"I know its my ADHD acting up," a mother of three young children recently said to me as an explanation for her inability to recall a particular piece of information. My observation, in the setting of my behavioral pediatrics practice, of increasing numbers of mothers of young children being diagnosed with ADHD is in keeping with a recent report from Express Scripts. This report, based on pharmacy claims data, showed a 53% rise in writing of prescriptions for ADHD in adults from 2008-2012, with "the largest gains seen in women age 26-34, climbing 85%."
A psychiatrist colleague of mine took this data at face value, saying that "ADHD is genetic" so with the rise in diagnosis in children, it makes perfect sense that there should be a parallel rise in diagnosis in adults.
But there are big holes in this argument. Certainly problems of regulation of attention, behavior and emotion, that are all called "ADHD," have a familial component. But we are far from identifying a specific genetic cause. These qualities, both in children and adults, represent a complex interplay between genetic vulnerability and environmental effects.
So how else might we explain this rise in writing of prescriptions for this group, many of whom are young mothers? In today's fast-paced society, parents of young children are often overextended and overwhelmed. In my practice many fathers work very long hours, leaving mothers alone to manage everything. In the absence of extended family this can be highly stressful. Physical activities such as yoga, running or even walking have a calming organizing effect on the brain, but often these mothers are unable to carve out time for themselves during the day. Sleep deprivation has a huge role to play. There is a well-established link between sleep deprivation and symptoms of distractibility, inattention, and hyperactivity. This may be an inevitable part of parenting young children. But often there are ways to improve sleep if parents have the opportunity to make sense of the situation and take the time to fix it. But often there is not this time, so families get stuck in a reactive mode, with a vicious cycle setting in as lack of sleep makes them increasingly less able to think clearly.
I have concerns about this trend of diagnosing and treating ADHD, particularly in this population of young mothers. If we label this behavior as a disorder and prescribe a pill, we are not placing responsibility (blame) squarely on the mother? Do we not have a responsibility as a society to care for mothers to support their efforts to care for the next generation? Will the motivation to find more creative solutions, such as flexible parental leave, and valuing of self-care (the airlines recognize this need in the instruction to adjust your own oxygen mask before your children's) be lost?
These medications are not without harmful effects. About a year ago, a young woman, not a mother but in this age group, wrote poignantly in the New York Times of her struggle with Adderall addiction that took hold in an environment of ever increasing demands for productivity.
I am probably not alone in wondering about an alternative explanation to that of my psychiatrist colleague. Clearly this trend is a boon for the pharmaceutical industry. Could it be that some very clever people in marketing saw an opportunity, and set about selling "Adult ADHD" to both a general and a professional audience? If so, they have certainly been very successful.
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28 Ocak 2016 Perşembe
Take new smartphone use study with a hefty dose of empathy for parents
A new study documenting the ubiquitous use of smartphones by parents at fast food restaurants with their young children is getting a lot of media attention. From Time magazine there is this headline: " Don't Text While Parenting- It Will Make You Cranky." "Put Down that Cellphone" from NBC. "Parents on Smartphone Ignore Their Kids," from ABC News.
I doubt that anyone is surprised by the findings of this study. People everywhere are on their smartphones all the time. In the arena of parenting, it is important to call attention to the impact of this behavior. There is extensive evidence that face-to-face interaction is critical for healthy emotional development. Mealtime offers an important opportunity for this type of interaction, especially in today's fast-paced culture.
However, I worry about the parent blaming tone of these headlines. Rather than saying, "This is bad, don't do it," perhaps we should be curious about why parents are using smartphones in this way.
One answer lies the increasing recognition of the addictive nature of these devices. Everyone, not just parents in fast food restaurants, is using smartphones all the time. The other may lie in the fact that parents, especially parents of young children, often feel alone, stressed and overwhelmed. Putting these two together and the allure of the screen becomes understandable.
The American Academy of Pediatrics press release states:
I doubt that anyone is surprised by the findings of this study. People everywhere are on their smartphones all the time. In the arena of parenting, it is important to call attention to the impact of this behavior. There is extensive evidence that face-to-face interaction is critical for healthy emotional development. Mealtime offers an important opportunity for this type of interaction, especially in today's fast-paced culture.
However, I worry about the parent blaming tone of these headlines. Rather than saying, "This is bad, don't do it," perhaps we should be curious about why parents are using smartphones in this way.
One answer lies the increasing recognition of the addictive nature of these devices. Everyone, not just parents in fast food restaurants, is using smartphones all the time. The other may lie in the fact that parents, especially parents of young children, often feel alone, stressed and overwhelmed. Putting these two together and the allure of the screen becomes understandable.
The American Academy of Pediatrics press release states:
The study raises several questions for future research, including ...what are the long-term effects on child development from caregivers who frequently become absorbed with a device while spending time with their children.I think we already know the answer to this question. I wonder if another important question might read: "How do we support parents in being more fully present with their young children, given the combination of high stress and an easy available, socially acceptable addictive device?"
ADHD, bipolar disorder and the DSM: A need for uncertainty?
A recent article in the New Republic, provocatively titled “ADHD Does Not Exist,” starts out well enough. The author, a psychiatrist with “over 50 years experience” points to the fact that ADHD describes a collection of symptoms, rather than their underlying cause. Using stimulants to control these symptoms, he argues, is analogous to prescribing pain medication for cardiac chest pain rather than addressing the underlying circulatory problem. But my antennae went up when he applied his views to a case, and concluded that his patient, a 12-year-old-boy, was misdiagnosed with ADHD, when in fact he had bipolar disorder. My level of alarm rose when he went on to describe his treatment:
In William’s case, the family agreed to try medication first without psychotherapy, to see what kind of impact the pharmaceutical treatment could have. The first medication we tried, an anti-seizure drug commonly prescribed for bipolar disorder, reduced the boy’s mood and behavioral symptoms dramatically but resulted in side effects including upset stomach and dizziness. We started William on lithium, and within two months we found a dosage that worked well for him, reducing his symptoms to very mild levels, with no significant side effects.
There is no mention of developmental history or family relationships. There is no exploration of the context in which these symptoms occur, and certainly no evidence that William’s experience being bounced from medication to medication is being considered. Dr. Saul in essence replaces one treatment of symptoms without determining the underlying cause with another treatment of symptoms without addressing the underlying cause.
The author points to a strong family history of bipolar disorder to support his diagnosis. Statistics from the National Institute of Mental Health indicate that when a parent or sibling has bipolar disorder, a child is up to six times more likely to develop the illness.
But when it comes to an individual child and family, not only are statistics meaningless, but they may also preclude exploration of the underlying cause of the child’s symptoms. These symptoms are usually due to a complex interplay of biology and environment. Statistics do not speak to the effect of early intervention in decreasing the risk.
Consider Jacob, a five-year-old boy I saw recently in my behavioral pediatrics practice. He was adopted, and two biological relatives had bipolar disorder. A pediatrician, his adoptive parents and a neurologist suspected that he too had the disorder. But with space and time to hear the story, the following emerged.
Consider Jacob, a five-year-old boy I saw recently in my behavioral pediatrics practice. He was adopted, and two biological relatives had bipolar disorder. A pediatrician, his adoptive parents and a neurologist suspected that he too had the disorder. But with space and time to hear the story, the following emerged.
