"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.
ADHD etiketine sahip kayıtlar gösteriliyor. Tüm kayıtları göster
ADHD etiketine sahip kayıtlar gösteriliyor. Tüm kayıtları göster
28 Ocak 2016 Perşembe
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.
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.
ADHD, the aggressive child and the elephant in the room
(Three recent news items lead me to republish a post that predated my Boston.com days. The first is a new study showing that antipsychotics and stimulants can be used together in treatment of aggression associated with ADHD. The second is a recent New York Times article, The Selling of Attention Deficit Disorder, the third an article from today's New York Times: ADHD Experts Re-evaluate Study's Zeal for Drugs. I am hopeful that 2014 will be a year of radical rethinking about what we now call "ADHD.")
In the Tony award winning play God of Carnage two couples meet in an elegant living room for an ostensibly civilized conversation about the aggressive act of one couple’s child against the other’s. The meeting soon degenerates to reveal the underbelly of conflict in the two marriages. Husband and wife hurl insults, precious items and even themselves with escalating rage. We see, as they attempt in vain to focus on the children’s behavior, the proverbial “elephant in the room.”
It brought to mind another depiction of the nature of the elephant, presented by the pharmaceutical industry. A recent issue of The Journal of Developmental and Behavioral Pediatrics features prominently a two page ad from Shire, makers of drugs commonly used for treatment of Attention Deficit Hyperactivity Disorder (ADHD). A mother and her son sit at the desk of a doctor in a white coat. Behind them is a large elephant draped in a red blanket on which is printed the words, “resentful, defiant, angry.” The ad recommends that these symptoms, in addition to the more common symptoms of inattention and hyperactivity, should be addressed. This is the message: doctors should be treating these symptoms with medication.
From my vantage point of over 20 years of practicing pediatrics, where I sit on the floor, not in a white coat, and play with children, I believe that the play’s depiction of the nature of the elephant is much more accurate and meaningful than that of the pharmaceutical industry. In the play the elephant is the environment of rage and conflict in which the aggression occurs, while in the ad the elephant is the child’s symptom. Consider these two stories from my pediatric practice (with details changed to protect privacy.)
Everything was a battle with six year old Mark. Though I asked both parents to come to the visit, Mom came alone. She was furious.”Tell me what to do to make him listen.” We had a full hour visit, and as she began to relax, she shared a story of constant vicious fighting between herself and her husband. Mark, who had been playing calmly and quietly, took a marker and slowly and deliberately made a black smudge on the yellow wall. His mother was too distracted by her own distress to stop him. I said, “You cannot draw on the wall, but maybe you are upset about what we are talking about.” He came and sat on his mother’s lap. She reluctantly revealed her suspicion that his angry behavior was a reflection of the rage he experienced at home. She agreed to get help for her marriage, and Mark’s behavior gradually began to improve.
Jane’s parents became alarmed when her aggressive behavior began to spill over into school. Her third grade teacher told them that not only was she distracted and fidgety, but she seemed increasingly angry. At our second visit, Dad became tearful as he described his cruel and abusive father. He acknowledged being overwhelmed with rage at Jane when she didn’t listen. He yelled at her and threatened her. He longed for a positive role model to learn how to discipline her in a different way. He realized he needed help to address the traumas of his own childhood in order to be a more effective parent for Jane.
If the elephant in the room is the child’s symptoms, as the drug companies would have us believe, then medication may be the solution. Children taking medication for ADHD often tell me that it makes them feel calm. The full responsibility for the problem then falls squarely on the child’s shoulders.
For Mark and Jane, and countless children like them, the elephant in the room, however, is not the child’s symptoms. It is the environment of conflict in which the symptoms occur. If the family environment is the elephant, the treatment of the problem is not as simple as prescribing a pill. Families must acknowledge and address seemingly overwhelming problems. The parents’ relationship with each other, and each parent’s relationship with his or her own family of origin, often contributes significantly to this environment.
