Insel of NIMH Misses the Mark: Medication as Social Control

Tom Insel, director of the National Institute of Mental Health (NIMH,) in his recent blog post Are Children Overmedicated? seems to suggest that perhaps more psychiatric medication is in order. Comparing mental illness in children to food allergies, he dismisses the "usual" explanations given for the increase prescribing of medication.  In his view these explanations are; blaming psychiatrists who are too busy to provide therapy, parents who are too busy to provide a stable home environment, drug companies for marketing their products, and schools for lack of recess.  Concluding that perhaps the explanation for increase in prescribing of psychiatric medication to children is a greater number of children with serious psychiatric illness,  he shows a lack of recognition of the complexity of the situation. 

When a recent New York Times article, that Insel makes reference to, reported on the rise in prescribing of psychiatric medication for toddlers diagnosed with ADHD, with a disproportionate number coming from families of poverty, one clinician remarked that if this is an attempt to medicate social and economic issues, then we have a huge problem. He was on to something.

In conversations with pediatricians (the main prescribers of these medications) and child psychiatrists on the front lines, I find many in a reactive stance. When people feel overwhelmed, they go in to survival mode, with their immediate aim just to get through the day.  They find themselves prescribing medication because they have no other options.

From many I have heard some variation of this statement:  "In light of my inability to address the family dynamics and social-economic circumstances, all I have available is medications to help with the child’s symptoms. I see patients who come from unstable environments, where parents are themselves stressed and overwhelmed. I recognized that a child's “difficult,” “impulsive,” “oppositional” behavior is most often a communication about family, social, and economic stressors that are making a child's family less competent at caring for him. However, I lack the resources or the tools to do anything about these overwhelming issues. I hate that feeling of impotence.  So I use the only tool I have, medication. When I can bear to think about it, I recognized that medication is just shutting off the child's efforts to tell me something – in effect silencing his voice- and that I have become a force for social control."

When that child is in a school setting, with a high student-teacher ratio, perhaps also with teachers who have little experience working with kids from stressed family backgrounds who are struggling with emotional regulation, the pressure to control the child’s behavior increases significantly. It is not simply that schools have reduced unstructured time (though this is a problem as well.) Medication again becomes an agent of social control. Rather than devote the resources to address the underlying issues, we can use the medication, so effective in the short term, to silence the children.

Insel also does not address contemporary research demonstrating the developmental and relational nature of emotional and behavioral problems in children, well known within the discipline of infant mental health. Referring to "biomarkers" he seems to have an idea that one day we may be able to test for mental illness in children with a blood test or a brain scan.   The importance of safe, secure primary caregiving relationships in healthy emotional development is supported by an abundance of research in neuroscience, genetics, and developmental psychology, One cannot treat emotional and behavioral problems in children by treating only the child.

As knowledge about early childhood mental health makes its way in to mainstream health care, there have been calls for universal screening. But if we are using medication as an agent of social control, we need to be very careful not to put the cart before the horse. 

If we do not first have a health care system, and an education system, that has time and space to listen, to support parents, to appreciate the complex interplay of biological vulnerability and environmental stress, to understand the meaning of a child's behavior, what may happen is that the huge numbers of children who screen positive will have no meaningful, relationship-based treatment available (and the medication/talk therapy dichotomy is another oversimplification- there are multiple evidence-based interventions that support parent-child relationships.)  This together with universal preschool has the potential, unless there is significant change, to result in massive numbers of young children silenced by psychiatric medication.

I wonder if Dr. Insel is himself feeling overwhelmed. Perhaps he realizes that the increase in children with emotional and behavioral challenges, as well as medicating of these children, is a symptom of an enormous social problem. That problem is our society's undervaluing of children and parents, our failure to devote resources to support healthy growth and development, described by Elizabeth Young Breuhl as childism, or prejudice against children. He has good reason to feel overwhelmed with this realization, as it makes his task as director of the NIMH exponentially larger. 

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?"

Legal marijuana, antidepressants, and the danger of not listening

 A popular blog post Why I Tried to Kill Myself at Penn is making its way around the college-age crowd. The author calls attention a high-stress a culture that does not value listening.

During my sophomore year at Penn, I tried to kill myself by swallowing a bottle of Wellbutrin. I spent 4 days in the hospital.
Penn’s response? – Sending some administrator to see me in the hospital (HUP). The first and only thing that she said was, “Are we going to make this an annual pattern?” because I had been hospitalized the year before. I said “No” and she gave me her business card.
After suicides, everyone laments, “Why didn’t they talk?” Often, we did. People just didn’t want to listen, because in the moment it was easier for everyone if you put on a smile and pretended to be okay.

A parent recently described calling the emergency student support services when she was worried about her son's emotional state during his first semester at college. After a five minute conversation, she was told by the person who responded to her call, " We can make an appointment with the psychiatrist to see if he needs medication."

