Recently I reviewed my son's high school essay on To Kill A Mockingbird. I was surprised and pleased to rediscover, or perhaps discover for the first time now that I was viewing it from the perspective of over 50 years of life experience, the profound wisdom of the book.
In one of the novel's most famous quotes, Atticus tell his daughter Scout, "you never really understand a person until you consider things from his point of view, until you climb in his skin and walk around in it."
I now understand this as a description of the essence of being human, namely the capacity to be curious about the meaning of another person's behavior. Peter Fonagy, whose research has shown how the development of this capacity is intimately linked to healthy emotional development, argues, in a way analogous to Bowlby's description of attachment behavior, that this capacity has evolutionary significance, and is essential to survival. My book Keeping Your Child in Mind presents this research for a general audience, showing its application to parenting.
I wonder if our current epidemic of "ADHD" is related to having lost sight of this essential human quality. The most common phrases I hear from parents who come to my office with concerns of problems of inattention and impulsivity are, "he never listens," followed by "tell me what to do to make him listen."
Perhaps ADHD is a problem of not listening. But it is the adults who are not listening to each other. In our fast-paced, technology driven age, we rarely take the time to listen to each other, to put ourselves in another person's skin.
When Scout comes home from her first day of school upset with the teacher, her father tells her, "she's new too." He is helping Scout to understand her teacher's perhaps impatient behavior from a different point of view, to appreciate that the teacher herself may have been stressed and overwhelmed.
Recently parents of 4-year-old Sam, who was having problems of impulsivity in the classroom, spent a good portion of our visit expressing anger at his teacher, who they were convinced just didn't like their child. But with a full hour, and a quiet space to tell the story, they came to recognize that just as they could get overwhelmed at times by their son's behavior, so could the teacher be overwhelmed. Perhaps she felt defensive when the parents got angry, as she was trying her best in less than ideal classroom setting, with a low teacher: student ratio.
In turn, with the parents and teacher listening to each other and not behaving defensively, they could reach a new level of understanding of what set Sam off, and to develop strategies both at home and in school to help him to feel calm.
I wonder if the current epidemic of what we call "ADHD" represents a loss of this capacity to put ourselves in another person's skin. I have had the pleasure of an email exchange with the New York Times journalist Alan Schwartz, whose multiple superb article, most recently The Selling of ADHD, have served to bring the subject to the forefront of public discourse. I am hopeful that he will help us to see the big picture, rather than to place blame.
I have wondered in conversation with him if the whole phenomenon of "ADHD" is itself a symptom of larger social ills, particularly in the education and health care systems as well as the medical education system. People, including parents, teachers, pediatricians and mental health professionals, are feeling overwhelmed and not heard.
The large scale medication of a whole generation of children has potential serious and profound long-term effects. These include the silencing of children whose symptoms represent complex underlying problems, as well as abuse of stimulant medication by high school and college students.
We will never go back to the slow pace depicted in the 1960 novel, where there are large expanses of time to listen. But we need to be very careful not to give it up completely. For it does take space and time to put yourself in another person's skin. If that is the essence of what makes us human, we need to value that space and time.
"ADHD" etiketine sahip kayıtlar gösteriliyor. Tüm kayıtları göster
"ADHD" etiketine sahip kayıtlar gösteriliyor. Tüm kayıtları göster
28 Ocak 2016 Perşembe
Rising incidence of "ADHD" calls for radical rethinking
When the American Academy of Pediatrics changed the guidelines for ADHD to expand age of diagnosis to include children from age 4-18 (from 6-12), that the number of cases would rise was, by definition, inevitable. The recent survey by the CDC, published in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry, indicating that one in 10 children in the US carry a diagnosis of ADHD, confirms just that.
I felt re-energized and hopeful in ongoing efforts to, in my colleague's words "move the mountain of ADHD," when I received a request to speak at an international child psychiatry conference as part of a panel with a working title: "The ADHD Diagnosis: a Deconstruction from Developmental, Psychoanalytic, Infant Mental Health and Neuropsychiatric Perspectives."
"Deconstruction" is a brilliant word, and captures well what I do in my clinical practice. Consider 4-year-old Max, whose parents brought him to my behavioral pediatrics practice to "see if he has ADHD." His preschool teacher had recommended the visit, suggesting that he might benefit from medication. I asked his parents, Ann and Peter, if we might, acknowledging that Max did have symptoms of inattention, hyperactivity and impulsivity, take the time (we had an hour) to ask why he had these symptoms: to make sense of his behavior. While they had been hopeful that they would leave the visit with a prescription, reflecting Max's teacher's concern that he might "fall behind" without treatment, they were overjoyed to consider another approach.