In the supportive setting of my office, Mark and Jane’s parents were freed to think about their child’s perspective and experience. Rather than focusing on “what to do” they understood what their children might be feeling growing up in an environment of conflict and rage. This ability for parents to think about their child’s feelings has been shown, in extensive research at the intersection of developmental psychology, genetics and neuroscience, to facilitate a child’s development of the capacity to manage strong emotions and adapt in social situations.
In another interesting link between this ad and God of Carnage, one of the fathers is an attorney representing a drug company. He speaks loudly on his cell phone, seemingly oblivious to the effect of his behavior on the other people in the room. His conversation reveals the profit motive of the drug company taking precedence over the well being of the patient.
God of Carnage was written by Yasmina Reza, a French playwright. While the play itself is hugely entertaining as a witty farce about family life, an important message was in a brief scene at the very end. The telephone rings. The mother answers. It is her daughter, all upset about the loss of her pet hamster, which the father had “set free” one night because he was annoyed by the animal’s habits. Suddenly the mood of the play, which was lively with scintillating dialogue throughout, becomes serene as the mother speaks lovingly to her distraught daughter. Perhaps most of the audience was barely aware of the sudden mood change. Yet it lifted this delightful play into universal significance. Freeing herself from the preceding chaos, she calmly gives her full attention to her daughter’s experience.
The popularity of the play gives me hope that people are hungry for a different way to think about children and families than that offered by the pharmaceutical industry, which, with the money to place an attention getting ad, has a very loud voice. It is joined by the equally loud voice of the private health insurance industry, which supports the quick fix of medication over more time intensive interventions. In contrast, Mark, with his black smudge on my yellow wall, has a very small voice. His voice says “Please think about my feelings, not just my behavior.”
His voice is particularly critical now, as our country strives to create social policy and a health care system that values prevention and primary care. Parents, if they are supported and nurtured, know what is best for their children. We as a culture must demonstrate that we respect both the difficulty and the critical importance of being an effective parent. In this way we will be able to help children, not only by treating their symptoms, but giving an opportunity for deeply rewarding changes in the important relationships in their lives.
In the Tony award winning play God of Carnage two couples meet in an elegant living room for an ostensibly civilized conversation about the aggressive act of one couple’s child against the other’s. The meeting soon degenerates to reveal the underbelly of conflict in the two marriages. Husband and wife hurl insults, precious items and even themselves with escalating rage. We see, as they attempt in vain to focus on the children’s behavior, the proverbial “elephant in the room.”
It brought to mind another depiction of the nature of the elephant, presented by the pharmaceutical industry. A recent issue of The Journal of Developmental and Behavioral Pediatrics features prominently a two page ad from Shire, makers of drugs commonly used for treatment of Attention Deficit Hyperactivity Disorder (ADHD). A mother and her son sit at the desk of a doctor in a white coat. Behind them is a large elephant draped in a red blanket on which is printed the words, “resentful, defiant, angry.” The ad recommends that these symptoms, in addition to the more common symptoms of inattention and hyperactivity, should be addressed. This is the message: doctors should be treating these symptoms with medication.
From my vantage point of over 20 years of practicing pediatrics, where I sit on the floor, not in a white coat, and play with children, I believe that the play’s depiction of the nature of the elephant is much more accurate and meaningful than that of the pharmaceutical industry. In the play the elephant is the environment of rage and conflict in which the aggression occurs, while in the ad the elephant is the child’s symptom. Consider these two stories from my pediatric practice (with details changed to protect privacy.)
Everything was a battle with six year old Mark. Though I asked both parents to come to the visit, Mom came alone. She was furious.”Tell me what to do to make him listen.” We had a full hour visit, and as she began to relax, she shared a story of constant vicious fighting between herself and her husband. Mark, who had been playing calmly and quietly, took a marker and slowly and deliberately made a black smudge on the yellow wall. His mother was too distracted by her own distress to stop him. I said, “You cannot draw on the wall, but maybe you are upset about what we are talking about.” He came and sat on his mother’s lap. She reluctantly revealed her suspicion that his angry behavior was a reflection of the rage he experienced at home. She agreed to get help for her marriage, and Mark’s behavior gradually began to improve.