I thought about these two stories when a study, a survey of 1,829 people being prescribed antidepressants, was released showing a much higher than expected rate of serious psychological side effects:

Over half of people aged 18 to 25 in the study reported suicidal feelings and in the total sample there were large percentages of people suffering from 'sexual difficulties' (62%) and 'feeling emotionally numb' (60%). Percentages for other effects included: 'feeling not like myself' (52%), 'reduction in positive feelings' (42%), 'caring less about others' (39%) and 'withdrawal effects' (55%). However, 82% reported that the drugs had helped alleviate their depression. 

Professor Read concluded: "While the biological side-effects of antidepressants, such as weight gain and nausea, are well documented, psychological and interpersonal issues have been largely ignored or denied. They appear to be alarmingly common."

Psychiatric medication side effects are a double-edged sword. The first, that receives the most, though as indicated by this study insufficient, attention is from the medication itself. But the second, and equally if not more serious, is the way prescribing of psychiatric medication becomes a replacement for listening.

What makes us human is our ability to empathize. Drawing from both Buddhism and psychoanalysis, the "presence of mind" of another person is responsible for therapeutic healing. "Being with," "bearing witness," are other phrases that describe this phenomenon. When we jump to a pill we run the risk of skipping this step. If the medication itself also has psychological side effects, it is not surprising that, in combination with feeling alone and unrecognized, a person might attempt suicide.

Psychiatric medication may be necessary when an individual is unable to function without it. Ideally such a determination is made in the setting of both psychotherapy and other self-regulating activities such as yoga or meditation. But that is not the way these medications are used. Because they can be so effective at eliminating distress in the short term, our fast-paced, quick-fix culture makes them very appealing, almost irresistible.

I decided to include the topic of legalization of marijuana in this post as a kind of cautionary tale. In California cannabis is commonly prescribed to treat anxiety. Psychiatric diagnoses and drug prescribing are often based on symptoms alone, as is well captured in this amusing though disturbing anecdote from a Psychology Today post by psychologist Jonathan Shendler:

During my first week as a psychiatry department faculty member, a fourth-year psychiatry resident—I will call her Gabrielle—staffed a case with me. She gave me some demographic information about her patient (38, White, female) and then proceeded to list the medications she was prescribing. The rest of our conversation went something like this:“What are we treating her for?” "Anxiety." "How do we understand her anxiety?"Gabrielle cocked her head to the side with a blank, non-comprehending look, as though I had spoken a foreign language. I rephrased the question.“What do you think is making your patient anxious?”She cocked her head to the other side. I rephrased again.“What is causing her anxiety?"
Gabrielle thought for a moment and then brightened. “She has Generalized Anxiety Disorder.”“Generalized anxiety disorder is not the cause of her anxiety,” I said. “That is the term we use to describe her anxiety. I am asking you to think about what is making your patient anxious.”She cocked her head again.“What is going on psychologically?”“Psychologically?”
“Yes, psychologically.”There was a pause while Gabrielle processed the question. Finally she said, “I don’t think it’s psychological, I think it’s biological.”

As we are on the cusp of general legalization of marijuana (that I do not oppose) it becomes imperative that psychiatric medications not replace listening. It is essential that we protect time and space for being present, for curiosity, for empathy. Otherwise we are simply offering another way, and one that is not without side effects itself, to devalue the role of human relationships in healing.

Lessons from Atticus: is "ADHD" a problem of not listening?

Recently I reviewed my son's high school essay on To Kill A Mockingbird. I was surprised and pleased to rediscover, or perhaps discover for the first time now that I was viewing it from the perspective of over 50 years of life experience, the profound wisdom of the book.

In one of the novel's most famous quotes, Atticus tell his daughter Scout, "you never really understand a person until you consider things from his point of view, until you climb in his skin and walk around in it."

I now understand this as a description of the essence of being human, namely the capacity to be curious about the meaning of another person's behavior. Peter Fonagy, whose research has shown how the development of this capacity is intimately linked to healthy emotional development, argues, in a way analogous to Bowlby's description of attachment behavior, that this capacity has evolutionary significance, and is essential to survival. My book Keeping Your Child in Mind presents this research for a general audience, showing its application to parenting.

I wonder if our current epidemic of "ADHD" is related to having lost sight of this essential human quality.  The most common phrases I hear from parents who come to my office with concerns of problems of inattention and  impulsivity are, "he never listens," followed by "tell me what to do to make him listen."

Perhaps ADHD is a problem of not listening. But it is the adults who are not listening to each other. In our fast-paced, technology driven age, we rarely take the time to listen to each other, to put ourselves in another person's skin.

When Scout comes home from her first day of school upset with the teacher, her father tells her, "she's new too." He is helping Scout to understand her teacher's perhaps impatient behavior from a different point of view, to appreciate that the teacher herself may have been stressed and overwhelmed.

Recently parents of 4-year-old Sam, who was having problems of impulsivity in the classroom, spent a good portion of our visit expressing anger at his teacher, who they were convinced just didn't like their child. But with a full hour, and a quiet space to tell the story, they came to recognize that just as they could get overwhelmed at times by their son's behavior, so could the teacher be overwhelmed. Perhaps she felt defensive when the parents got angry, as she was trying her best in less than ideal classroom setting, with a low teacher: student ratio.

