.
Finally, we turn to Rabbit. We note his tendency to be extraordinarily
self-important and his odd belief system that he has a great many relations
(many of other species!) and friends. He seems to have an overriding need
to organize others, often against their will, into new groupings, with
himself always at the top of the reporting structure. We believe that he
has missed his calling, as he clearly belongs in senior-level hospital
administration.
Somewhere at the top of the forest a little boy and his bear play. Sadly,
the forest is not, in fact, a place of enchantment, but rather one of
disenchantment, where neurodevelopmental and psychosocial problems go
unrecognized and untreated. It is unfortunate that an Expotition was never
Organdized to a Child Development Clinic.
Footnotes
Contributors: Sarah Shea was the principal author and contributed to the
concept and writing of the article and analysis of the literature. Kevin
Gordon, Ann Hawkins, Janet Kawchuk and Donna Smith contributed to the
concept, the literature analysis and revision of the initial draft.
Reprint requests to: Dr. Sarah E. Shea, Developmental Clinic, IWK Grace
Health Centre, 5850 University Ave., Halifax NS B3J 3G9; fax 902 428-3284
References
Milne AA. Winnie-the-Pooh. London: Methuen; 1926. Milne AA. The House at
Pooh Corner. London: Methuen; 1928. American Psychiatric Association.
Diagnostic and statistical manual of mental disorders. 4th ed. Washington:
The Association; 1994.
A.A. Milne Sarah E. Shea, Kevin Gordon, Ann Hawkins, Janet Kawchuk and
Donna Smith Sarah-the-Shea, Ann-the-Hawkins, Janet-the-Kawchuk and
Donna-the-Smith are with the Division of Developmental Pediatrics and
Kevin-the-Gordon is with the Division of Neurology, Department of
Pediatrics, Dalhousie University, Halifax, NS.
Abstract
Somewhere at the top of the Hundred Acre Wood a little boy and his bear
play. On the surface it is an innocent world, but on closer examination by
our group of experts we find a forest where neurodevelopmental and
psychosocial problems go unrecognized and untreated.
--------------------------------------------------------------------------------
On the surface it is an innocent world: Christopher Robin, living in a
beautiful forest surrounded by his loyal animal friends. Generations of
readers of A.A. Milne's Winnie-the-Pooh stories have enjoyed these
seemingly benign tales.1,2 However, perspectives change with time, and it
is clear to our group of modern neurodevelopmentalists that these are in
fact stories of Seriously Troubled Individuals, many of whom meet DSM-IV3
criteria for significant disorders (Table 1). We have done an exhaustive
review of the works of A.A. Milne and offer our conclusions about the
inhabitants of the Hundred Acre Wood in hopes that our observations will
help the medical community understand that there is a Dark Underside to
this world.
We begin with Pooh. This unfortunate bear embodies the concept of
comorbidity. Most striking is his Attention Deficit Hyperactivity Disorder
(ADHD), inattentive subtype. As clinicians, we had some debate about
whether Pooh might also demonstrate significant impulsivity, as witnessed,
for example, by his poorly thought out attempt to get honey by disguising
himself as a rain cloud. We concluded, however, that this reflected more on
his comorbid cognitive impairment, further aggravated by an obsessive
fixation on honey. The latter, of course, has also contributed to his
significant obesity. Pooh's perseveration on food and his repetitive
counting behaviours raise the diagnostic possibility of Obsessive
Compulsive Disorder (OCD). Given his coexisting ADHD and OCD, we question
whether Pooh may over time present with Tourette's syndrome. Pooh is also
clearly described as having Very Little Brain. We could not confidently
diagnose microcephaly, however, as we do not know whether standards exist
for the head circumference of the brown bear. The cause of Pooh's poor
brain growth may be found in the stories themselves. Early on we see Pooh
being dragged downstairs bump, bump, bump, on the back of his head. Could
his later cognitive struggles be the result of a type of Shaken Bear
Syndrome?
Pooh needs intervention. We feel drugs are in order. We cannot but wonder
how much richer Pooh's life might be were he to have a trial of low-dose
stimulant medication. With the right supports, including methylphenidate,
Pooh might be fitter and more functional and perhaps produce (and remember)
more poems.
I take a PILL-tiddley pom It keeps me STILL-tiddley pom, It keeps me
STILL-tiddley pom Not fiddling.
And what of little Piglet? Poor, anxious, blushing, flustered little
Piglet. He clearly suffers from a Generalized Anxiety Disorder. Had he been
appropriately assessed and his condition diagnosed when he was young, he
might have been placed on an antipanic agent, such as paroxetine, and been
saved from the emotional trauma he experienced while attempting to trap
heffalumps.
Pooh and Piglet are at risk for additional self-esteem injury because of
the chronic dysthymia of their neighbour, Eeyore. What a sad life that
donkey lives. We do not have sufficient history to diagnose this as an
inherited, endogenous depression or to know whether some early trauma
contributed to his chronic negativism, low energy and anhe(haw)donia.
