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.

Rising numbers of kids expelled from preschool and diagnosed with autism: are they linked?

Two alarming news items compete for attention. The first,  a New York Times editorial entitled Giving Up on Four-Year-Olds describes a recent report showing expulsion from preschool as a form of discipline occurring in increasing numbers. A second speaks to the new CDC statistics indicating that 1 in 68 children have autism, a change from 1 in 88 just 5 years ago.

Perhaps both represent a lack of value of space and time for listening, in particular for listening to children and parents. Elizabeth Young-Breuhl might refer to both phenomena as prejudice against children. 

Each child who is expelled from preschool has a story. Similarly, every child diagnosed with autism has a story. It takes time, and a safe non-judgmental environment to bring these stories to light and so make sense of a child's behavior.

There may be witnessed domestic violence. When  a child lives in fear, he may respond to the "threat" of a child standing too close to him in line by pushing him. A reprimanding voice may lead to escalation of stress and even the development of a "fight-flight reaction." Being sent to the principal's office leads to further disorganization. 

Sensory processing challenges are often prominent. A withdrawal from social interaction makes sense from the perspective of a child who is flooded and overwhelmed by a busy classroom. Crawling under a desk may not be something "wrong" but rather an adaptive response.

Increasingly structured school environments, with little room for variation and high student:teacher ratios may exacerbate both of these problems. 

However, once we have the opportunity to hear the story, what to do to help the child becomes clear. One boy whose behavior had escalated to the point where he was throwing things at the teacher felt calm if he could start the day with a few minutes buried under the plastic balls in the ball pit. Another who would run in circles much of the day discovered music. When she was invited to sing or play an instrument she could sit calmly with the other children. Another family recognized how the level of chaos in the home was particularly problematic given their son's vulnerabilities, and took steps to change that environment.

A recent New York Times article describes a wonderful school program, Head Start Trauma Smart, an example of an innovative program that takes time to listen to the story, make sense of a child's behavior and respond appropriately. In contrast, expelling children for "acting out" may result in a cascade of worsening behavior problems.

The massive rise in autism numbers may reflect a need to name a problem with certainty, rather than taking the time to let the story unfold, to let a child grow in to himself. Perhaps if parents, teachers and clinicians had the opportunity to get a child the help he needs without pressure to name the problem, the numbers would be much lower.

Clearly there are significant differences between these two issues. But an underlying theme emerges. 

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:

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?"

Authoritarian parenting vs. parenting with authority

Authoritarian parenting, as in "my way or the highway," and its opposite, permissive parenting with lack of limit setting, may be linked with difficulty with emotional regulation in children. In contrast, an "authoritative" parenting style is associated with an enhanced capacity for emotional regulation, flexible thinking and social competence. An authoritative parenting stance encompasses respect for and curiosity about a child, together with containment of intense feelings and limits on behavior.

Parental authority is something that in ideal circumstances comes naturally with the job. It is not something that needs to be learned in books from "experts." In fact our culture of  "advice" and "parent training" may unintentionally undermine that natural authority.

But what might cause a parent to lose that natural authority? Stress is far and away the most common culprit. That stress might be in part coming from the child himself, if, for example, he is a particularly "fussy" or "dysregulated" baby. It might come from the everyday challenges of managing a family and work in today's fast-paced culture, often without the support of extended family. It may come from more complex relational issues between parents, between siblings, between generations.

When I work with families of young children, my aim is to help parents reconnect with their natural authority. By offering space and time to listen to their story, including addressing the wide range of stresses in their lives, my hope is that together we will make sense of, or find meaning in, their child's behavior. Armed with this understanding, "what to do" usually follows naturally.

I have learned that it is important to be explicit about this approach. As I write on my website:

Parents often come to a pediatrician with expectation of advice and judgment. Our culture may support this expectation by our reliance on “behavior management” and increasingly on medication to treat “behavior problems” in children.

Some guidance about "what to do" may naturally enter in to the conversation. But I have found that premature "advice," without full understanding of the complexity of the situation, can often lead to frustration and failure. In contrast, when a parent has that "aha" moment of insight, the joy and pleasure that comes from recognition and reconnection, for both parent and child, can be exhilarating.

A Conversation with Paul Tough: How Children (Dont) Succeed

I had the privilege of speaking with Paul Tough on the very day that his new book How Children Succeed: Grit, Curiosity and the Hidden Power of Character was released. In the middle a massive publicity tour, including NPR interviews and major speaking engagements (he is speaking September 6th at Harvard), his publicist arranged for him to speak on the phone with me. Despite being under what I imagine to be intense pressure, he was very gracious and thoughtful.

It was really more of a conversation than an interview, as my hope was to introduce some ideas that were not addressed in his book. It was understandably relatively brief, and I am using my blog to elaborate on what we discussed. I am thrilled that his book is receiving the attention it is. In presenting his thesis that character, rather than cognitive skill, is the key to success,  he brings some very important research to the forefront of public discussion.