Jacob had been an easy baby. Then when he was about two, he experienced a number of significant losses. A foster child with whom he was very close was removed from the home because of behavior problems. Just weeks after his adoptive mother, Alice, learned she was pregnant, her sister died suddenly of a cerebral hemorrhage. Jacob’s maternal grandmother, in the face of the loss of her own daughter, threw herself in to caring for Jacob’s baby sister.
Jacob’s mother wept in my office as she spoke of her own loss, not only of her sister, but also of her mother who withdrew in the face of her grief. Shortly after these events, Jacob’s behavior problems began in earnest. He became alternatively clingy and aggressive. When I saw the family, no one had slept through the night for a long time.
Jacob’s mother wept in my office as she spoke of her own loss, not only of her sister, but also of her mother who withdrew in the face of her grief. Shortly after these events, Jacob’s behavior problems began in earnest. He became alternatively clingy and aggressive. When I saw the family, no one had slept through the night for a long time.
Jacob might very well have a biological vulnerability to emotional dysregulation inherited from his parents who carried the bipolar label. But multiple losses, subsequent disruptions in attachment relationships, sleep disruption, and other factors had significant roles to play in development of his symptoms. Had he, like William, been prescribed medication for his symptoms, this story, and the meaning of his behavior, would not have been heard. For every child I see in my practice, there is a story, often equally complex, behind the symptoms.
Rather than offer time and space for the nuances, complexities and uncertainties of human behavior and relationships, the DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm, with its diagnoses of disorders based on symptoms, often followed by prescribing of medication, creates an aura of certainty, as in “you have X and the treatment is Y.” But there is virtually no evidence of any known biological processes corresponding to either ADHD or bipolar disorder (or any other DSM diagnoses, for that matter.) This certainty implied in the giving of a diagnosis and prescribing of medication has a kind of comfort, but also a real danger. There is no room for curiosity, for wonder, for not knowing. Jacob’s behavior was a form of communication. Giving medication to control his behavior is in effect a silencing of that communication.
A recent New York Times article, “The Dangers of Certainty,” addresses this issue in a very different context. The author describes how he was profoundly influenced by the 1973 BBC documentary series, “The Ascent of Man,” hosted by Dr. Jacob Bronowski. The article describes an episode in which Bronowski discusses Heisenberg’s uncertainty principle.
Dr. Bronowski’s 11th essay took him to the ancient university city of Göttingen in Germany, to explain the genesis of Werner Heisenberg’s uncertainty principle in the hugely creative milieu that surrounded the physicist Max Born in the 1920s. Dr. Bronowski insisted that the principle of uncertainty was a misnomer, because it gives the impression that in science (and outside of it) we are always uncertain. But this is wrong. Knowledge is precise, but that precision is confined within a certain toleration of uncertainty….Dr. Bronowski thought that the uncertainty principle should therefore be called the principle of tolerance. Pursuing knowledge means accepting uncertainty. ..In the everyday world, we do not just accept a lack of ultimate exactitude with a melancholic shrug, but we constantly employ such inexactitude in our relations with other people. Our relations with others also require a principle of tolerance. We encounter other people across a gray area of negotiation and approximation. Such is the business of listening and the back and forth of conversation and social interaction.
As he eloquently put it, “Human knowledge is personal and responsible, an unending adventure at the edge of uncertainty.”The relationship between humans and nature and humans and other humans can take place only within a certain play of tolerance. Insisting on certainty, by contrast, leads ineluctably to arrogance and dogma based on ignorance.
The episode takes a dark turn when the scene shifts to Auschwitz, where many members of Bonowski’s family were murdered. The article’s author, a professor of philosophy at the New School, offers this interpretation:
The pursuit of scientific knowledge is as personal an act as lifting a paintbrush or writing a poem, and they are both profoundly human. If the human condition is defined by limitedness, then this is a glorious fact because it is a moral limitedness rooted in a faith in the power of the imagination, our sense of responsibility and our acceptance of our fallibility. We always have to acknowledge that we might be mistaken. When we forget that, then we forget ourselves and the worst can happen.
I can already hear the shouts of outrage that I dare to compare mental health care with Nazism. Having grandparents who survived a concentration camp, I know well that this is a highly fraught subject. But of course that is not what I am doing. I am simply pointing to this article as a beautiful articulation of the value of uncertainty, especially in the context of understanding human behavior.
Lessons from Atticus: is "ADHD" a problem of not listening?
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.
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.
Music and mental health: a tribute to Pete Seeger
This morning while driving my son and two friends to practice for their high school singing group, we listened, as part of an NPR report on his death at age 94, to Pete Seeger tell the story of his song Where Have All the Flowers Gone. His voice, his message and his music together had a profound calming effect on me, and I suspect on my passengers as well. There was quiet, and perhaps even a tear shed by others besides me.
In my behavioral pediatrics practice I make a point of asking about a child's interest in music. Whether the presenting problem is one of anxiety, frequent meltdowns, inattention, hyperactivity, or a range of other concerns, I have found that music often has a calming effect. One little girl, whose mother was under considerable pressure to have her diagnosed with ADHD and put on medication, stopped her scattered and frenetic play to sing me a song. Another, struggling with social anxiety, who for much of the visit refused to speak, at first with his back to me and then with increasing boldness, did the same. When parents see this effect of music on their child, they are moved to incorporate music in to our efforts to support development of emotional regulation. Problems with emotional regulation are central to all of these behavioral symptoms.
I was in need of emotional regulation myself this morning after spending the weekend embroiled in a difficult discussion about the subject of "ADHD." In a conversation on a list serve made up primarily of child psychiatrists, I pointed to a recent study about ADHD that showed very poor long-term outcome. I wondered if there might be an alternative explanation to that offered by the authors of the study, namely that ADHD is a chronic illness that requires lifelong treatment. Could it be, I asked, that the poor long-term outcome is because we are not properly treating the problem in the first place? That when we diagnose based on symptoms alone, and treat with behavior management and medication, we fail to address the full complexity of symptoms of dysregulation of attention, behavior, and emotion? I wondered how we would separate this issue from the possible long-term effects of stimulant medication itself.
I got a huge amount of push back, with a number of people implying that I was "unscientific," and that I might be affiliated with the church of Scientology. Given that there is extensive scientific evidence supporting an alternative paradigm for understanding symptoms of dysregulation of attention, behavior and emotion, this suggestion particularly got under my skin.
Not only music, but dance, martial arts, yoga and other activities have an important role to play in self-regulation. This is particularly true for children who have biological vulnerability to dysregulation, including those with problems of sensory processing. All of these activities occur in the context of important relationships, relationships that themselves are essential to development of emotional regulation. My little patients perform their songs in the context of a growing relationship with me.
But if we employ a purely medical model, diagnose ADHD, anxiety or any range of problems using the DSM ( Diagnostic and Statistical Manuel of Mental Disorders), we miss the relational and historical context of these symptoms. We need to offer room to hear the individual story of a child and his family in order to make sense of his symptoms. This story is itself can be a kind of music. Dar Williams incredible song "After All" offers a beautiful example.
When children present with a range of behavioral symptoms, if we simply "manage behavior" and treat with medication, where is there room for the music?