Eeyore would benefit greatly from an antidepressant, perhaps combined with
individual therapy. Maybe with a little fluoxetine, Eeyore might see the
humour in the whole tail-losing episode. Even if a patch of St. John's wort
grew near his thistles, the forest could ring with a braying laugh.
Our neurodevelopmental group agrees about poor Owl: obviously bright, but
dyslexic. His poignant attempts to cover up for his phonological deficits
are similar to what we see day in and day out in others so afflicted. If
only his condition had been identified early and he received more intensive
support!
We especially worry about baby Roo. It is not his impulsivity or
hyperactivity that concerns us, as we feel that those are probably age
appropriate. We worry about the environment in which he is developing. Roo
is growing up in a single-parent household, which puts him at high risk for
Poorer Outcome. We predict we will someday see a delinquent, jaded,
adolescent Roo hanging out late at night at the top of the forest, the
ground littered with broken bottles of extract of malt and the butts of
smoked thistles. We think that this will be Roo's reality, in part because
of a second issue. Roo's closest friend is Tigger, who is not a good Role
Model. Peer influences strongly affect outcome.
We acknowledge that Tigger is gregarious and affectionate, but he has a
recurrent pattern of risk-taking behaviours. Look, for example, at his
impulsive sampling of unknown substances when he first comes to the Hundred
Acre Wood. With the mildest of provocation he tries honey, haycorns and
even thistles. Tigger has no knowledge of the potential outcome of his
experimentation. Later we find him climbing tall trees and acting in a way
that can only be described as socially intrusive. He leads Roo into danger.
Our clinical group has had its own debate about what the best medication
might be for Tigger. Some of us have argued that his behaviours, occurring
in a context of obvious hyperactivity and impulsivity, would suggest the
need for a stimulant medication. Others have wondered whether clonidine
might be helpful, or perhaps a combination of the two. Unfortunately we
could not answer the question as scientifically as we would have liked
because we could find only human studies in the literature.
Even if we were able to help Tigger, we would still have the problem of
Roo's growing up with a single parent. Kanga is noted to be somewhat
overprotective. Could her possessiveness of Roo relate to a previous run-in
with social services? And where will Kanga be in the future? It is highly
likely that she will end up older, blowsier, struggling to look after
several joeys conceived in casual relationships with different fathers,
stuck at a dead end with inadequate financial resources. But perhaps we are
being too gloomy. Kanga may prove to be one of those exceptional single
mothers who show a natural resilience — an ability, if we may say so, to
bounce back. Maybe Kanga will pass her high school equivalency test, earn a
university degree and maybe even get an MBA. Perhaps some day Kanga will
buy the Hundred Acre Wood and develop it into a gated community of $500 000
homes. But that is not likely to happen, particularly in a social context
that does not appear to value education and provides no strong female
leadership.
What leadership there is in the Hundred Acre Wood is simply that offered by
one small boy, Christopher Robin. Our group believes that Christopher Robin
has not exhibited any diagnosable condition as yet, but we are concerned
about several issues. There is the obvious problem of a complete absence of
parental supervision, not to mention the fact that this child is spending
his time talking to animals. We also noted in the stories early signs of
difficulty with academics and felt that E.H. Shepard's illustrations
suggest possible future gender identity issues for this child. The more
psychoanalytical member in our group indicated that there could be some
Freudian meaning to his peculiar naming of his bear as Winnie-the-Pooh.
Finally, we turn to Rabbit. We note his tendency to be extraordinarily
self-important and his odd belief system that he has a great many relations
(many of other species!) and friends. He seems to have an overriding need
to organize others, often against their will, into new groupings, with
himself always at the top of the reporting structure. We believe that he
has missed his calling, as he clearly belongs in senior-level hospital
administration.
Somewhere at the top of the forest a little boy and his bear play. Sadly,
the forest is not, in fact, a place of enchantment, but rather one of
disenchantment, where neurodevelopmental and psychosocial problems go
unrecognized and untreated. It is unfortunate that an Expotition was never
Organdized to a Child Development Clinic.
Footnotes
Contributors: Sarah Shea was the principal author and contributed to the
concept and writing of the article and analysis of the literature. Kevin
Gordon, Ann Hawkins, Janet Kawchuk and Donna Smith contributed to the
concept, the literature analysis and revision of the initial draft.
Reprint requests to: Dr. Sarah E. Shea, Developmental Clinic, IWK Grace
Health Centre, 5850 University Ave., Halifax NS B3J 3G9; fax 902 428-3284
References
Milne AA. Winnie-the-Pooh. London: Methuen; 1926. Milne AA. The House at
Pooh Corner. London: Methuen; 1928. American Psychiatric Association.
Diagnostic and statistical manual of mental disorders. 4th ed. Washington:
The Association; 1994.