Extensive research has shown that in the setting of a safe secure caregiving relationship, children develop the capacity for emotional regulation, cognitive resourcefulness, resilience and the capacity for social adaptation. He uses somewhat different words-including grit, curiosity, self-control, and gratitude, and refers to these traits as a whole as "character."

From my view as a pediatrician and scholar of developmental theory, I see significant obstacles to promoting character development in the way he is advocating for.  I wonder if, in addition to funding programs that promote character, or funding research to study these programs, as Tough effectively argues we should be doing, we need to understand the nature of these obstacles.

With that in mind, I asked Tough about three interrelated issues. These are; our society's undervaluing of primary healthcare, overreliance on psychiatric medication, and childism.

Consider the following scenario, variations of which are exceedingly common. It starts with a mother who is under significant stress in pregnancy. Then she has a baby who "cries all the time." Stress in pregnancy is associated with this kind of behavioral "dysregulation" in the newborn.  She may struggle with postpartum depression(PPD). The combination of depression and a fussy baby makes providing the kind of attuned relationship a newborn needs extremely difficult. But in the absence of an effective PPD screening and treatment program, the pair may not get help. There is severe sleep deprivation, marital stress and many other factors that make it difficult to be responsive in the way that supports character development.

By age three, the child has significant trouble with emotional regulation. His pediatrician, under the time constraint of the 10-15 minute visit, likely will offer behavior management advice about such things as time out. She likely will not have the opportunity to hear about the stressed marriage or the mother's depression, much less to take the time necessary to make an appropriate referral.

At age four, the child is disruptive in preschool. An ADHD evaluation is recommended by his teachers. He meets diagnostic criteria as defined by DSM. He is started on stimulant medication and immediately his behaviour improves. But soon the problems resurface as the underlying issues have not been addressed. The dose is increased. The medication is changed. This continues throughout the rest of his childhood. When he gets to high school and confronts the barrage of tests Tough writes about in his book, he starts abusing his stimulants.

I'm a clinician, not a policy person, but  I do have some thoughts about what needs to happen to get children off this path and on to one where relationships and character development are supported.

1) Transform education of health care professionals, who are on the front lines with young children and families, to focus on relationships as the 4th vital sign. The American Academy of Pediatrics Early Brain and Child Development Initiative is an important step in the right direction.

2) Educate all professionals who work with children and families about practical application of contemporary developmental science  (I actually wrote my book Keeping Your Child in Mind, for this purpose)

3) Change the system of reimbursement so that primary care clinicians are among the highest rather than the lowest paid

4) Value time as a clinical intervention

5) Offer comprehensive screening and treatment for postpartum depression and other perinatal emotional complications. Representative Ellen Story working to implement just such a program in MA

6) Address the overreliance on psychiatric medication use. There is a severe shortage of qualified mental health care professionals, related in large part to low reimbursement rates for treatments other than medication. 

Just before I spoke with Tough, I read  the following from an interview with him in the Hechinger Report:

Is part of the problem in higher-education and K-12 policy circles that we’re myopic—and that it takes longer than we’re willing to wait to determine if something is working?

In general, yes. I think any time you’re talking about child development and public policy, there’s that problem, which is that any intervention is going to take a long time. There’s a good case to be made that the most effective interventions are early interventions, and quite literally you’re not going to see the payoff for years and years—and our political system is not set up to fund those sorts of things.

So we have all this evidence of the importance of promoting healthy relationships in early childhood, as well as compelling evidence from University of Chicago professor James Heckman that investing in early childhood is economically very wise, and still we are so short-sighted and impatient? I asked Tough if perhaps this was a manifestation of childism.

Childism: Confronting Prejudice Against Children is a brilliant book by Elisabeth Young-Bruehl who tragically died suddenly just before the book was released, depriving us of the opportunity to learn about her work through the kind of publicity tour that Tough is now having. I describe it in detail in a previous post, that I will summarize here.

Young-Breuhl, an analyst, political theorist and biographer, calls attention to the way human rights of children are threatened. Childism is defined as “a prejudice against children on the ground of a belief that they are property and can (or even should) be controlled, enslaved, or removed to serve adult needs.”

Young-Breuhl provides ample evidence for her assertions, including a detailed history of the field of child abuse and neglect.

She describes Child Protective Services (CPS) as a “rescue service-a child saving service-not a family service supporting child development generally and helping parents…” Rather than setting up a system of treatment, CPS became "an investigative service...a situation in which bad families suspected of making their children bad will be invaded and infiltrated." Young- Breuhl has empathy for both parent and child, arguing that failure to support families is a manifestation of childism. 