In turn, with the parents and teacher listening to each other and not behaving defensively, they could reach a new level of understanding of what set Sam off, and to develop strategies both at home and in school to help him to feel calm.

I wonder if the current epidemic of what we call "ADHD" represents a loss of this capacity to put ourselves in another person's skin. I have had the pleasure of an email exchange with the New York Times journalist Alan Schwartz, whose multiple superb article, most recently The Selling of ADHD, have served to bring the subject to the forefront of public discourse. I am hopeful that he will help us to see the big picture, rather than to place blame.

I have wondered in conversation with him if the whole phenomenon of "ADHD" is itself a symptom of larger social ills, particularly in the education and health care systems as well as the medical education system. People, including parents, teachers, pediatricians and mental health professionals, are feeling overwhelmed and not heard.

The large scale medication of a whole generation of children has potential serious and profound long-term effects. These include the silencing of children whose symptoms represent complex underlying problems, as well as abuse of stimulant medication by high school and college students.

We will never go back to the slow pace depicted in the 1960 novel, where there are large expanses of time to listen. But we need to be very careful not to give it up completely. For it does take space and time to put yourself in another person's skin. If that is the essence of what makes us human, we need to value that space and time.

ADHD: The Role of Curiosity

3-year-old Cara smiles impishly in to the camera.” You see she’s standing on the kitchen table,” her proud yet concerned grandmother, my dental hygienist, Anne, says to me. She explains that Cara was standing on the table because she never listens, and runs away when her mother tries to take her picture.

She knows that I am a pediatrician and “expert” in behavior problems, so, after showing me the picture, as she cleans my teeth she shares with me that her granddaughter might have ADHD. “She won’t sit in the circle with the other kids for the whole story time. They’ve started an evaluation.”

I nod in shared concern while she works on my teeth, and she goes on. She’s known me for many years, so the conversation flows easily. “It’s hard,” she says, “because Mindy (her daughter) just broke up with her boyfriend. “So she’s a single Mom, “ I say after a rinse. “Yes, and she works nights and lets Cara stay up til 11 so she can be with her.” At the next pause I comment, “So Cara must be tired in school. That can lead to problems of attention.” As Cara’s grandmother resumes her work on my mouth, she agrees. Then she goes on to explain that Cara is the youngest in her class of mostly 4-year-olds.  She begins to wonder if all of these things she is telling me might be related to the problems Cara is having in school. Her tone shifts.

“She’s just so engaged and curious,” Anne explains. “Maybe we need to channel that energy and help her to find ways to use it in a positive way.” Then she reflects, “Actually Mindy was like that as a child. She was so smart that she got bored in class and sometimes got in to trouble. But after some struggles during those years she found her way.” She tells me that Mindy is passionate about her work as a neonatal nurse.

During my visit I feel a shift in Anne’s thinking. Simply by talking with me, a captive audience with whom she has a longstanding relationship, she goes from describing her granddaughter in terms of “disorders” and “evaluations” to a stance of curiosity.

As we both stand to schedule our next appointment, Anne again looks at the impish face of her granddaughter, trapped on the kitchen table. She sees the picture, cute as it is, as a kind of sign that things may feel out-of-control for Cara. She even begins to wonder if her daughter is too stressed, and perhaps needs more help from her. Maybe, she says, if Mindy had a bit of time to herself, she could be more patient with Cara. She decides to offer her daughter a day of babysitting.

Recent statistics indicate that diagnosis of ADHD has increased 42% in the past 8 years. 3-year-old Cara might be on her way to joining that statistic. I am hopeful that the system of care will offer space and time to listen to the whole story. When her grandmother was able to wonder about the meaning of that photo, Cara’s communication, in the form of behavior, was understood. Being heard and recognized in this way gives Cara the opportunity to become not another statistic, but instead to develop in to her own true self.

Social responsibility to support new parents must follow demise of Isis Parenting

"Where I live (Paris) women are very lonely when having a baby. Is it the same in the US?"

A French journalist posed this question to me in an email interview two days ago. My verbatim response:

"Social isolation and often along with that postpartum depression are problems here in the US for new mothers.
There are mother- baby groups to try to address this issue, but not nearly enough."

Now, in our Boston communities and other places in the US, there are a lot fewer.

The economics of the sudden demise of Isis Parenting, a private retail company,is described in the Globe article today. But as my colleague at the Freedman Center at MSPP (Massachusetts School For Professional Psychology) that also runs mother-baby groups, said in reaction to the announcement by Isis, "you cant make money running mother-baby groups." 

A harsh tweet derides the company for catering to the wealthy with high end products. But in the absence of a system of social support of new parents, what choice is there? 

Isis offered what D.W. Winnicott termed a "holding environment" for new parents. Not just a physical space, but a community of relationships. This fact is reflected in a collection of tweets about Nancy Holtzman, vice president of clinical content and e-learning, at #thingsnancytaughtme.

Another way to describe what Isis offered is a "secure base:" In my book Keeping Your Child in Mind ( that was just released in France, thus the interview with the French journalist) I describe the extensive research evidence for the role of this secure base, both for parent and child, in healthy emotional development. 