Jane’s parents became alarmed when her aggressive behavior began to spill over into school. Her third grade teacher told them that not only was she distracted and fidgety, but she seemed increasingly angry. At our second visit, Dad became tearful as he described his cruel and abusive father. He acknowledged being overwhelmed with rage at Jane when she didn’t listen. He yelled at her and threatened her. He longed for a positive role model to learn how to discipline her in a different way. He realized he needed help to address the traumas of his own childhood in order to be a more effective parent for Jane.
If the elephant in the room is the child’s symptoms, as the drug companies would have us believe, then medication may be the solution. Children taking medication for ADHD often tell me that it makes them feel calm. The full responsibility for the problem then falls squarely on the child’s shoulders.
For Mark and Jane, and countless children like them, the elephant in the room, however, is not the child’s symptoms. It is the environment of conflict in which the symptoms occur. If the family environment is the elephant, the treatment of the problem is not as simple as prescribing a pill. Families must acknowledge and address seemingly overwhelming problems. The parents’ relationship with each other, and each parent’s relationship with his or her own family of origin, often contributes significantly to this environment.
In the supportive setting of my office, Mark and Jane’s parents were freed to think about their child’s perspective and experience. Rather than focusing on “what to do” they understood what their children might be feeling growing up in an environment of conflict and rage. This ability for parents to think about their child’s feelings has been shown, in extensive research at the intersection of developmental psychology, genetics and neuroscience, to facilitate a child’s development of the capacity to manage strong emotions and adapt in social situations.
In another interesting link between this ad and God of Carnage, one of the fathers is an attorney representing a drug company. He speaks loudly on his cell phone, seemingly oblivious to the effect of his behavior on the other people in the room. His conversation reveals the profit motive of the drug company taking precedence over the well being of the patient.
God of Carnage was written by Yasmina Reza, a French playwright. While the play itself is hugely entertaining as a witty farce about family life, an important message was in a brief scene at the very end. The telephone rings. The mother answers. It is her daughter, all upset about the loss of her pet hamster, which the father had “set free” one night because he was annoyed by the animal’s habits. Suddenly the mood of the play, which was lively with scintillating dialogue throughout, becomes serene as the mother speaks lovingly to her distraught daughter. Perhaps most of the audience was barely aware of the sudden mood change. Yet it lifted this delightful play into universal significance. Freeing herself from the preceding chaos, she calmly gives her full attention to her daughter’s experience.
The popularity of the play gives me hope that people are hungry for a different way to think about children and families than that offered by the pharmaceutical industry, which, with the money to place an attention getting ad, has a very loud voice. It is joined by the equally loud voice of the private health insurance industry, which supports the quick fix of medication over more time intensive interventions. In contrast, Mark, with his black smudge on my yellow wall, has a very small voice. His voice says “Please think about my feelings, not just my behavior.”
His voice is particularly critical now, as our country strives to create social policy and a health care system that values prevention and primary care. Parents, if they are supported and nurtured, know what is best for their children. We as a culture must demonstrate that we respect both the difficulty and the critical importance of being an effective parent. In this way we will be able to help children, not only by treating their symptoms, but giving an opportunity for deeply rewarding changes in the important relationships in their lives.
ADHD at 4, Violent at 15: Are Lessons Learned?
When I write about lessons I have learned from my patients, I go to great lengths to protect their privacy by altering details and identifying information. However, as the Serpico family has so generously and bravely offered their story to the public in the New York Times, the details are available for all to see. And the story offers a very important lesson.