Max had been adopted at age 3 months. Prior to this he had lived with his biological parents who were actively using drugs. They reportedly had a history of ADHD as did some biological siblings. Ann and Peter had been struggling in their marriage in the face of caring for this challenging child, and had recently separated. While Max had been a good sleeper, for the past several months he had been getting up multiple times a night and the whole family was chronically sleep deprived. Max had multiple sensory sensitivities. He cried with the sound of the vacuum cleaner; getting dressed was an ordeal because he could not find a pair of socks that was comfortable. He had difficulties with "personal space."
We had, in a sense, "deconstructed" the "symptom" to examine its various parts. We identified a genetic vulnerability for problems of attention, early neglect, ongoing family stress, sleep deprivation, and sensory processing challenges.
At age 4, there are multiple avenues of intervention. I usually start with sleep, as chronic sleep deprivation is inextricably linked with emotional and attentional dysregulation. Child-parent psychotherapy, where a clinician works with parents and child together, has been shown to be effective in helping children develop capacities for emotional regulation, even in the face of early developmental trauma. A good occupational therapist, who addresses sensory processing challenges in the context of relationships, can help Max to use his body to manage his symptoms. Ann and Peter could examine the effects of their marital conflict on Max, and perhaps consider couples therapy.
The preliminary write up for the panel I refer to above speaks of what is now called "ADHD" as a valid symptom complex. But it proposes that
If I were to diagnose Max with ADHD and start him on stimulant medication, it would be in keeping with the current standard of care. Stimulants are powerful medications that have been shown in the short term to eliminate symptoms. But such an approach is simply a silencing of children. It would be a great disservice to Max and his family.
Just as expanding the age range for diagnosis inevitably led to a rise in cases, "deconstructing" the diagnosis would lead to a significant drop in cases. The difference is that this change would reflect, not silencing of children, but rather improving access to meaningful help.
I felt re-energized and hopeful in ongoing efforts to, in my colleague's words "move the mountain of ADHD," when I received a request to speak at an international child psychiatry conference as part of a panel with a working title: "The ADHD Diagnosis: a Deconstruction from Developmental, Psychoanalytic, Infant Mental Health and Neuropsychiatric Perspectives."
"Deconstruction" is a brilliant word, and captures well what I do in my clinical practice. Consider 4-year-old Max, whose parents brought him to my behavioral pediatrics practice to "see if he has ADHD." His preschool teacher had recommended the visit, suggesting that he might benefit from medication. I asked his parents, Ann and Peter, if we might, acknowledging that Max did have symptoms of inattention, hyperactivity and impulsivity, take the time (we had an hour) to ask why he had these symptoms: to make sense of his behavior. While they had been hopeful that they would leave the visit with a prescription, reflecting Max's teacher's concern that he might "fall behind" without treatment, they were overjoyed to consider another approach.
Max had been adopted at age 3 months. Prior to this he had lived with his biological parents who were actively using drugs. They reportedly had a history of ADHD as did some biological siblings. Ann and Peter had been struggling in their marriage in the face of caring for this challenging child, and had recently separated. While Max had been a good sleeper, for the past several months he had been getting up multiple times a night and the whole family was chronically sleep deprived. Max had multiple sensory sensitivities. He cried with the sound of the vacuum cleaner; getting dressed was an ordeal because he could not find a pair of socks that was comfortable. He had difficulties with "personal space."
We had, in a sense, "deconstructed" the "symptom" to examine its various parts. We identified a genetic vulnerability for problems of attention, early neglect, ongoing family stress, sleep deprivation, and sensory processing challenges.
At age 4, there are multiple avenues of intervention. I usually start with sleep, as chronic sleep deprivation is inextricably linked with emotional and attentional dysregulation. Child-parent psychotherapy, where a clinician works with parents and child together, has been shown to be effective in helping children develop capacities for emotional regulation, even in the face of early developmental trauma. A good occupational therapist, who addresses sensory processing challenges in the context of relationships, can help Max to use his body to manage his symptoms. Ann and Peter could examine the effects of their marital conflict on Max, and perhaps consider couples therapy.
The preliminary write up for the panel I refer to above speaks of what is now called "ADHD" as a valid symptom complex. But it proposes that
this terminology should not ever be used in our clinical thinking. "ADHD," used as a primary diagnosis, has no etiologic significance, is conceptually and diagnostically distracting, leads to a paucity of thinking about a patient's early developmental history and trauma, and is therapeutically misleading.I hope that there will be a large scale movement to "deconstruct" the ADHD diagnosis. In essence deconstructing the diagnosis means eliminating the diagnosis. Instead we would understand and treat the multiple parts that make up what is now called "ADHD." Such a process would result in effective early intervention and prevention.