John Bowlby, describing the essential role of attachment relationships in survival, spoke of a child’s need for what he called a “secure base” from which to explore the world and grow into a separate person. He also recognized the need for a mother to have a secure base of her own in order to provide this security for her child

In our culture extended families, that in past times might have offered that "holding environment" or "secure base," are often fragmented by distance and/or divorce. If one parent, usually the father, works very long hours, a new mother may feel very much alone. Isis parenting helped these parents not to feel alone. 

The United States lags behind significantly in support of new parents, as represented by a highly restrictive parental leave policy. A recent BBC article described an alternative approach in Finland: 

For 75 years, Finland's expectant mothers have been given a box by the state. It's like a starter kit of clothes, sheets and toys that can even be used as a bed. And some say it helped Finland achieve one of the world's lowest infant mortality rates.

Not only does this gift offer material help, but also an official recognition by the government that new parents have an important role to play and deserve to be valued and supported.

President Obama has recognized the need to invest resources in early childhood, and developed an Early Childhood Initiative. This is an important step in the right direction. 

But this will not help the families in the Boston area, who are now on their own with the loss of Isis. What can we do on the local level? It is my hope that government agencies, foundations and others who are in a position to support the kind of services Isis offered, that almost by definition do not make money, will step up to the plate to help fill the void. It will be an important investment in children, families and our future.

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.

Days of Awe and the Certainty of Neuroscience

Just like the digital codes of replicating life held within DNA, the brain's fundamental secret will be laid open one day. But even when it has, the wonder will remain, that mere wet stuff can make this bright inward cinema of thought, of sight and sound and touch bound into a vivid illusion of instantaneous present, with a self, another brightly wrought illusion, hovering like a ghost at its centre. Could it ever be explained, how matter becomes conscious?

The actual words written by Ian McEwan, in his novel Saturday about a day in the life of a neurosurgeon, are worthy of awe of the human mind. In a recent blog post I referred to a piece by psychologist Gary Marcus in which he calls attention to "the trouble with brain science." Perhaps inspired by this very piece of writing, he refers to the lack of a bridge between neuroscience and psychology comparable to the bridge between genetics and living beings that discovery of the double helix provided.

I describe how absence of this bridge is the problem inherent in the oft-used comparison between depression, or ADHD, and diabetes. NIMH director Thomas Insel has called for a study of the neuroscience of mental illness in the same way we study cancer, food allergies, and diabetes.

Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. For the pancreas, there is no corresponding mind in the realm of thoughts and feelings. The pancreas does not love, does not grieve, does not produce great literature.

This wish to compare psychological experience to physical illness ostensibly comes from a wish to destigmatize emotional suffering. But in fact it may have the opposite effect, as it devalues the  human relationships. It is an effort to apply certainty to situations ripe with uncertainty.

There is a dark side to the certainty of neuroscience. Years ago I treated a young girl, Charlotte, who had been diagnosed with ADHD by a previous doctor.  I took over her care, following the standard practice in pediatrics for visits every 3 months for review of "symptoms" of hyperactivity and inattention and adjustment of medications. When she continued to struggle, her parents paid a large sum of money to have a brain scan done by a doctor who claimed to identify the exact location of her problem. Despite the alleged certainty of these results, her "symptoms" continued. I referred the family to a therapist, but lost touch with them when I left that practice.

Recently I learned from her mother, Jennifer, when I ran in to her on the street, that she was doing much better. "I know why," she told me. She had hidden from me, and from herself, that all along Charlotte's stepfather had been physically and emotionally abusing her. Only now, with this story brought to light, could she begin to heal.

Missing from treatment of this girl was not knowledge of brain science, but time for listening.  In 30-minute visits every three months, with Charlotte and Jennifer together in the room, neither she nor her mother felt safe enough to share what was really going on.

The week between Rosh Hashannah, the days of Awe, and Yom Kippur, the day of Atonement, seems an appropriate occasion for contemplating these issues. It offers an opportunity for awe at the wonder of the human mind. It might also offer opportunity to atone for not listening to children like Charlotte. When we make diagnoses, and use brain scans to verify them, we may miss the complexity of human experience. The essence of being human is the ability to find meaning in behavior. I hope that going forward, we can protect space and time to listen, to discover that meaning. We are not likely to find it on a brain scan.

Are iPad attachments for bouncy seats and potty seats a violation of infants rights?

I was contemplating writing a blog post about the movement by the Boston-based advocacy group Campaign for a Commercial Free Childhood urging Fisher-Price to recall the baby bouncy seat with an attachment for insertion of an iPad. When I then received an email from a colleague with a link for another product- a potty seat with an attachment for an iPad- there was no going back. I decided not to include the link to that product so as not to inadvertently be a source of free advertising, but it is easy to find. 

In our technology driven culture, a position maintaining that we need to put on the brakes is a challenging one to take. The force of "progress" is so powerful that one runs the risk of seeming out-of-touch or old fashioned. But in these two products I believe we have come face-to-face with exploitation of children ( and their parents) or what I have described in a previous post as a "prejudice" against children. I would even go so far as to say it is a violation of infants' rights.

