I recently became recertified by the American Board of Pediatrics. My certification was due to expire at the end of this year. In order to accomplish this task I had to do two things. One was to complete an assessment of my knowledge base. The other was to complete an approved "quality improvement activity." I chose one referred to as the "Attention Deficit Hyperactivity Disorder (ADHD) Performance Improvement Module" Clinicians who are currently seeing very few patients(the case for me due to the book writing) are able to use simulated patients for this online activity. By giving data for patients over three time points, this "performance improvement module" scored me in the high range of improvement of care because I gave the Vanderbilt( a standardized assessment tool for ADHD evaluation with a parent and a teacher version that assesses symptoms and academic performance) to every patient, discussed the option of medication, and if they were on medication, measured weight and blood pressure at every visit. That and pay $1,000 and I am now recertified until 2016.
This experience brought to mind a case of a seven-year-old boy who was referred to me for evaluation of ADHD. He arrived with the completed parent and teacher Vanderbilt forms on which he scored in the high range for inattentive and hyperactive ADHD. His mother had a high expectation that I would put him on medication. In our first visit, when I met with the mother alone, the following story emerged (details have, as always, been changed to protect privacy.)
For the first six years of his life this boy lived with his father, who was an actively drinking alcoholic. His mother lived in a different state and was intermittently involved in his life. When his father became ill with advanced liver disease, his mother moved closer to him and began to be more involved in his care. His father continued to drink despite his rapidly declining health, and though his mother was at first reluctant to share details, her son had witnessed his father's rather gruesome death at home about 6 months prior to our visit. He was now living with his mother and was struggling in school. He was receiving no psychotherapy or intervention of any kind. His teachers, who knew little of this story, had recommended the "ADHD evaluation" and had suggested strongly that he might benefit from stimulant medication.
The work of psychiatrist Bruce Perry, who taught one of the weekends of the Infant-Parent Mental Health Post Graduate Certificate program of which I have been writing for the past year, helped me to understand what was likely happening for this boy in school (for the sake of this blog post his work is simplified. For further information see the Child Trauma Academy website.) For most of his life this boy lived with an unreliable caregiver, who, when he was drinking likely was unrecognizable. The same person who he relied on for safety and security was frightening and unpredictable. The subsequent witnessing of his father's death adds a level of trauma that is almost unimaginable.
When children experience this kind of trauma from an early age, it affects the areas of the brain responsible for regulation of the most basic functions. A child may in a constant state of "hyper-arousal" in which he is constantly vigilant for possible danger. He does not have a normal sense of time and may exist only in the present. In the face of any kind of stimulation, he may experience either a fight-flight response or alternatively what is referred to as a dissociative response, in which his mind in a sense shuts down. In either state the brain does not function well and a person is unable to think, much less to learn.
In order to treat this kind of early trauma, one must start at these lower centers of the brain in order to help a child develop the basic capacity for self regulation. This may involve such activities as massage, walking, or martial arts. In essence, one needs to rebuild the brain from the bottom up. Only in this way can one hope to engage the higher centers of the brain and help a child make sense of his experience and begin to use his brain to learn.
Yet the standard of care in pediatrics, as reflected in my successful recertification experience, is to document symptoms of inattention and hyperactivity and then treat with stimulant medication. And the fact is that in the short term, stimulants may help a traumatized child to calm down. But the benefits are short lived, and often there is an escalation to higher and higher doses of medication over time.
A teacher of mine who is a leader in the discipline of infant mental health recently asked me why pediatricians should do this work, and not "a new front line practitioner trained in well child medicine and developmental mental health." The fact is that pediatricians, who are on the front lines and see children and parents early and often, do treat behavioral and developmental problems as a huge part of their practice. A 2001 policy statement The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care by the American Academy of Pediatrics reflects this fact.
As is clear from the above story, pediatricians are doing this work under the influence of a powerful pharmaceutical industry and pervasive culture of medication. Therefore, if we are to "do no harm" it is imperative that pediatricians are exposed to the wealth of knowledge and research generated in the discipline of infant mental health. This research offers a different model for understanding and treating behavior problems from the "advice giving", "parent training", "behavior management" and medication prescribing that is currently the standard of care in pediatrics. In my experience, as well as that of as small but growing number of pediatricians who are learning about infant mental health, these ideas have great relevance to our practice, and offer the opportunity to help young children and families in profoundly meaningful ways.