Evidence mounts that our current approach to "ADHD" is way off base

An NIH funded study published last week in the Lancet revealed that five major mental health disorders- ADHD, autism, bipolar disorder, depression and schizophrenia- share genetic roots. The authors state that their findings blur diagnostic categories. They write:

These results provide evidence relevant to the goal of moving beyond descriptive syndromes in psychiatry, and towards a nosology informed by disease cause.

Epigenetics, or the environmental influence on gene expression, must immediately be brought in to any discussion of these important findings. "Cause" is related to a complex interplay between genetic risk and environmental effects.

Another study on ADHD published this week points to the problems inherent using this oversimplified diagnostic category. The study, published in Pediatrics, showed that not only do symptoms of ADHD persist into adulthood in 30% of cases, but there is also a significant amount of "co-morbidity," including these alarming statistics:

The study also found the risk for suicide was nearly five times higher among those diagnosed with ADHD than in the comparison group, and nearly 3% of study participants were in jail when recruited for the adult portion of the study.

A review of the study published in USA today includes this telling line:

Symptoms[of ADHD] can be controlled by a combination of behavioral therapy and medication. 

Maybe the reason that so many people have such poor outcomes is that we are neglecting to understand the underlying cause of the problem and instead simply labeling and "managing" symptoms. These dismal long-term results, along with the similarly dismal results reported in the preschool ADHD study showing that 90 percent of children had signficant symptoms at 6 year follow up, state loud and clear that the way we approach what we are now calling "ADHD"  is not working. We need to do something dramatically different from the current standard of care.

What we are calling "ADHD" is a constellation of symptoms that represent problems with regulation of attention, behavior, and emotion. The term itself gives the illusion that we know the specific biological mechanism in the way that we know how lack of insulin causes diabetes. This is however, far from true.

As the first study I refer to indicates, we are just beginning to learn about the underlying biology of mental illness, and those findings suggest that "ADHD" may be an artificial construct.

My clinical experience tells me that these genes they have described may be functionally related to sensory processing.  Problems with sensory processing seem to be common to many diagnostic categories for mental illness that we currently use. However, children develop the capacity for self-regulation in the context of relationships. Identifying the problematic gene is only part of the answer. Understanding and addressing the environmental risk is the other.

If we consider the interplay of genetics and environment, then a third study published last week, this one also in Pediatrics, will point us in the direction of meaningful preventive intervention. This study identified the problem of postpartum anxiety, concluding that:

Postpartum state anxiety is a common, acute phenomenon during the maternity hospitalization that is associated with increased maternal health care utilization after discharge and reduced breastfeeding duration. 

Given what we already know about the risk of psychiatric disorders in children of parents struggling with depression,  these findings only increase the urgency of focusing our resources on supporting parent-infant pairs. We need to help set development in a healthy direction from the start.  Genetic vulnerabilities are present at birth, and if we devote maximum resources to supporting the environment, then we may significantly decrease the risk of those vulnerabilities manifesting as psychiatric illness.

Taking stimulants for SATs: sadly we taught them that

As a general and behavioral pediatrician I admit that I have participated in many conversations that went something like this. In a child's presence a parent says: "He does well in his morning classes, but then his grades are down in the afternoon-can we use something longer acting?" Or, "She did so well at first, but now she's getting 70's. I think she needs a higher dose." These conversations occurred in the setting of a brief follow-up visit for ADHD. These visits might be spread as far apart as 3 to 6 months. What else happened in those months? There was neither the time nor the expectation to address that question in a meaningful way.

Is it any surprise, given that this form, length and frequency of visits for ADHD is the standard of care in pediatrics, that now there is an explosion of abuse of prescription stimulants in the high pressure setting of the college application process? A recent New York Times article Risky Rise of the Good-Grade Pill addressing this issue states:

The number of prescriptions for A.D.H.D. medications dispensed for young people ages 10 to 19 has risen 26 percent since 2007, to almost 21 million yearly, according to IMS Health, a health care information company — a number that experts estimate corresponds to more than two million individuals. But there is no reliable research on how many high school students take stimulants as a study aid. Doctors and teenagers from more than 15 schools across the nation with high academic standards estimated that the portion of students who do so ranges from 15 percent to 40 percent.