Arlo Guthrie, who frequently performed with Seeger, in his song Alice's Restaurant, proposed that everyone being evaluated for the draft walk in singing the chorus of his song, and in doing so create an anti-war movement.
Borrowing the idea, espoused by both Arlo and Pete, of changing the world with music, what if every new evaluation of a child with a behavior problem included singing and/or listening to one of Pete's songs? It might help calm everyone down-parent, clinician, and child alike. If, in turn, the next generation were helped to develop in a healthy way, with an ability to think creatively and engage effectively in a complex social environment, it might change the world.
In my behavioral pediatrics practice I make a point of asking about a child's interest in music. Whether the presenting problem is one of anxiety, frequent meltdowns, inattention, hyperactivity, or a range of other concerns, I have found that music often has a calming effect. One little girl, whose mother was under considerable pressure to have her diagnosed with ADHD and put on medication, stopped her scattered and frenetic play to sing me a song. Another, struggling with social anxiety, who for much of the visit refused to speak, at first with his back to me and then with increasing boldness, did the same. When parents see this effect of music on their child, they are moved to incorporate music in to our efforts to support development of emotional regulation. Problems with emotional regulation are central to all of these behavioral symptoms.
I was in need of emotional regulation myself this morning after spending the weekend embroiled in a difficult discussion about the subject of "ADHD." In a conversation on a list serve made up primarily of child psychiatrists, I pointed to a recent study about ADHD that showed very poor long-term outcome. I wondered if there might be an alternative explanation to that offered by the authors of the study, namely that ADHD is a chronic illness that requires lifelong treatment. Could it be, I asked, that the poor long-term outcome is because we are not properly treating the problem in the first place? That when we diagnose based on symptoms alone, and treat with behavior management and medication, we fail to address the full complexity of symptoms of dysregulation of attention, behavior, and emotion? I wondered how we would separate this issue from the possible long-term effects of stimulant medication itself.
I got a huge amount of push back, with a number of people implying that I was "unscientific," and that I might be affiliated with the church of Scientology. Given that there is extensive scientific evidence supporting an alternative paradigm for understanding symptoms of dysregulation of attention, behavior and emotion, this suggestion particularly got under my skin.
Not only music, but dance, martial arts, yoga and other activities have an important role to play in self-regulation. This is particularly true for children who have biological vulnerability to dysregulation, including those with problems of sensory processing. All of these activities occur in the context of important relationships, relationships that themselves are essential to development of emotional regulation. My little patients perform their songs in the context of a growing relationship with me.
But if we employ a purely medical model, diagnose ADHD, anxiety or any range of problems using the DSM ( Diagnostic and Statistical Manuel of Mental Disorders), we miss the relational and historical context of these symptoms. We need to offer room to hear the individual story of a child and his family in order to make sense of his symptoms. This story is itself can be a kind of music. Dar Williams incredible song "After All" offers a beautiful example.
When children present with a range of behavioral symptoms, if we simply "manage behavior" and treat with medication, where is there room for the music?
Arlo Guthrie, who frequently performed with Seeger, in his song Alice's Restaurant, proposed that everyone being evaluated for the draft walk in singing the chorus of his song, and in doing so create an anti-war movement.
Borrowing the idea, espoused by both Arlo and Pete, of changing the world with music, what if every new evaluation of a child with a behavior problem included singing and/or listening to one of Pete's songs? It might help calm everyone down-parent, clinician, and child alike. If, in turn, the next generation were helped to develop in a healthy way, with an ability to think creatively and engage effectively in a complex social environment, it might change the world.
The Time-Out Wars: A Case for Curiosity
Dan Siegel's new book No-Drama Discipline is calling attention to our innate need for connection. In his Time magazine piece provocatively titled Time-Outs Are Hurting Your Child he writes:
The problem is, children have a profound need for connection. Decades of research in attachment demonstrate that particularly in times of distress, we need to be near and be soothed by the people who care for us. But when children lose emotional control, parents often put them in their room or by themselves in the “naughty chair,” meaning that in this moment of emotional distress they have to suffer alone.
Not surprisingly, his views are causing significant backlash from the pediatric community. This is from the Journal of Developmental and Behavioral Pediatrics
TIME magazine recently highlighted an editorial by Drs. Daniel J. Siegel and Tina Payne Bryson in their parenting section. In it, the authors claim that the time-honored tradition of time-out for discipline may actually be harming our children as a form of traumatizing experience. This has caused a wave of black lash from the behavioral health community, who retort that Drs. Siegel and Payne Bryson's claims are not only unsupported by research, but show a lack of understanding of proper use of time-out.
Extreme views generate publicity and lots of “hits” A more nuanced view is less popular in social media, as evidenced by this wise blog post on Psychology Today that got a meager 25 tweets:
To me, “time-ins” don’t solve it. But the concept does expose a nuance of giving time-outs that we don’t talk about enough. Namely, there’s a massive difference between giving your child a time out in anger and giving your child a time out in a loving, calm way. Too often we apply the technique, but not the spirit of technique. Time-outs are meant to deescalate a volatile situation and to help our children regain control, as much as they are to provide a consequence for unruly behavior.
The essence of Dan Siegel’s point is not to leave a child alone with out-of-control feelings. It is not the time out per se but rather the sense of abandonment that is potentially harmful. I articulate this point in a previous post entitled Never Leave a Child Alone During a Meltdown.
When a child is repeatedly abandoned both physically and emotionally in the middle of a meltdown, that experience in itself may be traumatic. In such a situation frequency and intensity of meltdowns often worsens.
A recent American Academy of Pediatrics document Bringing Out the Best in Your Child makes the important distinction between discipline, which means to teach, and punishment, which is rarely effective in changing behavior in a positive way. For young children, a matter-of-fact time out in the face of biting or hitting can help to teach them that this behavior is unacceptable. The shortcoming of this document is that it is very focused on the behavior, rather than the meaning of the behavior.
Taking time to listen to our child, and to take care of ourselves, is key. Rather than an either-or approach, a stance of wondering, of curiosity, will lead to the answer of “what to do.” We might ask the question, why is my child feeling out-of-control? Is he stressed from fatigue or hunger? Is he responding to tension in the home from marital conflict, a new sibling, or a parent’s new job with long hours? And what about my child’s behavior is provoking such anger, anxiety or some other intense response in me? Is it my fear that he will suffer as I did as a child with similar challenges? Is it my embarrassment, or even worse, shame, that I am not a good parent? Am I feeling alone and abandoned myself, by a spouse or parent, and so unable to tolerate my child’s need for me? When parents feel recognized and understood, they are better able to listen to their child. They are better able to connect with their natural intuition. They know "what to do."
Our ability to find meaning in behavior is essential to our humanity. Listening, being present in a way that supports connection, leads to healthy development. It is not so much about “what to do” as “how to be.” We are a culture of advice and quick fixes. Dr. Siegel's book is rich with important information and ideas. However, perhaps rather than spending precious free time reading another "how-to" parenting guide, taking a walk with a friend or going to a yoga class might be a better use of parents' all-too-limited time for themselves.