In today's society, where parents are often living in a state of high stress, with little support, either practical or emotional, the appeal of these products is very understandable. The allure of the screen is equally, if not more powerful for the infant. So from a marketing perspective, from a moneymaking perspective, it is a recipe for success. 

I became aware of the concept of infants' rights in my role as a board member of the Massachusetts chapter of the World Association of Infant Mental Health. A preliminary version the Declaration of Infants' Rights, a work in progress, reads:

The young child’s capacity to experience, regulate, and express emotions, form close and secure relationships, and explore the environment and learn are fundamental to mental as well as physical and developmental health throughout the life span.

So how do these products violate these rights? Lets start with toilet training. Recently I had the opportunity to write the parent guide for a new children's book, Potty Palooza. I identify the relational nature of toilet training:

Toilet training occurs in relationships. This includes a child’s relationship with his body, as well as his relationship with you. Toilet training will occur under the influence of a child’s inborn desire for mastery in relation to his body. A normal developmental movement toward separation and independence, together with your child’s wish to be like you and to please you, will move the process forward.

I do not know what will happen if you insert a screen between parent and child as part of this process (and sitting on the potty with a book is an entirely different experience.)  It is likely that the draw of the screen will interfere with a child's ability to read his body's natural signals.  The desire for treasured "screen time" will become the motivation for sitting on the potty, replacing his natural motivation to please his parents and to gain mastery over his body in a healthy way.  

Turning to the Ipad in the bouncy seat, the possible effects are more insidious and diffuse. Sitting in the bouncy seat in kitchen watching mom or dad prepare dinner is a time of great learning; a time of significant brain development. This learning occurs both through direct interactions with adults and older siblings, as well as through observation. The iPad interferes with both. As CCFC writes:

The Apptivity Seat is the ultimate electronic baby sitter. Because screens can be mesmerizing and babies are strapped down and “safely" restrained, it encourages parents to leave infants all alone with an iPad. To make matters worse, Fisher-Price is marketing the Apptivity Seat—and claiming it’s educational—for newborns. Parents are encouraged to download “early learning apps” that claim to “introduce baby to letters, numbers and more.” There’s no evidence that babies benefit from screen time and some evidence that it might be harmful. That’s why the American Academy of Pediatrics discourages any screen time for children under two.

Extensive evidence at the interface of neuroscience and developmental psychology shows how the brain is wired in relationships, with the most rapid brain growth occurring in the first three years. Instead of making products that come between parent and infant, our focus needs to be on supporting early caregiver-infant relationships, in the form of such things as parental leave, quality childcare and screening for and treatment of postpartum depression.

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.

Rethinking the Meaning and Use of the Word "Autism"

In the course of working on my new book about listening to parents and children, I have had the pleasure of immersing myself in the writing of D.W.Winnicott, pediatrician turned psychoanalyst.  Winnicott's professional life included both caring for countless young children and families as a pediatrician, and psychoanalytic practice, where his adult patients "regressed to dependence," giving him an opportunity to interact with their infantile qualities, but with adult capacities for communication. This combination of experiences gave him a unique vantage point from which to make his many brilliant observations about children and the nature of the parent-child relationship.

A recent New York Times Magazine article on autism prompted me to share his words of wisdom on the subject, which, though written in 1966, still have relevance today.  The following is from a collection of papers, Thinking About Children:

From my point of view the invention of the term autism was a mixed blessing...I would like to say that once this term has been invented and applied, the stage was set for something which is slightly false, i.e. the discovery of a disease…Pediatricians and physically minded doctors as a whole like to think in terms of diseases which gives a tidy look to the textbooks…The unfortunate thing is that in matters psychological things are not like that. 

Winnicott implores the reader to instead understand the child in relational and developmental context. He writes:

The subject quickly becomes one not of autism and not of the early roots of a disorder that might develop in to autism, but rather one of the whole story of human emotional development and the relationship of the maturational process in the individual child to the environmental provision which may or may not in any one particular case facilitate the maturational process.

In my behavioral pediatrics practice, parents of a young child may wish for a diagnosis to relieve them of the feeling that they are "bad parents;" that their child's challenging behavior is their "fault." Yet when I give parents space and time to make sense of their child's behavior, and in doing so help him learn to manage his unique vulnerabilities- essentially doing what Winnicott suggests-I find that most parents prefer not to have their child diagnosed with a disorder.

A recent book on the subject, Autism Spectrum Disorder: Perspectives From Psychoanalysis and Neuroscience, while still referring to a "disorder," captures the tenor of Winnicott's approach. My blurb on the book's cover reads:

This book, with its central focus on the parent-child relationship, offers a unique and very important contribution. Parents struggle terribly in their efforts to make sense of the behavior of a child with a wide range of neuro-developmental challenges that currently fall under the heading of Autism Spectrum Disorders. Drawing on extensive evidence from the fields of genetics and neuroscience as well as in-depth clinical material, the authors show how a clinician can set these children on healthy developmental paths by supporting parents’ efforts to find meaning in their children’s behavior.

