ADHD: biology or environment?

When I write from my clinical experience as a behavioral pediatrician, I am careful to change identifying information to protect the privacy of my patients. It is rather freeing, therefore, to write  about characters in a novel. Left Neglected by Lisa Genova, who is also a neuroscientist (perhaps she took the story from some real cases) offers some important insights into this complex subject.

The story revolves around Sarah, a 37-year-old mother of three young children, who, distracted by her cell phone on her drive to her high-powered job, crashes her car and suffers a traumatic brain injury. In the days just before the accident, she and her husband are called in to see their seven-year-old son's teacher who says, in not so many words, that they should have him evaluated for ADHD and possibly medicated. During the time that Sarah is hospitalized, he is in fact diagnosed and started on Concerta.

But there is another relevant story line. We learn that when she was a child, Sarah's 6-year-old brother accidentally drowned in a neighbor's pool. When Sarah's mother comes to take care of her in the wake of her accident, we gain further insight into the havoc this event wreaked on their relationship. Her mother is holding her hand in the hospital. She writes:

After Nate died, at first she held my hand a little tighter. I'm seven, and my hand is in hers when we cross the street, when she leads me through a crowded parking lot, when she paints my nails. Her hands are confident and safe. And then I'm eight, and my hand must be too awkward to hold along with all that grief, so she just lets go. Now I'm thirty-seven, and my hand is in hers.

Sarah acknowledges that her intense drive to succeed has been at least in part powered by this double loss of her mother and brother. In her pre-accident life she is a master multitasker who works very long hours and is rarely home for in time dinner. She clearly adores her kids and is devoted to them, but is usually answering emails while getting them ready for school.

As she and her mother work to heal their relationship, we see a new kind of calm in Sarah (part of this is necessitated by the restrictions on her life imposed by her brain injury.)  In a lovely scene where she is helping her son with his homework, she is present with him in a way that she was not in her prior frenetic lifestyle. Together they figure out that he works better standing up. If they cut out the problems, he can do them individually and not be distracted by all of the questions on the page. Both are thrilled by his success.

Jubilant pride skips along every inch of his face. It strikes me that he looks like me.

I recognize that these are fictional characters. Yet I think that an assessment, as I do with real patients I see in my practice, can offer some insight into this complex question of the interaction between biology and environment.

There is likely a genetic vulnerability for attention problems in Sarah's family. Her brother's accidental death may have in part been due to an impulsivity that can go along with these traits. Sarah herself may have some attention problems, but her behavior is also in large part fueled by the loss of her brother and her troubled relationship with her mother.

Her son may have this same genetic vulnerability, but his symptoms are also tied to his mother's intense, driven behavior. She may have difficulty being emotionally present with him, particularly as he reaches the age her brother was when he died. As Sarah's relationship with her own mother is healed, in turn she is able to be more fully emotionally present with her son.

My hope for these fictional characters is that Sarah's process of grieving and healing with her mother will in turn help to lessen her son's symptoms of inattention and distractibility, and so support his healthy development.

Grief and loss are frequently present in the family history of children who have been diagnosed with ADHD. But often, as in this story, these losses go unacknowledged for many years, sometimes for generations. They may take the form of "family secrets."

As I was working on this post, I suddenly recognized the double meaning of the book's title. Left neglect is the name given to the disability that results from Sarah's injury. But Sarah was also left neglected by her mother's grief.  Ironically it takes the first to repair the second. My hope for real families confronting similar issues to this fictional one is that they can find a way to address these unmourned losses and heal relationships without needing a devastating life event to motivate them. 

Program inspired by Daniel Pearl teaches kids to use music for peace

An extraordinary program, Music in Common (MiC), takes on particular significance in light of recent events in the Middle East, when a video that author Salman Rushdie referred to in an NPR interview as a "disgraceful, shoddy little thing," seems to be at least in part responsible for terrible violence and death. In stark contrast, MiC's mission statement reads:

By producing free, publicly accessible concerts, school programs, and multimedia productions with an interest in underserved areas and communities where there is a history of conflict, Music in Common (MiC) provides a platform for the exchange of ideas and collaborations that can lead to positive social change.

Originally called FODfest (Friends of Daniel) the organization was founded by Pearl's close friend and bandmate Todd Mack in response to Pearl's tragic death in 2002. Pearl was kidnapped while working as a journalist in Pakistan, and subsequently beheaded by his captors.

Groups of students in the MiC youth program work together with industry professionals to write, record, perform, and produce a music video of an original song, participating in all aspects of the creative and multimedia production process. Their website states:

MiC Youth Programs are free educational programs that extend the FODfest concept of community building through music to youth, serving to educate, inspire, and empower junior high and high school students.  MiC Youth Programs take place in local schools or community centers where FODfest concerts take place and provides an experiential education to students, teaching the essential life skills of team building, collaboration, and mutual respect. 

MiC international focuses on the Middle East, and has produced music videos with groups of Arab and Israeli students working together, including this one Peace*Shalom*Salaam.

I am fortunate that the organization's founder lives in my town, and has brought the program to my son's school. For the past two weeks, a group of nine high school students have worked long hours together in an intensive process to create a song and produce a music video.  I had the privilege to sit in on a group of kids discussing what they are learning. One said that in the age of the Internet, it is important to think carefully about how your message will be received by a large audience. Another reflected on the responsibility of using creativity for peace, not war.

Following the production period, there is a performance,  referred to as a "FODfest community concert." Here the song and video are debuted for an audience, and musicians swap songs and jam together onstage. The Mic brochure describes these events as:

Powerful and healing experiences generating a sense of community and hope, serving as a call to action for individuals and communities to discover common ground.