Misuse of ADHD label as symptom of a broken health care system
When the American Academy of Pediatrics came out with new guidelines a couple of years ago extending the age of diagnosis of ADHD (attention deficit hyperactivity disorder) down to age 4, it seemed as if Pfizer might have been waiting in the wings. Soon after, a new preparation of ADHD medication in an oral suspension, for kids too young to swallow pills, became available.
I was a lone voice expressing opposition to this change in the guidelines. As a primary care pediatrician I saw up close how the diagnosis was made based on symptoms alone, missing complex underlying problems. As the standard of care is to treat what we call "ADHD" with medication and/or "behavior management" these problems, which can include a history of abuse and neglect, family substance abuse, ongoing marital and family conflict, and history of significant loss, are not addressed. As the standard of care is also to see these kids every three months for brief follow up, these issues can go unaddressed for many years, as the focus of care becomes adjustment of dose and preparation of medication.
The reason this happens is not because these primary care clinicians are unaware of these underlying problems. It is because the burden of care for children with the constellation of the symptoms of dysregulation of attention, behavior, and emotion, that we now call ADHD, falls almost exclusively on their shoulders.
The economic reality of primary care practice, due in large part to the administrative costs of managing a huge array of different health care plans, is that clinicians are under pressure to see more and more patients in less and less time. Add to that the severe shortage of quality mental health care services, and the primary care clinician is really stuck. The appeal, both for parent and clinician, of a drug that can be very effective in controlling the symptoms of an out-of-control 4-year-old, is understandable.
Whenever I write about this subject, I get a barrage of comments from parents saying things like, "but my child really has ADHD." Therefore, I want to state clearly that I am referring to a public health problem, not to one specific child. In fact, if the system were not broken, I would not need to be writing all these blog posts about the misuse of the ADHD label. Children who are struggling in the ways I have described would be able to get the care they need.
If a broken health care system is the problem (a problem that extends beyond my level of expertise), what can we do for these symptomatic 4-year-olds?
Here is where a model of preventive mental health care comes in. When a child is symptomatic at 4, it is very likely that the roots of the problem were present at three, two or even in infancy. Recently, after I gave Dewald lecture at the St Louis Psychoanalytic Institute on this proposed model, I had the opportunity to have breakfast with a group of infant mental health colleagues. We spoke about what we termed "the nice lady (or man) down the hall" model.
A primary care practice would incorporate in to their team a mental health clinician trained to work with young children and parents together. The primary care clinician would have easy access to this clinician, who would work in collaboration with the primary care team. Ideally there would also be a team of such early childhood mental health specialists, including an occupational therapist.
When children are young, and their brains are rapidly growing, a brief intervention, such as several hour-long visit over a several month period, can go a long way towards placing that child and family on a different developmental path. It makes sense, both clinical and economic sense, to invest the greatest resources in care for this age group. By the time the child is in school, the problems have become more complex and entrenched.
There has been a lot of work lately on screening for mental health concerns in the 0-5 age population. It is imperative that we develop adequate model of treatment before screening is put in place. If such treatment is not in place first, large scale screening will likely insure that the folks at Pfizer who developed this new liquid form of ADHD medication will do very well.
Antipsychotics for ADHD: A Big Unknown
Polypharmacy, or use of multiple psychiatric drugs, for treatment of Attention Deficit Hyperactivity Disorder(ADHD) is on the rise. A recent study compared treatment with "basic therapy"-stimulants plus parent training- with "augmented therapy" those two plus risperidone, an atypical antipsychotic. The study concluded that treatment with risperidone was "superior."
When children show dramatic improvements in behavior on risperidone, now being prescribed with increasing frequency for ADHD and a range of other disorders that represent difficulty with emotional regulation, we need to ask ourselves one question. Does this change in behavior represent increased capacity for organization and self-regulation, or does it reflect a kind of compliance?
When children show dramatic improvements in behavior on risperidone, now being prescribed with increasing frequency for ADHD and a range of other disorders that represent difficulty with emotional regulation, we need to ask ourselves one question. Does this change in behavior represent increased capacity for organization and self-regulation, or does it reflect a kind of compliance?
We have over 40 years of longitudinal research in developmental psychology showing that safe, secure relationships support development of the capacity for emotional regulation, cognitive resourcefulness and social adaptation. We have evidence from the field of epigenetics that these relationships, through changes to gene expression, change the structure and function of the brain.
When children struggle with emotional and behavioral regulation, many evidence-based interventions can support development of these capacities. These include child-parent psychotherapy, DIR floortime, the Neurosequential Model of Therapeutics, and mentalization based treatment. These relationship-based interventions foster our innate need for connection.
The mechanism of action of risperidone is to block dopamine receptors in the cortex. We do not know what changes in the lower regulatory centers of the brain, if any, are occurring. It is possible that these centers remain dysregulated, and that this dysregulated signal is blocked by the medication. The antipsychotic might promote compliance, with improvement in behavior, but the underlying disorganization might remain. If that is the case, then the medication is not changing the brain in the way that we know relationships can change the brain.
This is an important question to answer. It goes well beyond the known significant side effects of antipsychotics. For when medication is so effective at controlling behavior, the motivation for investing time and effort in relationship-based interventions may be lost. Prescribing medication takes much less time. With atypical antipsychotics the results are often immediate, and can be dramatic.
If risperidone is found to significantly alter the brain’s capacity for emotional regulation, then it might have a role to play. But if it does not, and we have well-established methods of intervention that do, then the possibility exists that by prescribing this medication to children, particularly in the absence of relationship-based interventions, we are actively interfering in their development.
I am hopeful that all professionals who strive to promote healthy development in children can work to answer this question in a timely manner.
Are iPad attachments for bouncy seats and potty seats a violation of infants rights?
I was contemplating writing a blog post about the movement by the Boston-based advocacy group Campaign for a Commercial Free Childhood urging Fisher-Price to recall the baby bouncy seat with an attachment for insertion of an iPad. When I then received an email from a colleague with a link for another product- a potty seat with an attachment for an iPad- there was no going back. I decided not to include the link to that product so as not to inadvertently be a source of free advertising, but it is easy to find.
In our technology driven culture, a position maintaining that we need to put on the brakes is a challenging one to take. The force of "progress" is so powerful that one runs the risk of seeming out-of-touch or old fashioned. But in these two products I believe we have come face-to-face with exploitation of children ( and their parents) or what I have described in a previous post as a "prejudice" against children. I would even go so far as to say it is a violation of infants' rights.
In today's society, where parents are often living in a state of high stress, with little support, either practical or emotional, the appeal of these products is very understandable. The allure of the screen is equally, if not more powerful for the infant. So from a marketing perspective, from a moneymaking perspective, it is a recipe for success.
I became aware of the concept of infants' rights in my role as a board member of the Massachusetts chapter of the World Association of Infant Mental Health. A preliminary version the Declaration of Infants' Rights, a work in progress, reads:
Turning to the Ipad in the bouncy seat, the possible effects are more insidious and diffuse. Sitting in the bouncy seat in kitchen watching mom or dad prepare dinner is a time of great learning; a time of significant brain development. This learning occurs both through direct interactions with adults and older siblings, as well as through observation. The iPad interferes with both. As CCFC writes:
In our technology driven culture, a position maintaining that we need to put on the brakes is a challenging one to take. The force of "progress" is so powerful that one runs the risk of seeming out-of-touch or old fashioned. But in these two products I believe we have come face-to-face with exploitation of children ( and their parents) or what I have described in a previous post as a "prejudice" against children. I would even go so far as to say it is a violation of infants' rights.