The focus of the article, Seeing Son's Violent Potential, But Finding Little Help or Hope is on the current situation- on how a well-insured, well-educated family is struggling to get help for their deeply troubled teenage son.
But the lesson comes early on, and is contained in this paragraph:
The good news is that the brain continues to grow and change rapidly in the first 5 years. There is ample opportunity to set things on a better path even in the face of early adversity. Several evidence based interventions, such as Child-Parent Psychotherapy, can help parents make sense of a child's behavior and so set development, at the level of brain structure and function, on a better path. When early childhood educators recognize the impact of early experience, as in the Head Start-Trauma Smart program, there is opportunity to support healthy development in the classroom.
But for this child, there is no indication of any significant intervention before age 4, despite the fact that he was "restless and impulsive from the beginning." There seems to be no link made between his early developmental experience and his difficulty with self-regulation. Though the article does not address this question, I wonder how much information his adoptive parents were given about the developmental effects of his early life experience. I wonder how much support they were given in the early years of foster care and then adoption. Was there space and time to listen to them? By labeling his constellation of behaviors at age 4 as "ADHD" and prescribing medication, the path to finding meaning in his behavior was closed off.
Because stimulant medication is so effective at controlling behavior, his impulsively subsided in the elementary school years. But given his history, it is almost inevitable that without addressing the underlying cause for the behavioral and emotional dysregulation, with the onset of adolescence symptoms would resurface. While the short term goal of sitting still and paying attention in school was achieved, valuable time was lost. His opportunity to communicate his need for help with self-regulation was silenced by medication.
He showed an affinity for guitar during those years of relative peace. Music, martial arts, theater athletics, and a range of other activities, both through the activities themselves as well as the relationships formed, are other ways in which children can develop emotional, attentional and behavioral regulation. With a diagnosis made and his symptoms effectively eliminated, motivation to pursue more creative, long lasting interventions, either in addition to or instead of medication, was likely not there.
What instead followed was a string of different diagnoses and medications, with what his parents describe as a terrifying downward spiral in mental health, in parallel with a dramatic upward spiral of health care costs.
Virtually all of the comments on the article, over 800 as I write this, focus on the Serpico's struggles to get, and pay for, appropriate care for their teenage son. Certainly that is an important issue. Early intervention will be of no use to the Serpico family now. In fact, it might be quite painful to think of missed opportunities.
But the real value of this story lies in its cautionary nature. If it can be used to advocate for recognition of the impact of early development, and for investment in preventive intervention in the early years, their story could potentially help to save a lot of grief, suffering, and money.
The focus of the article, Seeing Son's Violent Potential, But Finding Little Help or Hope is on the current situation- on how a well-insured, well-educated family is struggling to get help for their deeply troubled teenage son.
But the lesson comes early on, and is contained in this paragraph:
Lena and Robert Serpico knew something was not right before their son was in kindergarten. They had taken him and his younger brother in as foster children from a mother who used drugs, and they later adopted both. The older boy, whose name is not being published at the Serpicos’ request, was restless and impulsive from the beginning and got his first diagnosis at age 4: attention deficit hyperactivity disorder.While the amount of time this boy lived with his biological mother is not stated, if he was the older of two brothers and they were placed in foster care together, it was at least nine months. The human infant is uniquely helpless in the early weeks and months of life. His brain develops the capacity for self-regulation when the people who care for him can be present and attuned. The brain undergoes its most rapid development in the first year. A caregiver who is using drugs will be impaired in her ability to offer this attunment, significantly impacting on that child's self-regulation capacity. Separation from a primary caregiver, no matter how impaired, is itself traumatic even for a very young child.
The good news is that the brain continues to grow and change rapidly in the first 5 years. There is ample opportunity to set things on a better path even in the face of early adversity. Several evidence based interventions, such as Child-Parent Psychotherapy, can help parents make sense of a child's behavior and so set development, at the level of brain structure and function, on a better path. When early childhood educators recognize the impact of early experience, as in the Head Start-Trauma Smart program, there is opportunity to support healthy development in the classroom.
