Antipsychotics for foster care kids with ADHD?

A recent study, one that received relatively scant media attention (compared with a concurrent New York Times piece about a new psychiatric diagnosis termed "sluggish cognitive tempo" that may be the "new ADHD") showed that antipsychotics are being prescribed to nearly one third of kids (age 2-17) in foster care who are diagnosed with attention deficit hyperactivity disorder (ADHD.)

This disturbing statistic brought to mind a common complaint I hear from parents about putting on shoes to go out of the house. A child will dawdle, ignoring multiple requests. The situation will escalate to the point where the parent becomes increasingly angry and frustrated, and the child descends in to an all out tantrum.

This kind of scene likely plays out in some form in every household with a young child. It can be useful to keep in mind as we aim to understand why a child who is in foster care might exhibit behavior that calls for bringing out these pharmaceutical big guns.

While there is a range of reasons for a child to be in foster care, one can assume that there has at minimum been some experience of trauma and loss. This might include physical and/or emotional abuse.

Research in the field of developmental psychology and attachment offers a way to understand this situation. Young children inevitably have tantrums. It is a normal healthy part of development. But if a caregiver herself has a history of trauma, her child's behavior may, as they say, "push her buttons." She may become flooded with stress in the face of her child's acting out. Unable to think clearly, she may respond with behavior that is either frightened or frightening. She may either become overwhelmed with rage, or shut down emotionally. In the language of psychology this is termed "dissociation." For the child, it is as if his caregiver suddenly isn't there. In this situation, the child learns to recognize his own emotional distress as a signal for abandonment.

Now put this same child in foster care and ask him to put his shoes on to go outside. What starts out as a "typical" parent-child interaction can quickly descend in to wildly uncontrollable behavior. I've heard parents who have adopted kids out of trauma say, "its like he's not even there." When the child was in this kind of situation with an abusing caregiver, he might, in a way that is in fact adaptive, responded to her dissociation with his own form of dissociation. Now he has learned that behavior. But out of context, in foster care with a non-abusing caregiver, it may look "crazy."

When this kind of "not listening" extends to other arenas, it may be reframed as "not paying attention."  This behavior often occurs together with the impulsivity. Impulsivity literally means to act without thinking. An inability to think in the face of strong emotions, as I describe in my book Keeping Your Child in Mind, can also be understood as part of the trauma, of not having been held in mind by caregivers early in development.  With problems of both inattention and impulsitivity the child may, according checklists commonly used to make the diagnosis, earn the ADHD label.

Perhaps this is how kids in foster care end up on antipsychotic medication for ADHD.

But by taking this path, we are essentially putting a muzzle on the child. The child's behavior is a form of communication. It says, "I have never learned how to manage myself in the face of life's inevitable frustrations." Rather than silence him with a powerful drug, that is well known to have serious side effects, we need to listen to that communication.

The first step is to recognize the meaning of the behavior. Once caregivers understand the "why" of the behavior, they can better support the child's efforts to regulate himself in the face of frustration. At first this might be in a very physical way. For example he might need to be held in a firm and loving embrace. Or he might need to run around the room. Or hit a punching bag. He might need a soft and gentle voice rather than a harsh and angry one. As a child gets older, regulating activities like dance, theater and martial arts can have a significant role to play. Once a child has developed the capacity to regulate his body in the face of distress, he can begin, perhaps in the setting of psychotherapy, to give words to his experience.

But if we simply silence him with medication, all of this opportunity for growth and healthy development may be lost.

Gym as treatment for ADHD?

An article in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry about the role of exercise in treatment of ADHD gives me hope that there is some movement in the direction of non-pharmacological treatment of problems of regulation of emotion, behavior, and attention. ( I do not use the term "ADHD" for as readers of my blog know, I believe that ADHD as defined by DSM is an oversimplified, artificial construct.)

However, the accompanying editorial entitled "Gym for the Attention Deficit/ Hyperactivity Disorder Brain?" gives me concern that this idea represents yet another oversimplification. The editorial calls for "empiric support" from "well- designed studies." Our culture has a love of "evidence-based medicine."  I hope that before embarking on these studies, there is consideration given to what a colleague referred to as "medicine-based evidence," or research based on what we have learned from both clinical experience as well as other disciplines.

Primarily what we have learned is that its not just "exercise" or "gym," but a very specific use of the body to help the brain with the task of self-regulation. In fact, for a child who is overwhelmed by sensory input and easily dysregulated, as many of the children carrying the "ADHD" label are, traditional "gym" may be a disorganizing experience.  I described this concept in detail in a previous post, Emotional Regulation in Children: Using the Body to Help the Brain. It preceded my Boston.com blog so I have re-posted it below:

I recently heard a great story from a parent in my behavioral pediatrics practice. Their son was very active and had a hard time settling down to learn, and so, before an early morning tutoring session, a very resourceful teacher suggested he ride a scooter down the empty halls to the room where a group of kids with reading difficulties met. To make it fair, the teacher allowed all of the students in the group to ride scooters to class. The kids lay on their stomachs and used their arms to propel them down the long hall. Interestingly, not only this boy, but also all of the kids in the class began to do better!

One of the best weekends of the Infant-Parent Mental Health Post-Graduate Certificate Program that I have been attending and writing about over the past year, was with child psychiatrist Bruce Perry. He spoke of the importance of what he referred to as "rapid alternating movements' in achieving emotional regulation. Dr. Perry's ideas grew out of his frustration with the traditional model of psychiatric care, where children who have experienced significant trauma are expected to sit and talk with a therapist about their experience( and of course are also medicated.) His model of intervention is based on knowledge of brain development and is termed the "Neurosequential Model of Therapeutics.'

While it is not my intention to describe the model in detail, one of the main messages, which has relevance not only to traumatized children, is that in order to think, learn and process experience, one must first feel calm. A range of activities can achieve this calm. Dr. Perry does therapy sessions with very troubled children while going on walks. Horseback riding, martial arts, drumming and dance are other activities that can serve to achieve this kind of calm. A group of fellows from the program got to try out the theory. After a long, very stimulating (and also somewhat dysregulating) day of learning with Dr. Perry, we went ice-skating. Not only was it a lot of fun, but it worked wonders in helping us to process the experience.

Often when kids are struggling in school, teachers express concern that they are "over-scheduled." But if extracurricular activities are carefully planned and well thought out, they can be considered an essential part of treatment. It is best to have some kind of a calming activity interspersed with homework, tutoring or therapy. These can be tailored to a child's particular talents and interests. Many know the story that Michael Phelps struggled terribly with ADHD. Swimming can be a very regulating activity, but some kids with learning and behavior problems also have sensory processing difficulties and can't stand to have their head under water. Clearly swimming isn't the right choice for them.

The more children I see with a range of "behavior problems," the more I recognize the importance of using the body to help the brain. Occupational therapy for young children can accomplish this goal. But as children get older, and can learn to express their feelings, parents can help them identify what works for them. This same boy on the scooter, several years later, learned to recognize that when he was feeling overwhelmed, going down to the basement to play his drums helped him to regroup. This kind of awareness, both of mind and body, can serve kids well not only in childhood, but over the course of a lifetime as they learn to adapt to their particular vulnerabilities.

Central to this notion of using the body to help the brain is that movement take place in relationships. We know that children develop the capacity for emotional regulation in the context of relationships. Things like martial arts, horseback riding and swimming involve intimate relationships with teammates, coaches and instructors.

So I hope that before psychiatrists head down the road in search of "evidence" that "gym" is good for ADHD, there is sufficient thought and attention to what kind of physical activity, how and when it occurs, and if it occurs in the context of meaningful relationships.