ADHD at 4, Violent at 15: Are Lessons Learned?

When I write about lessons I have learned from my patients, I go to great lengths to protect their privacy by altering details and identifying information. However, as the Serpico family has so generously and bravely offered their story to the public in the New York Times, the details are available for all to see. And the story offers a very important lesson.

The focus of the article, Seeing Son's Violent Potential, But Finding Little Help or Hope is on the current situation- on how a well-insured, well-educated family is struggling to get help for their deeply troubled teenage son.

But the lesson comes early on, and is contained in this paragraph:

Lena and Robert Serpico knew something was not right before their son was in kindergarten. They had taken him and his younger brother in as foster children from a mother who used drugs, and they later adopted both. The older boy, whose name is not being published at the Serpicos’ request, was restless and impulsive from the beginning and got his first diagnosis at age 4: attention deficit hyperactivity disorder.

While the amount of time this boy lived with his biological mother is not stated, if he was the older of two brothers and they were placed in foster care together, it was at least nine months. The human infant is uniquely helpless in the early weeks and months of life. His brain develops the capacity for self-regulation when the people who care for him can be present and attuned. The brain undergoes its most rapid development in the first year. A caregiver who is using drugs will be impaired in her ability to offer this attunment, significantly impacting on that child's self-regulation capacity. Separation from a primary caregiver, no matter how impaired, is itself traumatic even for a very young child.

The good news is that the brain continues to grow and change rapidly in the first 5 years. There is ample opportunity to set things on a better path even in the face of early adversity. Several evidence based interventions, such as Child-Parent Psychotherapy, can help parents make sense of a child's behavior and so set development, at the level of brain structure and function, on a better path. When early childhood educators recognize the impact of early experience, as in the Head Start-Trauma Smart program, there is opportunity to support healthy development in the classroom.

But for this child, there is no indication of any significant intervention before age 4, despite the fact that he was "restless and impulsive from the beginning." There seems to be no link made between his early developmental experience and his difficulty with self-regulation. Though the article does not address this question, I wonder how much information his adoptive parents were given about the developmental effects of his early life experience. I wonder how much support they were given in the early years of foster care and then adoption.  Was there space and time to listen to them? By labeling his constellation of behaviors at age 4 as "ADHD" and prescribing medication, the path to finding meaning in his behavior was closed off.

Because stimulant medication is so effective at controlling behavior, his impulsively subsided in the elementary school years. But given his history, it is almost inevitable that without addressing the underlying cause for the behavioral and emotional dysregulation, with the onset of adolescence symptoms would resurface. While the short term goal of sitting still and paying attention in school was achieved, valuable time was lost.  His opportunity to communicate his need for help with self-regulation was silenced by medication.

He showed an affinity for guitar during those years of relative peace. Music,  martial arts, theater athletics, and a range of other activities, both through the activities themselves as well as the relationships formed, are other ways in which children can develop emotional, attentional and behavioral regulation.  With a diagnosis made and his symptoms effectively eliminated, motivation to pursue more creative, long lasting interventions, either in addition to or instead of medication, was likely not there.

What instead followed was a string of different diagnoses and medications, with what his parents describe as a terrifying downward spiral in mental health,  in parallel with a dramatic upward spiral of health care costs.

Virtually all of the comments on the article, over 800 as I write this, focus on the Serpico's struggles to get, and pay for, appropriate care for their teenage son. Certainly that is an important issue. Early intervention will be of no use to the Serpico family now. In fact, it might be quite painful to think of missed opportunities.

But the real value of this story lies in its cautionary nature. If it can be used to advocate for recognition of the impact of early development, and for investment in preventive intervention in the early years, their story could potentially help to save a lot of grief, suffering, and money.