But for this child, there is no indication of any significant intervention before age 4, despite the fact that he was "restless and impulsive from the beginning." There seems to be no link made between his early developmental experience and his difficulty with self-regulation. Though the article does not address this question, I wonder how much information his adoptive parents were given about the developmental effects of his early life experience. I wonder how much support they were given in the early years of foster care and then adoption. Was there space and time to listen to them? By labeling his constellation of behaviors at age 4 as "ADHD" and prescribing medication, the path to finding meaning in his behavior was closed off.
Because stimulant medication is so effective at controlling behavior, his impulsively subsided in the elementary school years. But given his history, it is almost inevitable that without addressing the underlying cause for the behavioral and emotional dysregulation, with the onset of adolescence symptoms would resurface. While the short term goal of sitting still and paying attention in school was achieved, valuable time was lost. His opportunity to communicate his need for help with self-regulation was silenced by medication.
He showed an affinity for guitar during those years of relative peace. Music, martial arts, theater athletics, and a range of other activities, both through the activities themselves as well as the relationships formed, are other ways in which children can develop emotional, attentional and behavioral regulation. With a diagnosis made and his symptoms effectively eliminated, motivation to pursue more creative, long lasting interventions, either in addition to or instead of medication, was likely not there.
What instead followed was a string of different diagnoses and medications, with what his parents describe as a terrifying downward spiral in mental health, in parallel with a dramatic upward spiral of health care costs.
Virtually all of the comments on the article, over 800 as I write this, focus on the Serpico's struggles to get, and pay for, appropriate care for their teenage son. Certainly that is an important issue. Early intervention will be of no use to the Serpico family now. In fact, it might be quite painful to think of missed opportunities.
But the real value of this story lies in its cautionary nature. If it can be used to advocate for recognition of the impact of early development, and for investment in preventive intervention in the early years, their story could potentially help to save a lot of grief, suffering, and money.
27 Ocak 2016 Çarşamba
Preschool ADHD, preterm babies, and T. Berry Brazelton
There are two important studies published in the latest issue of the Journal of the American Academy of Child and Adolescent Psychiatry. First, the PATS (preschool attention deficit/hyperactivity disorder treatment study) showed that at 6 year follow-up the treatment, consisting of medication and/or behavior management, was not working. Ninety percent of children continued to experience symptoms 6 years after diagnosis and ongoing treatment. This is because the current standard of care does not look at the cause of the symptoms, as I have written about repeatedly on this blog and in my book Keeping Your Child in Mind. Here is an example of a story from a previous post.
Second, less well-noticed but perhaps more important, is a study showing the link between late preterm birth, maternal depression and preschool psychiatric disorders. It showed that late preterm babies (34-36 weeks) were at increased risk for anxiety disorders at preschool age if their mothers had postpartum depression.
How fitting that T. Berry Brazelton is receiving the Presidential Citizen's Medal in coincidence with these studies. It is Brazelton who taught us to look at each baby's unique qualities and capacities for complex communication. In settings such as the ones described in that study, where both mother and baby are vulnerable, his Neonatal Behavioral Assessment Scale, as modified to the NBO, has great relevance. Brazelton, in all his wealth of contributions, shows tremendous respect for both parents and children.
These two studies show that we need to invest resources in supporting mother-baby pairs from birth, and in listening to families with young children so that their stories can be heard.
Maybe Brazelton will tell this story to President Obama!!!