In today's society, where parents are often living in a state of high stress, with little support, either practical or emotional, the appeal of these products is very understandable. The allure of the screen is equally, if not more powerful for the infant. So from a marketing perspective, from a moneymaking perspective, it is a recipe for success.
I became aware of the concept of infants' rights in my role as a board member of the Massachusetts chapter of the World Association of Infant Mental Health. A preliminary version the Declaration of Infants' Rights, a work in progress, reads:
The young child’s capacity to experience, regulate, and express emotions, form close and secure relationships, and explore the environment and learn are fundamental to mental as well as physical and developmental health throughout the life span.So how do these products violate these rights? Lets start with toilet training. Recently I had the opportunity to write the parent guide for a new children's book, Potty Palooza. I identify the relational nature of toilet training:
Toilet training occurs in relationships. This includes a child’s relationship with his body, as well as his relationship with you. Toilet training will occur under the influence of a child’s inborn desire for mastery in relation to his body. A normal developmental movement toward separation and independence, together with your child’s wish to be like you and to please you, will move the process forward.I do not know what will happen if you insert a screen between parent and child as part of this process (and sitting on the potty with a book is an entirely different experience.) It is likely that the draw of the screen will interfere with a child's ability to read his body's natural signals. The desire for treasured "screen time" will become the motivation for sitting on the potty, replacing his natural motivation to please his parents and to gain mastery over his body in a healthy way.
Turning to the Ipad in the bouncy seat, the possible effects are more insidious and diffuse. Sitting in the bouncy seat in kitchen watching mom or dad prepare dinner is a time of great learning; a time of significant brain development. This learning occurs both through direct interactions with adults and older siblings, as well as through observation. The iPad interferes with both. As CCFC writes:
The Apptivity Seat is the ultimate electronic baby sitter. Because screens can be mesmerizing and babies are strapped down and “safely" restrained, it encourages parents to leave infants all alone with an iPad. To make matters worse, Fisher-Price is marketing the Apptivity Seat—and claiming it’s educational—for newborns. Parents are encouraged to download “early learning apps” that claim to “introduce baby to letters, numbers and more.” There’s no evidence that babies benefit from screen time and some evidence that it might be harmful. That’s why the American Academy of Pediatrics discourages any screen time for children under two.Extensive evidence at the interface of neuroscience and developmental psychology shows how the brain is wired in relationships, with the most rapid brain growth occurring in the first three years. Instead of making products that come between parent and infant, our focus needs to be on supporting early caregiver-infant relationships, in the form of such things as parental leave, quality childcare and screening for and treatment of postpartum depression.
Protecting a space for parenting in an age of expert advice
In my behavioral pediatrics practice, it never ceases to amaze me how, given the space and time, parents come around to making sense of their child's "difficult" behavior without my giving "advice" about "what to do." They may recognize that they share a trait with their child that has troubled them their whole life. They may become tearful, thinking of how that child represents a lost loved one. There are countless variations. The process of telling the story, of finding the meaning in the behavior, is often itself the treatment. Once parents have these insights, "what to do" follows naturally. In contrast, if I give advice without a full understanding of the story, things may not go well.
Recently in working on a new book, I have had the pleasure of returning to a close look at the work of D. W. Winnicott, pediatrician turned psychoanalyst and a kind of British Dr. Spock. In my review of his writings on the subject of advice, I came across a wonderful piece from this past spring in The Guardian: Mothers on the naughty step: the growth of the parenting advice industry, that references Winnicott.
When we talk about parents and children, we are talking about passionate love relationships. The feelings are deep, intense and sometimes painful. It makes sense that we might choose to avoid them. But this is not a long-term solution. We would do well to instead make a space for them, starting from birth.
I borrowed this phrase "protecting a space" from my good friend Gale Pryor, who's wonderful book Nursing Mother, Working Mother was also heavily influenced by Winnicott. In such a space parents can connect with their natural intuition. It is in this space that we give room for healthy development of parent and child together.
Recently in working on a new book, I have had the pleasure of returning to a close look at the work of D. W. Winnicott, pediatrician turned psychoanalyst and a kind of British Dr. Spock. In my review of his writings on the subject of advice, I came across a wonderful piece from this past spring in The Guardian: Mothers on the naughty step: the growth of the parenting advice industry, that references Winnicott.
Winnicott abhorred the idea of giving advice. He believed that when mothers tried to do things by the book – or by the wireless: "They lose touch with their own ability to act without knowing exactly what is right and what is wrong." Yet today there are far more parenting advice books (each with their own regime to promote) than 30 years ago, and the radio and TV schedules are full of programmes such as Supernanny, which train a critical eye on what are generally called parents but most of us understand to be mothers. It sometimes seems it is mothers, rather than children, who are being dispatched to the naughty step...
Winnicott feared that focusing on pathological families rather than "the ordinary devoted mother and her baby" (the title of his most famous series) could excite anxiety in listeners without access to therapy. "I cannot tell you exactly what to do," he said, "but I can talk about what it all means." And so he did, extolling the role of the good enough mother – one who can be loved, hated and depended on – in enabling the baby to develop into a healthy, independent, adult. While many of today's parenting gurus focus on a child's deviant behaviour and the contribution of supposed misparenting, Winnicott tried to help mothers understand the significance of their child's behaviour, whether it was "cloth-sucking" or a display of jealousy, and the ways that they instinctively contained their child's anxieties.The author refers to the British program "Supernanny," the "high priestess of behaviorist parenting."
Tracey Jensen, lecturer in media and cultural studies at Newcastle University, says Supernanny reverses Winnicott, offering up the spectacle of the "bad enough mother", usually working-class, who is shamed before she is transformed. Jensen watched the programme with a group of mothers, relieved that it was not their parenting practices being scrutinised, but those of someone else onto whom all their own worries and fears could be displaced. But they also shouted back at the programme, discomfited by the judgment and humiliation meted out to the mothers featured. Such series foster the very anxiety they claim to assuage, and substitute "training" for thinking and feeling.This last phrase captures the essence of the issue. I shudder whenever I see the term "parent training." But this phrase, as well as others such as "management of symptoms" or "parent education" are pervasive in our culture. These kinds of interventions may improve behavior in the short term. But if they substitute for "thinking and feeling" it is likely that symptoms will re-emerge at a later date, in a different form.
When we talk about parents and children, we are talking about passionate love relationships. The feelings are deep, intense and sometimes painful. It makes sense that we might choose to avoid them. But this is not a long-term solution. We would do well to instead make a space for them, starting from birth.
I borrowed this phrase "protecting a space" from my good friend Gale Pryor, who's wonderful book Nursing Mother, Working Mother was also heavily influenced by Winnicott. In such a space parents can connect with their natural intuition. It is in this space that we give room for healthy development of parent and child together.