My daughter is a senior at one of these "high-pressure private schools" referred to in the article. She confirms these statistics, putting the number at about one third. A previous post, Meds for ADHD: They Work But is that the Right Question?, was inspired by conversation in which she asked me about the ethics of taking these drugs for the SATs. In that post I speak to the need to understand ADHD as a problem regulation of attention, emotion and behavior, and to focus on relationship-based interventions to promote self-regulation. It is the hyperfocus on medication to the exclusion of both understanding of the child's experience, and also other forms of intervention, that has led to this problem in the high school setting.

Relationship-rich interventions include such things as martial arts, music, and team sports (Michael Phelps had severe ADHD), activities that foster relationships and also promote self-regulation. Family systems are often severely strained when a child is struggling, and interventions aimed at supporting the family as a whole are very important. Careful examination of the school setting and accommodations to decrease over-stimulation are similarly necessary. But if the drug makes the symptom go away, there is no motivation to devote effort and resources to make these kinds of changes.

When I asked my daughter today if she had ever taken stimulants before a test she replied that she thought it was a silly idea. Her reason? "If you do well on stimulants it's not really you, and you will end up at a college where you will be miserable. Then you will need to keep taking the drugs." Such a wise child!

Childhood trauma: stories that must be told

My 51st birthday is approaching. My father is 87 years old. Yet it was not until this spring that I learned details of the story of his childhood in Nazi Germany, his escape to America as a teenager, and his dramatic rescue of his parents from the concentration camp Theresienstadt when he returned to Germany as a soldier with the United States army.  It took his grandson, my 13-year-old son, to get him to break this silence, when my son requested that his grandfather speak to his 8th grade class following their visit to the Holocaust museum in Washington, DC.

My father's story is one of not only survival, but of triumph in the midst of unimaginable horror. He would never use the word "trauma" to describe his experience.  Bits of the story had emerged at times, in part around my daughter's bat-mitzvah 4 years earlier. But in general he ascribed to Elie Weisel's notion that it was a horror so great it could not be spoken of.

French psychoanalysts Francoise Davoine and Jean-Max Gaudilliere have a different adage on the cover of their book, History Beyond Trauma; "Whereof one cannot speak, thereof one cannot stay silent." They argue that personal stories of war and societal trauma, if not told in words, emerge as symptoms, sometimes as mental illness, sometimes in subsequent generations.

Davoine offers a wonderful example in a story of her own family. She and her husband were on a trip with their young children when she discovered a growth in her abdomen. Despite a fear of cancer, they decided to say nothing to their children and finish the month-long trip. Shortly after the discovery, her son developed severe anxiety around bedtime and refused to go to sleep. It emerged that, being highly sensitive to his parents emotions, as children can be, he was worried, but didn't know what to be afraid of. When his parents explained about the lump, his sleep problem resolved. They write:

Let us imagine, for a moment, the following catastrophic scenario: continuing to play the admirable mother, Francoise keeps the secret. The child would find himself burdened by the cut out truth of the story. Rushing into a hyperactive exploration, or barricaded in a hyperpassive withdrawal, nowadays he might have been quickly diagnosed and chemically brought back to reason.

In my behavioral pediatrics practice, I often hear stories like this from parents, both of major trauma in the form of such things as abuse or death of a sibling, or subtler trauma of having an emotionally troubled parent. At first parents focus on the child's "behavior problem." But in a non-judgmental atmosphere where sufficient time is given,  parents are usually eager talk about their own history, and become curious about the effects of their experience on themselves as parents, and on their child.

For example, a 4-year-old girl  had severe separation anxiety. It emerged that her mother had a miscarriage when she was three, and had never had the opportunity to mourn the loss. Her daughter was worried about her, and so did not want to leave her either to go to school or go to sleep.  A father of another boy with "defiant behavior." had been abused by his own father, and found himself full of explosive rage that came out, against his will, in his relationship with his young son.