Tears ran down Elena’s cheeks as she described being so overwhelmed and full of rage that she forcefully held her fully clothed 4-year-old son, James, under the shower when he wouldn’t go to bed. Later in the same 50-minute visit she revealed that she had suffered years of physical and emotional abuse as a child. As is typical of visits to my behavioral pediatrics practice, she had brought James because he was “defiant.” “Something must be wrong with him,” was followed by, “Tell me what to do to make him listen.” James’ preschool teachers, who were having trouble managing his behavior, had suggested that he might have attention deficit hyperactivity disorder (ADHD.) They recommended to Elena that medication be considered. They knew nothing of this history. My wish in listening to this story is not to judge, but rather to understand the experience of both mother and child.As I elaborate in more detail in that post, this prescribing of medication to young children represents a prejudice against children. A colleague described it as a massive exercise in societal repression. Hidden abuse is an extreme example. It may be simply that the classroom environment is not suited to the child's particular vulnerabilites. There are countless different stories in between. It is not surprising that without an opportunity to hear these stories, medication and behavior management would fail to alleviate symptoms.
Second, less well-noticed but perhaps more important, is a study showing the link between late preterm birth, maternal depression and preschool psychiatric disorders. It showed that late preterm babies (34-36 weeks) were at increased risk for anxiety disorders at preschool age if their mothers had postpartum depression.
How fitting that T. Berry Brazelton is receiving the Presidential Citizen's Medal in coincidence with these studies. It is Brazelton who taught us to look at each baby's unique qualities and capacities for complex communication. In settings such as the ones described in that study, where both mother and baby are vulnerable, his Neonatal Behavioral Assessment Scale, as modified to the NBO, has great relevance. Brazelton, in all his wealth of contributions, shows tremendous respect for both parents and children.
These two studies show that we need to invest resources in supporting mother-baby pairs from birth, and in listening to families with young children so that their stories can be heard.
Maybe Brazelton will tell this story to President Obama!!!
ADHD treatment gone wrong: when prescriptions replace listening
Now that the letters to the editor in response to the New York Times article Drowned in a Stream of Prescriptions have been published, I am going to take advantage of this blog to publish mine.
There is one glaring error in the generally well-researched and deeply disturbing article Drowned in a Stream of Prescriptions. In a record review of Richard’s treatment the reporters found none of “the more conventional talk-based therapies that experts generally consider an important component of A.D.H.D. treatment.” If only this were true. Just last week, AAP Smartbriefs, a review of newsworthy events in pediatrics, offered this headline Non-Drug ADHD Treatments Don't Pan Out in Study. The “psychological treatments” the study refers to are cognitive and behavioral training and neurofeedback. Talk-based therapy isn't even mentioned.
What is noticeably absent in Richard’s treatment is not talking, but listening. In the age of the 10-minute med check, there is no room for listening. If Richard was truly a well functioning person until mid-college, was his primary diagnosis schizophrenia? Was there some kind of trauma? In a world where ADHD is so quickly diagnosed, there was no time given to fully hear his story. That time that might have saved his life.
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.
14 Ocak 2016 Perşembe
Behind the Scenes Look at ADHD Treatment
Recently I went to a talk given by a local "ADHD (attention deficit hyperactivity disorder) expert" to a group of primary care pediatricians. The aim of the talk was to guide these practitioners in doing "ADHD evals" given the time constraints of primary care practice.
"Its all about the rating scales," he said. "You need to train your staff to give out the right scales. The key to working kids up is getting the scales done ahead of time. Nothing happens in the office."
This doctor proudly displayed his version of the main rating scale, the Vanderbilt, which he has divided into two time slots, because "kids have different symptoms at different times of day." Evaluation and treatment of ADHD consists primarily of scoring rating scales, making a decision to use medication, and once the decision is made, having follow-up visits every three months to adjust medication dose according to symptoms and side effects.
One pediatrician, someone for whom I have great respect as a clinician, was alarmed about a 5-year-old who was placed on a very high dose of medication by another doctor. When I asked her what was going on in the child's life that might cause him to have so much trouble, she didn't know. She had changed the medication, which did in fact improve the child's symptoms. Her approach is the standard of care in pediatrics.
