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 and Donna Smith

http://www.cmaj.ca/cgi/reprint/163/12/1557

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

  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.