Rising incidence of "ADHD" calls for radical rethinking

When the American Academy of Pediatrics changed the guidelines for ADHD to expand age of diagnosis to include children from age 4-18 (from 6-12), that the number of cases would rise was, by definition, inevitable. The recent survey by the CDC, published in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry, indicating that one in 10 children in the US carry a diagnosis of ADHD, confirms just that.

I felt re-energized and hopeful in ongoing efforts to, in my colleague's words "move the mountain of ADHD,"  when I received a request to speak at an international child psychiatry conference as part of a panel with a working title: "The ADHD Diagnosis: a Deconstruction from Developmental, Psychoanalytic, Infant Mental Health and Neuropsychiatric Perspectives."

 "Deconstruction" is a brilliant word, and captures well what I do in my clinical practice. Consider 4-year-old Max, whose parents brought him to my behavioral pediatrics practice to "see if he has ADHD." His preschool teacher had recommended the visit, suggesting that he might benefit from medication.  I asked his parents, Ann and Peter, if we might, acknowledging that Max did have symptoms of inattention, hyperactivity and impulsivity, take the time (we had an hour) to ask why he had these symptoms: to make sense of his behavior. While they had been hopeful that they would leave the visit with a prescription, reflecting Max's teacher's concern that he might "fall behind" without treatment, they were overjoyed to consider another approach.

Max had been adopted at age 3 months. Prior to this he had lived with his biological parents who were actively using drugs. They reportedly had a history of ADHD as did some biological siblings. Ann and Peter had been struggling in their marriage in the face of caring for this challenging child, and had recently separated. While Max had been a good sleeper, for the past several months he had been getting up multiple times a night and the whole family was chronically sleep deprived. Max had multiple sensory sensitivities. He cried with the sound of the vacuum cleaner; getting dressed was an ordeal because he could not find a pair of socks that was comfortable. He had difficulties with "personal space."

We had, in a sense, "deconstructed" the "symptom" to examine its various parts. We identified a genetic vulnerability for problems of attention, early neglect, ongoing family stress, sleep deprivation, and sensory processing challenges.

At age 4, there are multiple avenues of intervention. I usually start with sleep, as chronic sleep deprivation is inextricably linked with emotional and attentional dysregulation. Child-parent psychotherapy, where a clinician works with parents and child together,  has been shown to be effective in helping children develop capacities for emotional regulation, even in the face of early developmental trauma. A good occupational therapist, who addresses sensory processing challenges in the context of relationships, can help Max to use his body to manage his symptoms. Ann and Peter could examine the effects of their marital conflict on Max, and perhaps consider couples therapy.

The preliminary write up for the panel I refer to above speaks of what is now called "ADHD" as a valid symptom complex. But it proposes that

this terminology should not ever be used in our clinical thinking.  "ADHD," used as a primary diagnosis, has no etiologic significance, is conceptually and diagnostically distracting, leads to a paucity of thinking about a patient's early developmental history and trauma, and is therapeutically misleading.

 I hope that there will be a large scale movement to "deconstruct" the ADHD diagnosis. In essence deconstructing the diagnosis means eliminating the diagnosis.  Instead we would understand and treat the multiple parts that make up what is now called "ADHD." Such a process would result in  effective early intervention and prevention.

If I were to diagnose Max with ADHD and start him on stimulant medication, it would be in keeping with the current standard of care. Stimulants are powerful medications that have been shown in the short term to eliminate symptoms. But such an approach is simply a silencing of children. It would be a great disservice to  Max and his family.

Just as expanding the age range for diagnosis inevitably led to a rise in cases, "deconstructing" the diagnosis would lead to a significant drop in cases. The difference is that this change would reflect, not silencing of children, but rather improving access to meaningful help.

Yale lab calls babies bigots- a worrisome interpretation

A CBS 60 minutes segment: Born good? Babies help unlock the origins of morality is getting a lot of attention. The opening observation that babies are in fact not blobs is certainly apt. Pediatrician T. Berry Brazelton has been telling us this for over 40 years, since he developed the Neonatal Behavioral Assessment Scale that clearly shows babies as young as a few hours having complex capacities for communication. When I teach pediatric residents I show them a 2-minute video clip of a three-day-old baby following my gaze and moving his mouth as if in conversation with me. Clearly not a "blob."

However, when the researchers at Yale went on to interpret their findings as indicating an innate capacity for bigotry, I became alarmed. Certainly their research results are robust in showing a baby's preference for stuffed toys that exhibit behavior that is "like them." Researcher Paul Bloom states in the program:

If you want to eradicate racism, for instance, you really are going to want to know to what extent babies are little bigots, to what extent is racism a natural part of humanity.

Here is Webster's definition of bigot:

A person who is obstinately or intolerantly devoted to his or her own opinions and prejudices. 

Using such a negative word to describe a baby feels a bit like a prejudice itself.  Elizabeth Young Breuhl in her book Childism: Confronting Prejudice Against Children, describes prejudice as projection of bad feelings from inside out on to another person.

At another point in the interview Bloom suggests that there might be sets of genes and areas of the brain responsible for such things as resilience and morality.  This rings of the approach of "biological psychiatry" with its history of placing complex developmental/relational problems squarely within a child.

I wonder if another interpretation of the results is in order. I immediately thought of Daniel Stern, a brilliant child psychoanalyst who recently passed away. In his book The Interpersonal World of the Infant he points to the explosion of infant research as evidence of an emerging sense of self in early infancy. He writes:

Recent findings about infants...support the view that the infant's first order of business, in creating an interpersonal world, is to form the sense of core self and core others. The evidence supports the notion that this task is largely accomplished during the period between two and seven months.

So these 3-5 month old babies in the Yale lab, shown out of relational context in interaction with a toy, are in the heart of this process of developing a sense of self in relation to others. An adult, who has a fully developed sense of self, must exercise extreme caution in interpreting their behavior using negatively charged words such as bigot and racist. The behavior must be interpreted in the context of this complex developmental task.

In keeping with the subject of sameness and difference,  the day that I learned of the CBS program I read a review of the new book Far From the Tree: Parents, Children, and the Search for Identity.  The book explores the issue of individual differences, and the complex interplay of genes and environment, through extensive interviews with families of children with various forms of difference or disability. Author Andrew Solomon is not a scientist, but a father and a writer who has done an enormous amount of research.  Though I have only read the first few pages of the over 900-page tome, I am already captivated. On page one he writes:

Our children are not us: they carry throwback genes and recessive traits and are subject right from the start to environmental stimuli beyond our control. And yet we are our children; the reality of being a parent never leaves those who have braved the metamorphosis. The psychoanalyst D. W. Winnicott once said, "There is no such thing as a baby, you will find you are describing a baby and someone. A baby cannot exist alone but is essentially part of a relationship."

 New York Times reviewer Julie Myerson writes of the book:

 This is a passionate and affecting work that will shake up your preconceptions and leave you in a better place.

This book seems an appropriate bookend to the Yale research, with all of the extensive research at the interface of neuroscience, developmental psychology and genetics on how a person develops a healthy sense of self in relation with other people in between.

Taking calls for breech