Many adults with autism now advocate for the idea that autism is not a disorder. But they come from a very different perspective, arguing that their unique way of interacting with the world is simply different, not abnormal. Certainly for an adult this is a valid perspective. However, when I work with parents and young children where the diagnosis is being entertained, the whole family is struggling terribly. It feels to me a great disservice to a young child to think of calling this situation "normal." 

An approach like that of Winnicott, Sherkow and Harrison may be fraught in the context of the history of "refrigerator mothers." While this theory has been widely discounted, any attempt to consider the child's relational and developmental context may be interpreted as "blaming the parent." That is why I love Winnnicott's approach. Rather than asking, "Is it or is it not autism?" we might be wise to discard the term completely.  Instead, if we offer space and time to learn, "the whole story of human emotional development," the very act of listening to the story becomes the cornerstone of treatment. 

Moving beyond the DSM paradigm of mental health care

A paradigm is a way of thinking about things. For the past 60 or so years, our thinking about mental health and illness has been dominated by what can be referred to as the "DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm." What this looks like in everyday practice is that when a child is referred to my behavioral pediatrics practice for say, anxiety, the questions that parents, referring doctors, and teachers ask is, "Does he have anxiety disorder?" followed by  "How to we manage his behavior?" and "Does he need medication?"

The DSM paradigm has been useful as a way of organizing our thinking. But it is important to recognize that these "disorders" of anxiety, depression, ADHD etc, are simply lists of symptoms that tend to go together. They do not correspond to any known biological processes in the way that, for example, diabetes is a result of lack of insulin.

When the DSM system was first created, we did not have the powerful health insurance and pharmaceutical industries that we have today. Because of the existence of these entities, we are currently in a position of being forced in to a very narrow view of mental health and illness.

The DSM system is a black and white paradigm with only the possibility of "normal" or "disordered."
According to the DSM paradigm, if the answer to the first question about my anxious patient is no, and there is no diagnosis, there is no insurance coverage, and so no help. But clearly such a family is struggling.

 We need a paradigm shift, defined as a fundamental change in approach and underlying assumptions. A new paradigm is needed that gives room for the complexity that we have learned from the abundance of research at the interface of developmental psychology, neuroscience and epigenetics.

The child above may have a strong family history of anxiety traits. He may have a strong genetic vulnerability for anxiety. However, if a parent who shares these traits was slapped across the face for her "difficult behavior" when she was a child, she may become so overwhelmed with stress in the face of her child's challenges that she is unable to help him to manage his anxiety. Marital conflict, perhaps exacerbated by the stress of a child who is struggling, can further add to the complexity. The environment in which this child grows and develops will determine the way in which his genetic vulnerability is expressed.

As I described in a previous post, the field of infant mental health offers such a paradigm. It is relational, developmental and founded in the basic principle that behavior has meaning. It gives us a way to organize our thinking about the problems of the family I describe above.  It offers a path to treatment, namely to support the efforts of the child's parents to recognize the complex meaning of his behavior. Once parents feel heard and understood, and have the opportunity to make sense of their child's behavior, they will be better able to help him manage his anxiety. They might involve him in physical activities or creative activities that help him to feel calm in his body. They might get help for their own relationship. They might work together with the child's teachers to strategize about how to support him in the school setting.

Thanks to my book, Keeping Your Child in Mind, I had the honor of being invited to give the Paul A. Dewald lecture this week in St Louis.  My book is about the idea that rather than jump  "what to do" about a child's behavior, it is important to simply "be" with that child,  to think about that child. As I prepared the talk I came to recognize that the same holds true for our whole system of mental health care.  Before we can plan "what to do" to apply the wealth of research I refer to above, we must first recognize that we need to "think" differently. We need move beyond the DSM paradigm and embrace a new paradigm; to facilitate a paradigm shift. An important first step is to name it as such.

Supporting Parent-Baby Pairs in the Wake of Infertility

A new study in Denmark demonstrated a 33% increased risk of a range of psychiatric disorders in children whose mothers were treated for infertility. The authors do not offer a cause, but postulate that the increased risk is related not to the treatments, but to the infertility itself.

These findings echo research showing increased risk of psychiatric problems in children whose mothers have struggled with perinatal emotional complications such as anxiety and depression.

How can we make sense of this?

Mental health, including the capacity for emotional regulation, empathy, resourceful thinking and resilience, develops in relationships. So the answer to this question lies in the way infertility impacts on parent-child relationships.

I recently came upon a beautiful expression in a work of literature that captures pediatrician D.W. Winnicott's concept of primary maternal preoccupation, that he identifies as central to a child's healthy emotional development.

The book is James Agee's A Death in the Family. In this early scene, the father is awakened during the night because his father is ill. As he dresses to leave the house, his wife, on her way downstairs to make him breakfast, whispers to him to bring his shoes in to the kitchen.