In other areas of medicine, we treat the underlying cause, not just the symptom. In treating bacterial pneumonia, for example, we use an antibiotic, not a cough suppressant. The Vanderbilt lists symptoms of problems with regulation of behavior, emotions, and attention, which together may be labeled as ADHD. The question should be not “How do we control the symptoms?” but rather “What is making self-regulation difficult for this particular child?” followed by “What can we do to help promote self-regulation?”
Recently I saw several children who had been diagnosed with ADHD but medication "didn't work". One mother told me about her own struggles with untreated depression. Another child spent weekends with an actively drinking alcoholic father. A third child quietly spoke with her mother of being frightened when she pulled her hair and hit her.
Nowhere on these rating scales does it ask about family history or life stressors. According to the current standard of care it is possible to diagnose and treat ADHD without ever learning about any of this history. Detailed family history (see previous post), as is well described in the book A Lethal Inheritence, is essential to diagnostic evaluation. In addition, detailed early developmental history may reveal significant sensory processing problems that have been unrecognized.
When I have written about ADHD in the past, I usually get a number of angry responses from parents who say everything is fine in their family and I shouldn't blame them for the problem. In my experience, about 10 % of kids seen for "ADHD eval" have what I refer to as "straightforward ADHD." They have symptoms and an extensive family history of inattention and/or hyperactivity with no other issues. If you are in that 10%, this blog post is not about you.
Giving a list of therapists does not solve the problem, because the child is usually the "identified patient." Family therapy can be an important component of treatment when a child struggling with self-regulation, as is well described in the recent book, Suffer the Children: The Case against Labeling and Medicating and an Effective Alternative. Furthermore, once a child is placed on medication, his behavior is "better" for the short term and the motivation to do the more challenging, time intensive work to uncover the cause is lost.
The term "ADHD eval" implies only two options- a child does or does not have ADHD. It leaves no room for curiousity about the meaning of behavior. Then there is the term "co-morbidity." This simply offers the opportunity for more labels without exploring the cause of symptoms.
There is a reason why, as one of the pediatricians at this presentation bemoaned, a parent may say, "by the way" just when when a doctor has his hand on the doorknob to leave. It takes time to develop sense of safety and trust to be able to say what's really important.
Fortunately I work in a practice that is open to a different approach. Here are some initial changes I propose:
Stanley Greenspan's book Overcoming ADHD: Helping Your Child Become Calm, Engaged, and Focused--Without a Pill offers an excellent holistic approach that is founded in quality scientific research. One key component of his treatment is to support "reflective thinking." This involves helping a child to recognize both his strengths and challenges, and to develop strategies to manage his own unique vulnerabilities.
"We don"t have time" is not an acceptable answer. Changes must be made in our healthcare system to insure better reimursement for time spent listening in this way, and to improve access to quality mental health care services.
This is child's life we are talking about. If the root cause of the problem is not addressed, there may be years of medication adjustment until something bad happens- car accident, school failure, violent crime, prison. If I sound alarmist, it is because I am alarmed. The current standard of care of ADHD treatment, particularly now that diagnosis is extended down to age 4, effectively silences huge numbers of children. We need to give these children a voice.
"Its all about the rating scales," he said. "You need to train your staff to give out the right scales. The key to working kids up is getting the scales done ahead of time. Nothing happens in the office."
This doctor proudly displayed his version of the main rating scale, the Vanderbilt, which he has divided into two time slots, because "kids have different symptoms at different times of day." Evaluation and treatment of ADHD consists primarily of scoring rating scales, making a decision to use medication, and once the decision is made, having follow-up visits every three months to adjust medication dose according to symptoms and side effects.
One pediatrician, someone for whom I have great respect as a clinician, was alarmed about a 5-year-old who was placed on a very high dose of medication by another doctor. When I asked her what was going on in the child's life that might cause him to have so much trouble, she didn't know. She had changed the medication, which did in fact improve the child's symptoms. Her approach is the standard of care in pediatrics.