In recent posts I have been focusing on qualities a child brings to the relationship with his parents. In our quest to understand a child's experience, this is an essential piece. But equally important is to understand what parents bring to the relationship, in particular in terms of their own unique history. Parent-child relationships are a complex, intricate dance. At times they can be clumsy and full of stepped on toes. But with work and careful attention, they can be transformed back into a dance of joy and grace.

I am blessed by the fact that my father is alive and in good health. I am hopeful that we now have the opportunity to write a book together telling of both his remarkable life, and also how his experience came to be known by me and my children. It will serve as a dramatic example of a story that needs to be told.

More proof that homebirth with Midwives is safe

Meds for ADHD: They Work, But Is That the Right Question?

Recently my teenage daughter presented me with a moral dilemma. Up to one third of the kids in her high school are prescribed some kind of psychiatric drug, most of them stimulants like Ritalin. Many of the others students buy drugs from those who are getting them by prescription. If a person who has not been prescribed the drug takes it for the SAT's, is that cheating?

My reflexive response was "yes," but on further thought I wondered: If it has become so much the norm to be on stimulants, are the kids who are not taking them at a disadvantage? As my daughter wisely observed, anyone has trouble paying attention when sitting for a 5 hour test.

The point of this story is that there are serious long-term consequences to prescribing stimulant medication to large numbers of children. In addition to the above dilemma, by controlling symptoms with medication, the motivation to provide more comprehensive treatment is lost.

To the statement that they "work" I answer that yes, the drugs, at least in the short term, reduce symptoms of inattention and hyperactivity. They make a child conform to society's expectations. If medication helps a child to learn, then in our current educational and social system prescribing may be necessary. But is it right?

Bruce Perry, a psychiatrist who has developed a comprehensive treatment approach based on brain development captures this dilemma well when he writes:

Human beings are biological creatures. Of the 250,000 years or so that our species has been on the planet, we spent 245,000 years living in small transgenerational hunter-gatherer bands. The human brain has evolved specific capabilities that are hominid and pre-hominid adaptations to the millions of years of living in the natural world in groups of 40-50 individuals in these transgenerational groups.

The relationally-enriched, developmentally heterogeneous environment of our past is what our brain "prefers." Our brain is not well-designed for the artificial light, pervasive visual over­ stimulation from television, the distracting sounds, images, anonymous social interactions and host
of other phenomenon related to life in the modern Western world. The impact of the changes in the way we live, work and raise our children has not been completely examined. While well­ intended, many of our current lifestyle choices are likely contributing to the emotional, social, cognitive and physical health problems in our children. The most alarming is the relational poverty that many of our children are experiencing. This is most disturbing because humans are fundamentally relational creatures.

Relationship-rich interventions include such things as martial arts, music, and team sports (Michael Phelps had severe ADHD), activities that foster relationships and also promote self-regulation. Family systems are often severely strained when a child is struggling, and interventions aimed at supporting the family as a whole are very important. Careful examination of the school setting and accommodations to decrease over-stimulation are similarly necessary. But if the drug makes the symptom go away, there is no motivation to devote effort and resources to make these kinds of changes.

Obama's health care reform takes a small step in the right direction. ACO's (accountable care organizations), if they work the way they are intended to work, will encourage primary care clinicians to take the time to carefully listen to patients stories. In building relationships with parents, these clinician have the opportunity to support healthy development of the next generation in a preventive model.

Last week there was a little noticed news item about reports of the possible association between suicidal ideation and Focalin, a stimulant medication used for ADHD.

The FDA said it received eight reports of suicidal thoughts for children or adolescents who took the drug over the past six years, and four of the cases appeared to be linked to the medicine. The link for the remaining cases was less clear.

Kaitlin Bell Barnett, a journalist who writes very intelligently about psychiatric medication, asks on her facebook page "Based on 8 cases of suicidal thoughts ever reported?" I'm not sure what she meant by this question. But it seems to me that even 4 cases is enough to make us seriously rethink this path we are on to medicate away symptoms rather than address "relational poverty" in a meaningful way.

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