Overreliance on psychiatric medication is in her view is example of childism:

She writes of “a childism of the sort that is now fueling an epidemic of diagnoses of bipolar II disorder and the prescription of medications to children who are, in effect, being doped into acquiescence." 

Young-Breuhl compares the situation in our country with comparable developed countries that have lower rates of child abuse and neglect.

There, “children have a range of preventative and development-oriented services: universal health care, health services, and parent support services in homes after the birth of a child; maternal and parental leaves for infant care; developmental preschool programs; after-school programs; and economic supports of various kinds.”

I don't claim to have the answer to the problem of childism, but I do think that if we are going to be able to make use of Tough's very important book to implement meaningful change, it a least needs to be acknowledged.

Pediatrician T. Berry Brazelton, whose work is featured as an antidote to childism, endorses [Young-Breuhl's] book, recommending that all who are involved with children and families should read it. This book has helped me, like nothing else I've read, to understand why it is so hard to get the kind of help for children that all the best science of our time is telling us they need. I hope everyone reads it. As Young-Breuhl states, “prejudice has to be recognized in order to be overcome.

Addressing the question: Is something wrong with my child?

In the setting of my behavioral pediatrics practice, this can be a loaded question. One would assume that parents are hoping very much for the answer to be "no." But they wouldn't be in my office if there weren't something wrong. Therefore if I say "no," parents may be left feeling there is something wrong with them.  At moments like this, I turn to the growing discipline known as "infant mental health." (Here infant refers to children under age five.) Charles Zeanah, MD, in the Handbook of Infant Mental Health writes: 

The relational focus of infant mental health has been the sine qua non of this field from the beginning. It is not the infant who is the target of intervention but rather the infant-parent relationship. . . . Instead of the problem or disturbance being understood as within the child or within the parent, the problem may be understood as between the child and caregiver.

The child brings his or her own qualities to the relationship, qualities referred to as "biological vulnerabilities." These may include difficulties with sensory processing and inflexibility. The parent brings his or her own issues, which include not only biological vulnerabilities, that in adult life may manifest as actual mental illness, but a whole history of relationships and experience.

"Infant mental health" can be a confusing term, as it may imply that there is such a thing as "infant mental illness." As those who read my blog know, I am very much opposed to diagnosing mental illness in young children.  Rather, infant mental health is about understanding and supporting the young child's ability to experience, regulate and express emotions, form close relationships, and explore the environment and learn.

Many forces, including the education system and health insurance industry, push parents in the direction of answering the above question in the form of a diagnosis. On a purely emotional level, during the time it takes to  address the problems in the relationship (and it does take time, but for a young child, not that much time) it can be hard to hold on to the complexity. The need to answer this question with a definitive "yes" or "no" may be put aside, only to resurface at a later time.

Daphne Merkin, in last week's New York Times piece Is Depression Inherited? tackles this challenging issue. Merkin, who has had a lifelong struggle with depression, looks at the question from her perspective as mother to a now 22-year-old daughter. She writes:

Probably the most basic error we make is in trying to frame the puzzle of how human character evolves in stark oppositional terms — nature or nurture — rather than seeing it as an inextricable mix of things.

Her most important point comes in a parenthetical statement. In considering how to use the current information available to guide parenting, she writes:

Until more compelling genetic information becomes available, it seems that the best we can do is to keep our children’s predispositions in mind while focusing on the pieces of the developmental puzzle over which we can exert control. (This includes being attuned to your child’s nature, especially when it differs from your own.)

 This last concept of "being attuned to your child's nature, especially when it differs from your own,"  is the essence of healthy parenting. She is describing a parent's recognition of what D. W, Winnicott termed the child's "true self." It involves recognizing a child as a person with thoughts and feelings that are his own. It is an excellent goal to work towards, though not always easy.   Issues that get in the way of recognizing the child's true self, including stresses in a parent's life and other relationships, may need to be addressed.

When viewed from this perspective, the question becomes not "is there something wrong with my child?" but rather "Who is this child, and how is he or she both alike and different from me?"

As I write in my book Keeping Your Child in Mind, where I explore this issue in much more depth:

It is my hope that we can move from an emphasis on diagnosis and labeling to an emphasis on prevention. We need to ask not “what is the disorder?” but rather, “what is the experience of this particular child and family?” and “what can we do to move things in a better direction?”

Birthful podcast with Gail and Adriana

Orgasmic Italy with Debra Pascali-Bonaro

Daddys night with the Boys.

Say goodnight to your brother. Showered, creamed, groomed, fed, pooped & changed. This eatable guy is ready for bed.

I was anticipating only 10 to 15 mins to put this cupcake to bed and attend to my 5 year old, but my 15 minute turned into an hour and it must have been a century for this big guy.  

He was so excited to help out with a new video. We were suppose to head down to the studio and shoot some footage infront of the green screen with his new Fire Fighter Suit. 

