Pathology in the Hundred Acre Wood (eng.).pdf

Research of the Holiday Kind

Pathology in the Hundred Acre Wood:

a neurodevelopmental perspective on A.A. Milne

Sarah E. Shea, Kevin Gordon, Ann Hawkins, Janet Kawchuk, Donna Smith

S OMEWHERE AT THE TOP OF

THE H UNDRED A CRE W OOD

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 neurodevel-

opmental and psycho-

social problems go unrec-

ognized and untreated.

an innocent world:

Christopher Robin,

living in a beautiful forest

surrounded by his loyal ani-

mal friends. Generations of

readers of A.A. Milne’s

Winnie-the-Pooh stories

have enjoyed these seem-

ingly benign tales. 1,2

However, perspectives

change with time, and it

is clear to our group of mod-

ern neurodevelopmentalists that these

are in fact stories of Seriously Trou-

bled Individuals, many of whom meet

DSM-IV 3 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 inhabi-

tants of the Hundred Acre Wood in hopes that our obser-

vations 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 sub-

type. 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 con-

cluded, however, that this reflected more on his comorbid

cognitive impairment, further aggravated by an obsessive

fixation on honey. The latter, of course, has also con-

tributed to his significant obesity. Pooh’s perseveration on

food and his repetitive counting behaviours raise the diag-

nostic possibility of Obsessive Compulsive Disorder

(OCD). Given his coexisting ADHD and OCD, we ques-

tion 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 micro-

cephaly, however, as we do not know whether standards ex-

ist for the head circumference of the brown bear. The

cause of Pooh’s poor brain growth may be found in the sto-

ries themselves. Early on we see Pooh being dragged

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1557

O n the surface it is

Shea et al

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.

Eeyore. What a sad life that donkey lives. We do not have

sufficient history to diagnose this as an inherited, endoge-

nous 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 an-

tidepressant, perhaps combined with individual therapy.

Maybe with a little fluoxetine, Eeyore might see the hu-

mour 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 con-

dition had been identified early and he received more in-

tensive support!

We especially worry about baby Roo. It is not his impul-

sivity or hyperactivity that concerns us, as we feel that those

are probably age appropriate. We worry about the environ-

ment in which he is developing. Roo is growing up in a sin-

gle-parent household, which puts him at high risk for

Poorer Outcome. We predict we will someday see a delin-

quent, jaded, adolescent Roo hanging out late at night at

the top of the forest, the ground littered with broken bot-

tles of extract of malt and the butts of smoked thistles. We

think that this will be Roo’s reality, in part because of a sec-

ond issue. Roo’s closest friend is Tigger, who is not a good

Role Model. Peer influences strongly affect outcome.

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, flus-

tered 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 in-

jury because of the chronic dysthymia of their neighbour,

Table 1: DSM-IV multiaxial diagnosis of conditions demonstrated by the inhabitants of the Hundred Acre Wood

Inhabitant

Axis I

Clinical disorders

Axis II

Personality disorders/

mental retardation

Axis III

General medical

conditions

Axis IV

Psychosocial/

environmental problems

Winnie-the-Pooh

ADHD, inattentive subtype;

OCD (provisional diagnosis)

Borderline intellectual

functioning (Very Little

Brain)

Poor diet, obesity,

binge eating

–

Piglet

Generalized anxiety disorder

–

Failure to thrive

–

Eeyore

Dysthymic disorder

–

Traumatic amputation

of tail

Housing problems

Rabbit

–

Narcissistic personality

disorder

–

Owl

Reading disorder

–

Housing problems

Tigger

ADHD, hyperactivity–

impulsivity subtype

–

Kanga

–

Single parent,

unemployed,

overprotective of child

Roo

–

Single parenthood,

undesirable peer group,

victim of unusual feeding

practices (extract of malt)

Christopher Robin Gender identity disorder

of childhood (provisional

diagnosis)

–

Lack of parental

supervision, possible

educational problems

Note: ADHD = attention deficit hyperactivity disorder, OCD = obsessive compulsive disorder.

*The Axis V (global assessment of functioning) scale was deferred.

1558

JAMC • 12 DÉC. 2000; 163 (12)

Neurodevelopmental perspective on A.A. Milne

We acknowledge that Tigger is gregarious and affec-

tionate, but he has a recurrent pattern of risk-taking behav-

iours. Look, for example, at his impulsive sampling of un-

known 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 knowl-

edge 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 con-

text of obvious hyperactivity and impulsivity, would suggest

the need for a stimulant medication. Others have wondered

whether clonidine might be helpful, or perhaps a combina-

tion 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 com-

munity of $500000 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 exhib-

ited 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 ani-

mals. 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 sys-

tem 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 en-

chantment, but rather one of disenchantment, where neu-

rodevelopmental and psychosocial problems go unrecog-

nized and untreated. It is unfortunate that an Expotition

was never Organdized to a Child Development Clinic.

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 Di-

vision of Neurology, Department of Pediatrics, Dalhousie University, Halifax, NS.

Contributors : Sarah Shea was the principal author and contributed to the concept

and writing of the article and the analysis of the literature. Kevin Gordon, Ann

Hawkins, Janet Kawchuk and Donna Smith contributed to the concept, the litera-

ture analysis and revision of the initial draft.

References

1. Milne AA. Winnie-the-Pooh . London: Methuen; 1926.

2. Milne AA. The House at Pooh Corner . London: Methuen; 1928.

3. American Psychiatric Association. Diagnostic and statistical manual of mental

disorders. 4th ed. Washington: The Association; 1994.

Reprint requests to: Dr. Sarah E. Shea, Developmental Clinic, IWK

Grace Health Centre, 5850 University Ave., Halifax NS B3J 3G9;

fax 902 428-3284

CMAJ • DEC. 12, 2000; 163 (12)

1559

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