"He watched her disappear, wondering what in hell she meant by that, and was suddenly taken with a snort of silent amusement. She looked so deadly serious, about the shoes. God, the ten thousand little things every day that a woman kept thinking of, on account of children. Hardly even thinking, he thought to himself as he pulled on his other sock. Practically automatic. Like breathing."

The experience of infertility may get in the way of this breathing. Without appropriate support, a mother may feel that she is suffocating.

A mother, and also a father who, while not experiencing the physical assaults of infertility treatments, certainly shares in the emotional trauma, may come to the experience of parenthood with a range of significant vulnerabilities.

Anxiety over the well being of a new baby, no matter how much reassurance well meaning clinicians offer, may be unrelenting. In the face of repeated loss, as occurs in the process of infertility treatment, not only with every period, but sometimes with early pregnancy loss, may lead a parent to, in an adaptive effort to protect themselves from further loss, disengage emotionally. A parent may not fully surrender to the falling in love that accompanies the birth of a baby. And parents may be simply emotionally exhausted.

The baby also may have a role to play. There is evidence that stress in pregnancy, as is almost inevitable in a pregnancy that follows infertility treatments, is associated with what is termed "behavioral dysregulation" in the baby. That is, the baby may be more difficult to feed, may cry more or have irregular sleep patterns.

The good news is that, having identified infertility as a risk factor in development of mental illness, there is ample opportunity to set these vulnerable parent-baby pairs on a healthy path. One option is suggested in a recent article in the Atlantic, How Supportive Parenting Protects the Brain, where the possible role of the pediatrician is addressed.

What if every parent-baby pair, in the aftermath of infertility treatment, got some extra time and attention? An extra hour-long visit-with clinicians reimbursed for their time- to meet with parent and baby together, to listen to them both? Even better, as pediatricians have variable interest/expertise in this kind of work, have an infant mental health specialist, physically located in the pediatrician's office. The Newborn Behavioral Observation system is a wonderful tool for listening to parent and baby together in a way that sets development on a healthy path.

The idea is to normalize, rather than stigmatize.

This study might cause alarm for parents who are already stressed by the process of infertility treatment. I was alarmed myself by the statement by one of the study's authors that "this knowledge should be balanced against the physical and psychological benefits of pregnancy." To even entertain the idea of not getting pregnant because of this potential risk to the child is absurd, and feels almost punishing.

But if instead we use this study as further evidence of the value of protecting space and time to listen to parents and babies, then alarm could be transformed in to hope.

Protecting a space for parenting in an age of expert advice

In my behavioral pediatrics practice, it never ceases to amaze me how, given the space and time, parents come around to making sense of their child's "difficult" behavior without my giving "advice" about "what to do." They may recognize that they share a trait with their child that has troubled them their whole life. They may become tearful, thinking of how that child represents a lost loved one.  There are countless variations. The process of telling the story, of finding the meaning in the behavior, is often itself the treatment. Once parents have these insights, "what to do" follows naturally. In contrast, if I give advice without a full understanding of the story, things may not go well.

Recently in working on a new book, I have had the pleasure of returning to a close look at the work of D. W. Winnicott, pediatrician turned psychoanalyst and a kind of British Dr. Spock. In my review of his writings on the subject of advice, I came across a wonderful piece from this past spring in The Guardian: Mothers on the naughty step: the growth of the parenting advice industry, that references Winnicott.

Winnicott abhorred the idea of giving advice. He believed that when mothers tried to do things by the book – or by the wireless: "They lose touch with their own ability to act without knowing exactly what is right and what is wrong." Yet today there are far more parenting advice books (each with their own regime to promote) than 30 years ago, and the radio and TV schedules are full of programmes such as Supernanny, which train a critical eye on what are generally called parents but most of us understand to be mothers. It sometimes seems it is mothers, rather than children, who are being dispatched to the naughty step...

Winnicott feared that focusing on pathological families rather than "the ordinary devoted mother and her baby" (the title of his most famous series) could excite anxiety in listeners without access to therapy. "I cannot tell you exactly what to do," he said, "but I can talk about what it all means." And so he did, extolling the role of the good enough mother – one who can be loved, hated and depended on – in enabling the baby to develop into a healthy, independent, adult. While many of today's parenting gurus focus on a child's deviant behaviour and the contribution of supposed misparenting, Winnicott tried to help mothers understand the significance of their child's behaviour, whether it was "cloth-sucking" or a display of jealousy, and the ways that they instinctively contained their child's anxieties.

The author refers to the British program "Supernanny," the "high priestess of behaviorist parenting."

Tracey Jensen, lecturer in media and cultural studies at Newcastle University, says Supernanny reverses Winnicott, offering up the spectacle of the "bad enough mother", usually working-class, who is shamed before she is transformed. Jensen watched the programme with a group of mothers, relieved that it was not their parenting practices being scrutinised, but those of someone else onto whom all their own worries and fears could be displaced. But they also shouted back at the programme, discomfited by the judgment and humiliation meted out to the mothers featured. Such series foster the very anxiety they claim to assuage, and substitute "training" for thinking and feeling.