My heart started to ache as I realized he's growing up, he didn't need me to put him to sleep.  He patiently waited, exhausted, he crawled up onto the couch and just crashed.  I cradled him up to his room like he was a newborn, tucked him in and said a prayer. Before walking out of his room, he popped up, stumbling from being half asleep and said: 

"Daddy, we were suppose to make the movie."  I kissed him on his forehead and said it's alright we can do it another time.

These precious moments are results, motivating me to overcome barriers and obstacles that will in turn be beneficial to my children, family and heart.  We as parents, sometimes take things for granted as we get lost in this world of consumption.  Let us remember what our basic obligations are and find means to balance those obligations.  Teach, love & respect your children as they grow, develop & mature.  Once they are grown, we'll be praying for those precious moments again.

Jamal Qazi.

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Fun Winter Day Sledding with the GT Racer Sled

A fun and engaging video of a child playing with his GT Racer SLED on a local snow hill.  Learning the Alphabet becomes fun, your child will be entertained during the learning process.  The child narrates a story about his experience going down the hill with the GT Racer SLED, and helps your child spell the word SLED.

We captured our footage using the GoPro Hero 3, GoPro Hero 3+ camera & the iPhone 5/5S.  In addition, we used the GoPro Junior Chesty harness to mount the GoPro camera.  Moreover, we used the GoPro Jaws Flex clamp.

This video will help toddlers, preschoolers & kindergarten children learn letters of the Alphabet using Mnemonic techniques.  We help stimulate retention of information in your child's brain by creating many pathways and connections between those pathways.  With the use of rhythm, rhymes, patterns & visuals, we help increase the level of memorization in a short period.  Try it out, your children will see visuals, hear rhythms & be engaged with our cute narrator's voice.

QAZIINC brings you Intelligent Kids World - iKIDSWORLD creating FREE Educational E-learning videos for Children.  Our Video Flashcards & eBooks help Babies, Toddlers, Preschoolers & Kindergarten Kids learn The Alphabet Song, Colors | Colours, Numbers, Counting, Animals & much more.

We help create a learning Environment that will engage kids & encourage them to Interact.  We achieve this by using a cute child's voice throughout our video's to relate & maintain the attention of our little viewer's.

Occupy your kid's time efficiently and effectively. Having a routine will encourage responsibility and help children develop quality skills that will allow them to succeed and excel in school.

TRANSCRIPT:

Thank you for watching Intelligent Kids World.
Please Subscribe, See you later.
(random noise by child)

ABC Song
The Alphabet
Alphabet Song
The Alphabet Song
Phonetics Alphabet
Phonetics Alphabet Song
The Alphabet Song for Children
The Alphabet Song for Toddlers
The Alphabet Song for Preschoolers
The Alphabet Song for Kindergarten

Jamal Qazi All Rights reserved 2013.

子供のためのアルファベット。アルファベットの歌からの手紙Sを学習。スイミングプールで泳ぐことを学びました. 幼児や未就学児のための教育ビデオ。コメントを購読してお任せください。

الفيديو التعليمية لمرحلة ما قبل المدرسة والأطفال الرضع. الرجاء ترك تعليق والاشتراك.

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I get by with a little help from my friends.....

Today my dear friends, I was visited by the "Curriculum Police" who walked into my class along with my Principal. THANK- GOD I wasn't in the middle of taking pictures for my blog...LOL!!! 

I had Deanna's Common Core Standards Posters up which caught their eye....thank- you Deanna! They were impressed with this :)

They stayed for what seemed like an eternity!! Here are the things we were working on:

My Spring Math Journal Pack

 {click on the picture to purchase} 

Rachelle's {What the Teacher Wants} Handwriting Fairy Unit
(Several kids were finishing this up- we started it the day before)

{click on the picture to purchase}

Christie's {First Grade Fever} What's Hatchin' Chick?

{Click on the the picture to purchase}

& we just had to begin our "Waddle we do if it rains?" craftivities from the awesome Teri aka Mrs. Cupcake.

{click on the picture to purchase}

What in the world would I do without teacher BLOGS?!! ;)
And don't forget to enter my giveaway...ends on March 27th. GOOD LUCK!!!

Apple Helps Children with Autism

Some autistic students who struggle to communicate become engaged when exposed to the iPad, Apple's popular touch-screen tablet computer.

"There is a level of engagement that the students have with these devices that we hadn't seen with other teaching tools before."

"Within seconds you can create a meaningful 'right now' communication board for students. There is a level of engagement that the children have with these devices that we hadn't seen with other teaching tools before."

"It could have to do with the vibrancy of the colours and the ease with which they can manipulate the images on screen."

CBC NEWS ARTICLE

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More proof that homebirth with Midwives is safe

March of DImes Prevent Prematurity with Midwives & lowering induction

Spouse The others With child Imply and children driving Nellore CVR Healthiness