In other areas of medicine, we treat the underlying cause, not just the symptom. In treating bacterial pneumonia, for example, we use an antibiotic, not a cough suppressant. The Vanderbilt lists symptoms of problems with regulation of behavior, emotions, and attention, which together may be labeled as ADHD. The question should be not “How do we control the symptoms?” but rather “What is making self-regulation difficult for this particular child?” followed by “What can we do to help promote self-regulation?”
Recently I saw several children who had been diagnosed with ADHD but medication "didn't work". One mother told me about her own struggles with untreated depression. Another child spent weekends with an actively drinking alcoholic father. A third child quietly spoke with her mother of being frightened when she pulled her hair and hit her.
Nowhere on these rating scales does it ask about family history or life stressors. According to the current standard of care it is possible to diagnose and treat ADHD without ever learning about any of this history. Detailed family history (see previous post), as is well described in the book A Lethal Inheritence, is essential to diagnostic evaluation. In addition, detailed early developmental history may reveal significant sensory processing problems that have been unrecognized.
When I have written about ADHD in the past, I usually get a number of angry responses from parents who say everything is fine in their family and I shouldn't blame them for the problem. In my experience, about 10 % of kids seen for "ADHD eval" have what I refer to as "straightforward ADHD." They have symptoms and an extensive family history of inattention and/or hyperactivity with no other issues. If you are in that 10%, this blog post is not about you.
Giving a list of therapists does not solve the problem, because the child is usually the "identified patient." Family therapy can be an important component of treatment when a child struggling with self-regulation, as is well described in the recent book, Suffer the Children: The Case against Labeling and Medicating and an Effective Alternative. Furthermore, once a child is placed on medication, his behavior is "better" for the short term and the motivation to do the more challenging, time intensive work to uncover the cause is lost.
The term "ADHD eval" implies only two options- a child does or does not have ADHD. It leaves no room for curiousity about the meaning of behavior. Then there is the term "co-morbidity." This simply offers the opportunity for more labels without exploring the cause of symptoms.
There is a reason why, as one of the pediatricians at this presentation bemoaned, a parent may say, "by the way" just when when a doctor has his hand on the doorknob to leave. It takes time to develop sense of safety and trust to be able to say what's really important.
Fortunately I work in a practice that is open to a different approach. Here are some initial changes I propose:
1) Schedule the visit as "evaluation of problem of attention, behavior and emotion," or more simply "behavior problem,"rather than "ADHD eval"Such an approach involves a change in expectation on the part of parents, teachers and clinicians. Parents are often under tremendous pressure from teachers to get a prescription for medication.
2) Have a minimum of two 50 minute visits for an evaluation
3) See parents alone without the child for the first visit. Aim to include both parents whenever possible
4) Goal of initial evaluation is to get detailed family and social history, and to offer parents an opportunity to be heard. Very often the parent and/or couple need support and possibly referral
5) Medication may be considered for an older child if he is unable to learn or function in a social environment without it. Equal attention must be given to other interventions, including addressing diet, sleep, and physical activity
Stanley Greenspan's book Overcoming ADHD: Helping Your Child Become Calm, Engaged, and Focused--Without a Pill offers an excellent holistic approach that is founded in quality scientific research. One key component of his treatment is to support "reflective thinking." This involves helping a child to recognize both his strengths and challenges, and to develop strategies to manage his own unique vulnerabilities.
"We don"t have time" is not an acceptable answer. Changes must be made in our healthcare system to insure better reimursement for time spent listening in this way, and to improve access to quality mental health care services.
This is child's life we are talking about. If the root cause of the problem is not addressed, there may be years of medication adjustment until something bad happens- car accident, school failure, violent crime, prison. If I sound alarmist, it is because I am alarmed. The current standard of care of ADHD treatment, particularly now that diagnosis is extended down to age 4, effectively silences huge numbers of children. We need to give these children a voice.
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