This last phrase captures the essence of the issue. I shudder whenever I see the term "parent training."  But this phrase, as well as others such as "management of symptoms" or "parent education" are pervasive in our culture. These kinds of interventions may improve behavior in the short term. But if they substitute for "thinking and feeling" it is likely that symptoms will re-emerge at a later date, in a different form. 

When we talk about parents and children, we are talking about passionate love relationships. The feelings are deep, intense and sometimes painful. It makes sense that we might choose to avoid them. But this is not a long-term solution.  We would do well to instead make a space for them, starting from birth.

I borrowed this phrase "protecting a space" from my good friend Gale Pryor, who's wonderful book Nursing Mother, Working Mother was also heavily influenced by Winnicott. In such a space parents can connect with their natural intuition. It is in this space that we give room for healthy development of parent and child together.

In the age of DSM 5, what is normal?

In an interesting coincidence, a couple of weeks ago I received two emails on the same day asking me to write about books that are about the same subject. One is  Child Temperament: New Thinking About the Boundary Between Traits and Illness,  the second Back To Normal: Why Ordinary Childhood Behavior is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum Disorder.

The first was written by David Rettew, MD a child psychiatrist at the University of Vermont College of Medicine, where at the Vermont Center for Children, Youth, and Families ( VCCYF) they have an innovative family centered, strength-based approach to children's emotional and behavioral problems.

In a language that is based in science and research,  Rettew explores the overlap and interplay between the concepts of "temperament" and "psychopathology. He tackles the complex science of behavioral epigenetics- the impact of life experience on gene expression and subsequent behavior and development. He then describes how he integrates these ideas in to his care of children and families. For example, he describes how he might speak to a child patient:

I've heard a lot about you today and one of the things that I hear from you and your parents is that you are a very kind person who can really tune in to other people.  That is a wonderful quality that will serve you well in the future. At the same time, I also hear that you can get so concerned about what others think about you that you avoid things you like doing just so there is no chance you will feel embarrassed. Doctors sometimes use the term  social anxiety disorder to describe this situation, and if you are willing there are things we can do to help you feel more at ease in social situations.

He masterfully takes on very complex issues, including the way a child's behavior may provoke a parent's negative response.

A father of a temperamentally irritable boy who is prone to shout at the boy for  relatively minor infractions is certainly not relieved of responsibility for his behavior, but can be understood from a prespective that some of his suboptimal responses are evoked by the child's behavior, partially influenced by shared genes that cause both of them to escalate in negative ways.

The second book is organized around examples from the practice of the author Enrico Gnaulati, PhD, a clinical psychologist specializing in child and adolescent therapy. He examines our cultures rush to diagnose and medicate, and what he terms the "casualties of casual diagnosis." He writes:

In the past four decades we have gone from blaming parents for kids' problem behavior to blaming kids' brains....yet rarely can a child's behavior be explained exclusively in terms of child rearing or brain chemistry. In most cases, it is causes- plural, not singular- that explain why a child behaves the way he or she does. 

The underlying problem both authors address is embedded in the paradigm of mental health in which they practice.  Rettew seems to be trying to wrestle out of the paradigm in the last section where he describes an evaluation process that makes use of other tools besides DSM. However, the above example shows how the language of DSM permeates care, when albeit reluctantly, he uses the term "social anxiety disorder." This "disorder" may be in the DSM, but it is not a "real" disorder in the way, for example, diabetes is.

Earlier this year, the head of the National Institute for Mental Health tried to discredit DSM 5 by saying that they would not fund research based on the DSM system but rather aim to find the underlying "cause" in the realm of neuroscience and genetics. But as Gnaulati points out, we will never find the cause by just looking at the brain.

Gnaulati is similarly trying to find another way to think about this paradigm that offers oversimplified labels. But I am concerned that framing the issue as "normal" vs "disordered" is  misguided, and a result of the author being unable to see his way out of the DSM paradigm.

If a child and family are seeking help, then by definition the behavior is not "normal." Given the continued stigma associated with mental health problems, for a family to make the effort to call, make an appointment and actually show up, they are likely to be struggling in a significant way. Thus to call this "normal," even though the intention may be to be reassuring, is actually dismissive of the family's suffering. I wrestle with this dilemma every day in my clinical practice. Parents come to me and ask, "Is my child normal?"

I speak to this issue in a previous post: Answering the question: is something wrong with my child?
I refer to an article by Daphne Merkin on the question of whether depression is inherited:

The 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?"

I wonder if Rettew and Gnaulati are so much a part of the prevailing paradigm that they do not recognize that what they are actually doing in their books is questioning the very paradigm in which they practice. If they were to step outside of the paradigm, they might, rather than asking the question "does a child have ADHD?" , asking the more salient question, "Is ADHD ( or autism or bipolar disorder or OCD for that matter) the way we as a culture use the term, a "real" thing, or is it an artificial construct defined by the DSM system and perpetuated by the pharmaceutical and health insurance industries?"

I believe that what both of these authors are actually doing is describing a new paradigm of mental health care that recognizes the relational nature of human development and offers opportunity for curiosity about the complex meaning of behavior. I'm calling them on it.