Mourning and music: a song for Boston
I had been working on a post on the subject of mourning and music. But with the trauma of the Boston Marathon bombing still so fresh, it did not seem appropriate to write about any other subject. I wondered, what could I add to the discussion? Then this morning, with the idea of music as a means to connect with feelings on my mind, I heard on the radio the song Learn Me Right by Mumford and Sons. The lyrics, specifically the chorus (not the verses), are perfectly fitting to the moment, though the "scream" with hope will be one of joy, not terror. And the music, particularly the version performed by Birdy for the movie Brave, captures the spirit of resilience. It can represent hope for the triumph of the people of Boston and of the Marathon itself. It may not be everyone's cup of tea, but for me, and perhaps for others, the music can help connect with the feelings of the day.
We will run and scream
You will dance with me
We’ll fulfill our dreams and we’ll be free
We will be who we are
And they’ll heal our scars
Sadness will be far away
You will dance with me
We’ll fulfill our dreams and we’ll be free
We will be who we are
And they’ll heal our scars
Sadness will be far away
27 Ocak 2016 Çarşamba
Is ADHD a real disorder? Part 2
A number of people commented that my previous post seemed unfinished in that I did not offer an alternative approach. This is a valid point, and in part due to the fact that my household has been under siege by the flu. I decided to republish a post from two years ago (before I wrote for the Globe.) It offers an example of my approach, which I describe in detail, along with the research to support it, in my book Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes.
Holding A Child in Mind
Sam burst into the office, a two-year-old wild bundle of energy. Squealing with delight--or was it distress; it was hard to tell--he ran from toy to toy not looking at me or his mother, Jane. He was unable to engage with anything. Jane had brought him to see me in my pediatric practice because, “he hits me, has explosive tantrums, and I can’t take him anywhere.” She sank into the couch. I sat on the floor, wanting to listen to Jane, but also to include Sam in the visit. At first, I focused my attention on her story, while Sam continued his frantic exploration of the room.
Jane described a scene at the playground. The other mothers had been engaged in easy conversation, but she was on edge. She knew Sam was “inflexible” and at any moment could go from happy play to a full-blown tantrum. Sure enough, as she tried to join in the group, she saw him getting upset because his toy car was stuck. She rushed over to calm him, but his crying escalated. As the other kids and moms turned to look, she quickly went from embarrassment to rage. She yelled at Sam to cut it out. This only made him scream more. Finally, she grabbed him, her bag and his toys and ran to her car, where she collapsed in tears of helplessness.
Things had not been easy for Jane. Sam’s father had abused her and was in prison. She was afraid when she felt Sam’s anger that he would turn out like his father. Of her own mother she said, “She was never there for me.” Jane was frustrated and bewildered by the fact that Sam could relate to other people, yet reserved all his difficult behavior for her.
At the beginning of the visit, Jane made several awkward attempts to interact with Sam, but without success. She was anxious and her body language felt intrusive, which seemed to cause Sam to withdraw. As she opened up and shared more of her painful feelings with me, however, an interesting transformation occurred. Sam began to engage in more focused play. Mom and I talked about what Sam was doing, observing together how he was calming down. At first he talked to me, bringing me toys and naming them and describing what he was doing. But then he spontaneously ran over and gave his mother a hug. Her whole body relaxed, she leaned forward on the couch toward him, her pleasure and relief palpable in the room. Sam began to engage her in his play, and to communicate with her. Jane told me that she had been reluctant to come for the appointment, but was glad she had.
Being a parent of such a child is a hard job. Raising a child alone, without support from extended family or a spouse, is even harder. In our culture of advice and quick fixes, in seeking help for her problems with him, Sam’s mother would find many who would offer “expert” advice about how to manage her child’s behavior. An increasing number would recommend some type of medication to control his “hyperactivity.” Helping her to be fully emotionally present with her child--supporting her in the challenges she faced as a mother--is not a common approach.
Yet current research at the interface of developmental psychology, neuroscience and behavioral genetics is showing that it is just this type of intervention that will help children like Sam to manage strong emotions and relate to other people. A child’s mind grows and develops when the people who are most important to the child are able to think about and understand a child’s experience from the child’s perspective, without being overwhelmed or shutting down. A parent’s capacity to “hold the child in mind” leads to a child’s increased cognitive resourcefulness, greater social skills, and better capacity to regulate emotions. If we -pediatricians, teachers, therapists, grandparents, neighbors--can help a mother like Sam’s to join her child, to accept his “low frustration tolerance” as part of him, not a reflection of her own failure as a parent, then she can help him regulate his frustration. He can then learn to manage his feelings on his own. Most important, if she can do this, she may actually change the way his brain handles stress and strong emotions.
Holding A Child in Mind
Sam burst into the office, a two-year-old wild bundle of energy. Squealing with delight--or was it distress; it was hard to tell--he ran from toy to toy not looking at me or his mother, Jane. He was unable to engage with anything. Jane had brought him to see me in my pediatric practice because, “he hits me, has explosive tantrums, and I can’t take him anywhere.” She sank into the couch. I sat on the floor, wanting to listen to Jane, but also to include Sam in the visit. At first, I focused my attention on her story, while Sam continued his frantic exploration of the room.
Jane described a scene at the playground. The other mothers had been engaged in easy conversation, but she was on edge. She knew Sam was “inflexible” and at any moment could go from happy play to a full-blown tantrum. Sure enough, as she tried to join in the group, she saw him getting upset because his toy car was stuck. She rushed over to calm him, but his crying escalated. As the other kids and moms turned to look, she quickly went from embarrassment to rage. She yelled at Sam to cut it out. This only made him scream more. Finally, she grabbed him, her bag and his toys and ran to her car, where she collapsed in tears of helplessness.
Things had not been easy for Jane. Sam’s father had abused her and was in prison. She was afraid when she felt Sam’s anger that he would turn out like his father. Of her own mother she said, “She was never there for me.” Jane was frustrated and bewildered by the fact that Sam could relate to other people, yet reserved all his difficult behavior for her.
At the beginning of the visit, Jane made several awkward attempts to interact with Sam, but without success. She was anxious and her body language felt intrusive, which seemed to cause Sam to withdraw. As she opened up and shared more of her painful feelings with me, however, an interesting transformation occurred. Sam began to engage in more focused play. Mom and I talked about what Sam was doing, observing together how he was calming down. At first he talked to me, bringing me toys and naming them and describing what he was doing. But then he spontaneously ran over and gave his mother a hug. Her whole body relaxed, she leaned forward on the couch toward him, her pleasure and relief palpable in the room. Sam began to engage her in his play, and to communicate with her. Jane told me that she had been reluctant to come for the appointment, but was glad she had.
Being a parent of such a child is a hard job. Raising a child alone, without support from extended family or a spouse, is even harder. In our culture of advice and quick fixes, in seeking help for her problems with him, Sam’s mother would find many who would offer “expert” advice about how to manage her child’s behavior. An increasing number would recommend some type of medication to control his “hyperactivity.” Helping her to be fully emotionally present with her child--supporting her in the challenges she faced as a mother--is not a common approach.