If I were to diagnose Max with ADHD and start him on stimulant medication, it would be in keeping with the current standard of care. Stimulants are powerful medications that have been shown in the short term to eliminate symptoms. But such an approach is simply a silencing of children. It would be a great disservice to Max and his family.
Just as expanding the age range for diagnosis inevitably led to a rise in cases, "deconstructing" the diagnosis would lead to a significant drop in cases. The difference is that this change would reflect, not silencing of children, but rather improving access to meaningful help.
Connecting the dots to discover the cause of "ADHD"
A reader of my previous post asked how I "connect the dots" from supporting newborns and parents to "ADHD" treatment. He states that, "trying to figure out the cause will not help any kid today." This comment motivated me to clarify what I mean by cause, as I think finding out the cause will help every kid today.
What I mean by "finding out the cause" is to give parents the space and time to tell their story, to make sense of their child's symptoms. The aim is not to determine if the child has enough symptoms to meet diagnositic criteria for a DSM defined disorder, but rather to support parents' efforts to find a coherent narrative. It involves starting with at least 1-2 full hour visits with both parents. I put "ADHD" in quotes because by giving the symptoms a name, as in "ADHD evaluation" we narrow our thinking before we even start. Ideally we listen to the family's story with an open minded curiosity.
The story often starts with a fussy or colicky baby. Even before this, there may have been stress in pregnancy which is known to be associated with advanced motor development and behavioral dysregulation in the newborn. Postpartum depression and/or anxiety may have been present. Supporting a dysregulated baby is particularly challenging when a parent is affected by depression and/or anxiety. These babies often continue to have symptoms of dysregulation into the toddler and preschool years, with frequent tantrums, "not listening" or "explosive behavior." There is often a strong family history of "ADHD," substance abuse or other mental illnesses. This history is closely linked with current relationships. For example, if one parent has "ADHD," the child's behavior may be especially dysregulating for that parent. One parent who does not have "ADHD" may blame the other parent, resulting in marital discord. The child may have significant sensory processing challenges. The child may be developmentally immature and the youngest in a structured preschool program. Sleep disurbance on the part of both parent and child has a significant role to play in development of symptoms. There are as many variations to this narrative as there are families. Clinicians also need to be attentive to the fact that child maltreatment is a rare cause of "ADHD" that we do not want to miss, and must be considered.
Once parents have the opportunity to make sense of their child's symptoms, "what to do" follows naturally. Medication may, in a few cases, be indicated, particularly if a child's self esteem is suffering due to academic demands. But more often than not, the "what to do" is elsewhere. For example, a parent may need to do his own therapy to address troubled past relationships. A parent may take up yoga to manage the dysregulation her child's symptoms precipitate, so that she can remain calm in the face of his difficulties. Sleep disruptions are often part of the story and must be addressed. Marital counselling may be necessary. A good occupational therapist, who helps the family to manage the child's unique challenges in the context of relationships, can be invaluable.
Time, space and a nonjudgmental listener are essential first step in evaluation of any child with behavioral symptoms. The "why" must come before the "what." Then the "what to do"will follow naturally.
What I mean by "finding out the cause" is to give parents the space and time to tell their story, to make sense of their child's symptoms. The aim is not to determine if the child has enough symptoms to meet diagnositic criteria for a DSM defined disorder, but rather to support parents' efforts to find a coherent narrative. It involves starting with at least 1-2 full hour visits with both parents. I put "ADHD" in quotes because by giving the symptoms a name, as in "ADHD evaluation" we narrow our thinking before we even start. Ideally we listen to the family's story with an open minded curiosity.
The story often starts with a fussy or colicky baby. Even before this, there may have been stress in pregnancy which is known to be associated with advanced motor development and behavioral dysregulation in the newborn. Postpartum depression and/or anxiety may have been present. Supporting a dysregulated baby is particularly challenging when a parent is affected by depression and/or anxiety. These babies often continue to have symptoms of dysregulation into the toddler and preschool years, with frequent tantrums, "not listening" or "explosive behavior." There is often a strong family history of "ADHD," substance abuse or other mental illnesses. This history is closely linked with current relationships. For example, if one parent has "ADHD," the child's behavior may be especially dysregulating for that parent. One parent who does not have "ADHD" may blame the other parent, resulting in marital discord. The child may have significant sensory processing challenges. The child may be developmentally immature and the youngest in a structured preschool program. Sleep disurbance on the part of both parent and child has a significant role to play in development of symptoms. There are as many variations to this narrative as there are families. Clinicians also need to be attentive to the fact that child maltreatment is a rare cause of "ADHD" that we do not want to miss, and must be considered.