Yet current research at the interface of developmental psychology, neuroscience and behavioral genetics is showing that it is just this type of intervention that will help children like Sam to manage strong emotions and relate to other people. A child’s mind grows and develops when the people who are most important to the child are able to think about and understand a child’s experience from the child’s perspective, without being overwhelmed or shutting down. A parent’s capacity to “hold the child in mind” leads to a child’s increased cognitive resourcefulness, greater social skills, and better capacity to regulate emotions. If we -pediatricians, teachers, therapists, grandparents, neighbors--can help a mother like Sam’s to join her child, to accept his “low frustration tolerance” as part of him, not a reflection of her own failure as a parent, then she can help him regulate his frustration. He can then learn to manage his feelings on his own. Most important, if she can do this, she may actually change the way his brain handles stress and strong emotions.
Is ADHD a real disorder?
I have deliberately given this post a provocative title to offer a counter weight to the outpouring of news covering the California study demonstrating a close to 25% increase in ADHD diagnosis from 2001 to 2010. I will say at the outset that I am not against medication, and recognize that a small percentage of children who have the diagnosis of ADHD may have a well-defined neurologically based difficulty with focusing and attention. If such a child is already school-age and falling behind academically, treatment with stimulants may protect that child from the damaging effects of low self esteem.
However, for the vast majority of children who have this label, things are much more complex. ADHD is diagnosed by DSM criteria that define the disorder by symptoms alone. In clinical setting in which these diagnoses are made, usually with one 50-minute visit for diagnostic evaluation and subsequent medication checks in 15-30 minutes at 3 month intervals, the child's story is usually not heard.
This story may be of an active, curious boy too restricted by the highly structured setting of today's kindergarten classrooms (a November 2012 study showed that the youngest in the class was 50% more likely to be treated with stimulants for ADHD), or of a child with sensory hypersensitivity who is unable to manage the barrage of sensory stimuli in a lunchroom or hallway.
The story may be one of a child who witnesses domestic violence or a parent who actively abuses alcohol, or both. A child may herself have been abused. In my behavioral pediatrics practice I have listened to countless stories of children, some as young as 2, who has been suspected to have ADHD. I find almost without exception a mulilayered story, sometimes involving multiple generations, that represents a complex interplay of biology and environment. The dignosis of ADHD as defined by DSM in these cases represents an artificial construct.
This past week I attended the National Meeting of the American Psychoanalytic Association in New York. Multiple excellent presentations offered a refreshing change from the oversimplified approach that is now the standard of care in both pediatrics and child psychiatry. Dr. David Mintz, a psychiatrist who has written extensively about what is termed psychodynamic psychopharmacology, in his presentation, entitled "Recovery from Childhood Psychiatric Treatment," addressed the complex developmental meaning of medication. The presentation was filled with rich insights from his research and clinical experience, including, for example, his observation that a pill is often used to localize family pathology in a concrete way in one child.
Another highly instructive presentation came from Jack Novick, co-author with Kerry Kelly Novick of the book Emotional Muscle:Strong Parents, Strong Children, on the out-of control child. I was particularly struck by the opening paragraphs to this presentation, which offered an alternative model, similar to what they describe in their book. The paper is not yet published, but the authors gave me permission to use it. I have included the quote in its entirety, as it is an apt response to the current ADHD study.
However, for the vast majority of children who have this label, things are much more complex. ADHD is diagnosed by DSM criteria that define the disorder by symptoms alone. In clinical setting in which these diagnoses are made, usually with one 50-minute visit for diagnostic evaluation and subsequent medication checks in 15-30 minutes at 3 month intervals, the child's story is usually not heard.
This story may be of an active, curious boy too restricted by the highly structured setting of today's kindergarten classrooms (a November 2012 study showed that the youngest in the class was 50% more likely to be treated with stimulants for ADHD), or of a child with sensory hypersensitivity who is unable to manage the barrage of sensory stimuli in a lunchroom or hallway.
The story may be one of a child who witnesses domestic violence or a parent who actively abuses alcohol, or both. A child may herself have been abused. In my behavioral pediatrics practice I have listened to countless stories of children, some as young as 2, who has been suspected to have ADHD. I find almost without exception a mulilayered story, sometimes involving multiple generations, that represents a complex interplay of biology and environment. The dignosis of ADHD as defined by DSM in these cases represents an artificial construct.
This past week I attended the National Meeting of the American Psychoanalytic Association in New York. Multiple excellent presentations offered a refreshing change from the oversimplified approach that is now the standard of care in both pediatrics and child psychiatry. Dr. David Mintz, a psychiatrist who has written extensively about what is termed psychodynamic psychopharmacology, in his presentation, entitled "Recovery from Childhood Psychiatric Treatment," addressed the complex developmental meaning of medication. The presentation was filled with rich insights from his research and clinical experience, including, for example, his observation that a pill is often used to localize family pathology in a concrete way in one child.
Another highly instructive presentation came from Jack Novick, co-author with Kerry Kelly Novick of the book Emotional Muscle:Strong Parents, Strong Children, on the out-of control child. I was particularly struck by the opening paragraphs to this presentation, which offered an alternative model, similar to what they describe in their book. The paper is not yet published, but the authors gave me permission to use it. I have included the quote in its entirety, as it is an apt response to the current ADHD study.
Children Out Of Control: Working With Unregulated Affect
Jack Novick and Kerry Kelly Novick
Vulnerable Child Workshop
APsaA, New York, January 2013
There seems to be an exponential increase in the number of children who are described by parents, teachers and therapists as out of control. How are we to understand this kind of behavior, and how as therapists are we able to intervene and help restore these children to the path of progressive development? Currently the tendency is to diagnose these children as having neurological difficulties characterized as ADHD, OCD, executive function disorder (EFD), pervasive developmental disorder (PDD), or, increasingly, bipolar disorders.
These children now seldom come for psychotherapy, but instead are treated by their desperate parents and teachers with reactive, repressive models of external behavioral controls, almost a reversion to 19th-century modes of authoritarian domination. More perniciously, there is an explosive increase in the prescription of stimulant, anti-anxiety and antidepressant medications, as well as widespread off-label use of antipsychotic drugs. The assumption seems to be that there is a one-to-one relationship between atypical behavior and some specific brain disorder. This of course is the age-old dream of finding a single cause in the body or the mind.
Recent neuroscience investigations, utilizing advances in the development of computer algorithms for classifying MRI images, have made possible large scale studies of normal and atypical brain development. These are able to capture any changes associated with these diagnoses. In an overview of such studies the authors conclude, "There is no identified 'lesion' common to all, or even most, children with the most frequently studied (psychiatric) disorders"
Ignoring such findings, pediatricians, psychiatrists and other clinicians continue to prescribe at ever-growing rates. ADHD and bi-polar diagnoses and their accompanying prescriptions have increased drastically in the past twenty years. 2.5 million American children are medicated for ADHD (10% of all 10-year-old boys); between 1994 and 2003 the number of children diagnosed with bi-polar disorder increased 40-fold. The proportion of underprivileged and minority children sedated for life is a blot on our health system, a social/political disgrace, and a permanent drain on our economy. Despite all the millions spent by pharmaceutical companies in marketing these drugs, the number of children struggling with such troubles continues to rise. If this rate of treatment failure occurred with a strictly medical treatment, the drugs would be withdrawn.
Towards a new (or return to an old) paradigm of finding meaning
I am fortunate that my father is my greatest fan, although, perhaps because his original language was German, it has taken me years of patient listening and translation to recognize this fact. Recently, after receiving a biography of Charles Darwin for his 89th birthday, he has taken to comparing me to Darwin.