Once parents have the opportunity to make sense of their child's symptoms, "what to do" follows naturally. Medication may, in a few cases, be indicated, particularly if a child's self esteem is suffering due to academic demands. But more often than not, the "what to do" is elsewhere. For example, a parent may need to do his own therapy to address troubled past relationships. A parent may take up yoga to manage the dysregulation her child's symptoms precipitate, so that she can remain calm in the face of his difficulties. Sleep disruptions are often part of the story and must be addressed. Marital counselling may be necessary. A good occupational therapist, who helps the family to manage the child's unique challenges in the context of relationships, can be invaluable.
Time, space and a nonjudgmental listener are essential first step in evaluation of any child with behavioral symptoms. The "why" must come before the "what." Then the "what to do"will follow naturally.
Evidence mounts that our current approach to "ADHD" is way off base
An NIH funded study published last week in the Lancet revealed that five major mental health disorders- ADHD, autism, bipolar disorder, depression and schizophrenia- share genetic roots. The authors state that their findings blur diagnostic categories. They write:
Another study on ADHD published this week points to the problems inherent using this oversimplified diagnostic category. The study, published in Pediatrics, showed that not only do symptoms of ADHD persist into adulthood in 30% of cases, but there is also a significant amount of "co-morbidity," including these alarming statistics:
What we are calling "ADHD" is a constellation of symptoms that represent problems with regulation of attention, behavior, and emotion. The term itself gives the illusion that we know the specific biological mechanism in the way that we know how lack of insulin causes diabetes. This is however, far from true.
As the first study I refer to indicates, we are just beginning to learn about the underlying biology of mental illness, and those findings suggest that "ADHD" may be an artificial construct.
My clinical experience tells me that these genes they have described may be functionally related to sensory processing. Problems with sensory processing seem to be common to many diagnostic categories for mental illness that we currently use. However, children develop the capacity for self-regulation in the context of relationships. Identifying the problematic gene is only part of the answer. Understanding and addressing the environmental risk is the other.
If we consider the interplay of genetics and environment, then a third study published last week, this one also in Pediatrics, will point us in the direction of meaningful preventive intervention. This study identified the problem of postpartum anxiety, concluding that:
These results provide evidence relevant to the goal of moving beyond descriptive syndromes in psychiatry, and towards a nosology informed by disease cause.Epigenetics, or the environmental influence on gene expression, must immediately be brought in to any discussion of these important findings. "Cause" is related to a complex interplay between genetic risk and environmental effects.
Another study on ADHD published this week points to the problems inherent using this oversimplified diagnostic category. The study, published in Pediatrics, showed that not only do symptoms of ADHD persist into adulthood in 30% of cases, but there is also a significant amount of "co-morbidity," including these alarming statistics:
The study also found the risk for suicide was nearly five times higher among those diagnosed with ADHD than in the comparison group, and nearly 3% of study participants were in jail when recruited for the adult portion of the study.A review of the study published in USA today includes this telling line:
Symptoms[of ADHD] can be controlled by a combination of behavioral therapy and medication.Maybe the reason that so many people have such poor outcomes is that we are neglecting to understand the underlying cause of the problem and instead simply labeling and "managing" symptoms. These dismal long-term results, along with the similarly dismal results reported in the preschool ADHD study showing that 90 percent of children had signficant symptoms at 6 year follow up, state loud and clear that the way we approach what we are now calling "ADHD" is not working. We need to do something dramatically different from the current standard of care.
What we are calling "ADHD" is a constellation of symptoms that represent problems with regulation of attention, behavior, and emotion. The term itself gives the illusion that we know the specific biological mechanism in the way that we know how lack of insulin causes diabetes. This is however, far from true.
As the first study I refer to indicates, we are just beginning to learn about the underlying biology of mental illness, and those findings suggest that "ADHD" may be an artificial construct.
My clinical experience tells me that these genes they have described may be functionally related to sensory processing. Problems with sensory processing seem to be common to many diagnostic categories for mental illness that we currently use. However, children develop the capacity for self-regulation in the context of relationships. Identifying the problematic gene is only part of the answer. Understanding and addressing the environmental risk is the other.
If we consider the interplay of genetics and environment, then a third study published last week, this one also in Pediatrics, will point us in the direction of meaningful preventive intervention. This study identified the problem of postpartum anxiety, concluding that:
Postpartum state anxiety is a common, acute phenomenon during the maternity hospitalization that is associated with increased maternal health care utilization after discharge and reduced breastfeeding duration.Given what we already know about the risk of psychiatric disorders in children of parents struggling with depression, these findings only increase the urgency of focusing our resources on supporting parent-infant pairs. We need to help set development in a healthy direction from the start. Genetic vulnerabilities are present at birth, and if we devote maximum resources to supporting the environment, then we may significantly decrease the risk of those vulnerabilities manifesting as psychiatric illness.
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