I would certainly be more modest, recognizing that the ideas I write about draw on the work of great thinkers and researchers, together with my own clinical experience. One of these great minds is Sigmund Freud. His discovery of the unconscious, his greatest contribution, is so much a part of the way we think and behave that is difficult to appreciate the revolutionary nature of this idea. Even before he used the term unconscious, in his work as a neurologist, his original discovery was that symptoms have meaning.
Freud did not write very much about development under age three, perhaps because there was only so much he could do. However we do know that when he was a toddler his younger brother died. I wonder how much this early experience, and his mother's concurrent grief over the loss of her child, influenced the development of Freud's theories, though perhaps in a way that he himself was not conscious of.
Fortunately the next wave of researchers, including such great minds as John Bowlby, Peter Fonagy and Ed Tronick, and many others in the growing discipline of infant mental health, have focused on early development, showing that not only does behavior have meaning, but also how that meaning is co-created in relationships.
Here is an example. I have written on this blog about my growing recognition of the significance of sensory processing challenges in development. While such a trait may originate in the child, it immediately takes on meaning within relationships. A newborn that is not cuddly and does not like to be held may evoke feelings of shame and even depression in a mother. A father who himself had sensory processing challenges but was physically abused because of his difficulties may be overwhelmed with anxiety in the face of his child's similar problems. The child's behavior takes on meaning in the context of the parent-child relationship. When a child is a newborn, it may be relatively easy to identify the relational nature of these problems. But when a child is older, there are layers of complexities, such as learning difficulties and concurrent self esteem issues that may accompany sensory processing challenges, or marital conflict that may occur in the face of a child who is struggling. These complexities are usually out of a parent's awareness, or, returning to Freud's term, unconscious.
As a society we have come far from this idea of looking for the meaning of behavior. Instead we treat only the symptom. Thus a child who has sensory processing challenges, unless he is working with an occupational therapist trained in infant mental health, may be treated by brushing, or listening to tapes designed to "re-program" his brain. Many parents have told me that they are actively discouraged from participating in the therapy. Yet if parent and child are separated in this way, the meaning of a symptom within the context of relationships is never discovered.
In mental health care, this shift away from the search for meaning is due at least in part to the birth of "biological psychiatry" and the hope that complex emotional struggles have a simple chemical explanation that can be solved with a drug.
On the list serve of the American Psychoanalytic Association there is currently an active discussion about the issue of CPT codes. In order for a service to be covered by insurance, a clinician must provide both a diagnostic code and a code for the type of service. An underlying problem is that our system of diagnosis, largely based on the DSM (Diagnostic and Statistical Manual) is organized by symptoms, not by meaning. Clinicians who are used to helping people to discover meaning are restricted by a system that reduces these complex meanings to a number that corresponds to a list of behaviors. It is a deeply entrenched issue related to the whole structure of the health insurance industry and of our health care system. It is further complicated by the rise of electronic medical records and concurrent implications for confidentiality. Helping people to discover meaning that may be unconscious often involves intimate and private conversations.
This brings me full circle to my father's flattering comparison. It is indeed true that I am motivated not only to help the individual children and families I work with, but also to promote a paradigm shift in how we as a society understand human development, and, in turn, support newborns, young children and families.
Though my father is a magazine publisher, he is not a big fan of social media. He told me that Darwin kept his discoveries to himself, partly in fear of upsetting the mainstream thinking, until he had it all written down in the Origin of Species. My father suggested that I concentrate my efforts on producing my own analogous work.
He has a point. However, I choose to embrace the age of social media, and so aim to move our thinking one blog post at a time (although another book will also be forthcoming.)
I would certainly be more modest, recognizing that the ideas I write about draw on the work of great thinkers and researchers, together with my own clinical experience. One of these great minds is Sigmund Freud. His discovery of the unconscious, his greatest contribution, is so much a part of the way we think and behave that is difficult to appreciate the revolutionary nature of this idea. Even before he used the term unconscious, in his work as a neurologist, his original discovery was that symptoms have meaning.
Freud did not write very much about development under age three, perhaps because there was only so much he could do. However we do know that when he was a toddler his younger brother died. I wonder how much this early experience, and his mother's concurrent grief over the loss of her child, influenced the development of Freud's theories, though perhaps in a way that he himself was not conscious of.
Fortunately the next wave of researchers, including such great minds as John Bowlby, Peter Fonagy and Ed Tronick, and many others in the growing discipline of infant mental health, have focused on early development, showing that not only does behavior have meaning, but also how that meaning is co-created in relationships.
Here is an example. I have written on this blog about my growing recognition of the significance of sensory processing challenges in development. While such a trait may originate in the child, it immediately takes on meaning within relationships. A newborn that is not cuddly and does not like to be held may evoke feelings of shame and even depression in a mother. A father who himself had sensory processing challenges but was physically abused because of his difficulties may be overwhelmed with anxiety in the face of his child's similar problems. The child's behavior takes on meaning in the context of the parent-child relationship. When a child is a newborn, it may be relatively easy to identify the relational nature of these problems. But when a child is older, there are layers of complexities, such as learning difficulties and concurrent self esteem issues that may accompany sensory processing challenges, or marital conflict that may occur in the face of a child who is struggling. These complexities are usually out of a parent's awareness, or, returning to Freud's term, unconscious.
As a society we have come far from this idea of looking for the meaning of behavior. Instead we treat only the symptom. Thus a child who has sensory processing challenges, unless he is working with an occupational therapist trained in infant mental health, may be treated by brushing, or listening to tapes designed to "re-program" his brain. Many parents have told me that they are actively discouraged from participating in the therapy. Yet if parent and child are separated in this way, the meaning of a symptom within the context of relationships is never discovered.
In mental health care, this shift away from the search for meaning is due at least in part to the birth of "biological psychiatry" and the hope that complex emotional struggles have a simple chemical explanation that can be solved with a drug.
On the list serve of the American Psychoanalytic Association there is currently an active discussion about the issue of CPT codes. In order for a service to be covered by insurance, a clinician must provide both a diagnostic code and a code for the type of service. An underlying problem is that our system of diagnosis, largely based on the DSM (Diagnostic and Statistical Manual) is organized by symptoms, not by meaning. Clinicians who are used to helping people to discover meaning are restricted by a system that reduces these complex meanings to a number that corresponds to a list of behaviors. It is a deeply entrenched issue related to the whole structure of the health insurance industry and of our health care system. It is further complicated by the rise of electronic medical records and concurrent implications for confidentiality. Helping people to discover meaning that may be unconscious often involves intimate and private conversations.
This brings me full circle to my father's flattering comparison. It is indeed true that I am motivated not only to help the individual children and families I work with, but also to promote a paradigm shift in how we as a society understand human development, and, in turn, support newborns, young children and families.
Though my father is a magazine publisher, he is not a big fan of social media. He told me that Darwin kept his discoveries to himself, partly in fear of upsetting the mainstream thinking, until he had it all written down in the Origin of Species. My father suggested that I concentrate my efforts on producing my own analogous work.
He has a point. However, I choose to embrace the age of social media, and so aim to move our thinking one blog post at a time (although another book will also be forthcoming.)
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