Never leave a child alone during a meltdown

A commonly held belief among parents is that one should leave a child alone, or "ignore" him, when he is having a meltdown. Yet all of the best of developmental science tell us that this approach is completely wrong.

When I work with families who are struggling with a child's out-of-control behavior, I explain that in the middle of a meltdown, a child feels completely helpless. If left alone, he will feel not only frightened, but also abandoned. I explain that at such a moment, the higher cortical centers of the brain responsible for rational thought are not functioning properly.

These types of severe meltdowns are common in children who have experience early trauma, at the time when the higher cortical centers of the brain were not yet fully developed. Stress of a seemingly minor nature can lead the rational brain to in a sense go "off-line."  The child will have access only to the lower brain centers that function more instinctively.

I recall working with the parents of a four-year-old child who had been adopted from another country. There he had lived on the street with his mentally ill mother, from whom he had been separated at one year of age and placed in an orphanage. His adoptive parents where both horrified and overwhelmed by what they interpreted as "anger." He would scream at them,  spit at them, kick and hit them. Not only would they get angry in return, interpreting his behavior as "defiant," but they would send him to his room, saying, "I'll be back when you can calm down and behave nicely."

When I explained that during a meltdown he was developmentally more like a newborn than a four- year-old, their approach to him completely changed. Rather than react in anger, they would ask calmly, "Do you need a hug?" Or they would try to hold him. If he were too out-of-control to allow physical contact, they would take him to a place where he was physically safe, and speak to him reassuringly until he began to calm down. Not only did the tantrums subside, but his parents began to learn to recognize when he was about to descend into what they now understood as a lower center of brain function. They would try to engage him when the thinking part of his brain was still working.

Similar mechanisms are at play in a child who has not had this kind of severe trauma. Frequent meltdowns are common in the setting of sensory processing problems and developmental problems such as speech and language delay (as apparently was the case for Rose, the child described the New York Times piece.) When a child is repeatedly abandoned both physically and emotionally in the middle of a meltdown, that experience in itself may be traumatic. In such a situation frequency and intensity of meltdowns often worsens.

Parents often feel that holding a child in this way is counter intuitive. "Won't I teach him that he can get whatever he wants? " they often ask. But the opposite is true. When a child feels held and understood, with time he learns to manage these difficult moments on his own. 

Discipline, both in the home and in the school setting, should be founded in contemporary developmental science. This science tells us that when we aim to see the world through the child's eyes, and approach his behavior from a stance of empathy and understanding, he learns to regulate emotions, think clearly, and manage himself in a complex social environment. 

A Conversation with Paul Tough: How Children (Don't) Succeed

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

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

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

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

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

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

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

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

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

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

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

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

4) Value time as a clinical intervention

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Paul Tough Speaks at Harvard: How Children Succeed

One of the highlights of Paul Tough's new book How Children Succeed:  Grit, Curiosity and the Hidden Power of Character comes in the final chapter, when he describes how he and his wife interact with their three-year-old son Ellington to help develop the qualities he spends the rest of the book demonstrating are associated with success.

He describes helping Ellington to calm down after a tantrum or bad scare, providing discipline and rules, and, in addition to lots of hugs and comfort, helping him learn to manage failure. These are exactly the parenting behaviors that research has shown lead to the capacity for emotional regulation, cognitive resourcefulness, resilience, and the ability to adapt to a complex social world.

The thesis of this book, whose primary focus is the education system-Tough is speaking on Thursday September 6th at the Gutman Library of the Harvard School of Education-, is that the conventional wisdom about the key to success has been misguided. Rather than focus on promoting cognitive abilities, our focus should be on development such things as gratitude, curiosity, self-control and grit, all of which are distilled into the word "character."

While Tough does not explicitly make this point, but rather demonstrates it in writing about his son, character develops in relationships.  When a person has a relationship with someone who not only cares about him, but also thinks about him, understands his perspective and unique challenges, helps him calm down in the face of difficult feelings, sets limits on his behavior and trusts him enough to let him fail, he is more likely to develop the "non-cognitive skills" associated with success. He will be able to think clearly and flexibly in the face of stress.

The first chapter offers an excellent overview of the current explosion in research on toxic stress, or stress in the absence of such a secure, safe relationship. Tough refers to the  ACES (Adverse Childhood Experiences) study, a huge longitudinal study that dramatically demonstrated the association between early adversity, including such things as abuse and neglect, parental mental illness and substance abuse, and family discord, with many negative health outcomes including not only mental illness but also chronic illnesses such as diabetes, asthma and heart disease.

Particularly important is the work of Alicia Lieberman, one of the pioneers in the field of infant mental health. Tough writes of Lieberman's collaboration with pediatrician Nadine Burke Harris in an innovative San Francisco based program that applies the ACES study to preventive work with children and families.  Lieberman recognizes that providing a secure attachment relationship "takes a superhuman quality" in the face of poverty, uncertainty and fear. Her model of intervention works with parent and child together.

Lieberman's treatment is relatively intensive, administered in weekly sessions that can continue for as long as one year. But the principle behind it-improving children's outcomes by promoting stronger relationships between children and their parents-is increasingly in use across the country in a wide variety of interventions. And the results, when the interventions are evaluated, are often powerful.

The rest of Tough's book focuses on interventions for school age children. The implication is that these children have had stressed early relationships, but that interventions in the school setting that focus on character development may mitigate against these early experiences. He writes:

It is hard to argue with the science behind early intervention. Those first few years matter so much in the healthy development of a child's brain; they represent a unique opportunity to make a difference in a child's future. But one of the most promising facts about programs that target emotional and psychological and neurological pathways is that they can be quite effective later on in childhood too-much more so than cognitive interventions. 

Tough describes successful school programs that have focused on character development. The Youth Advocate Program, or YAP, in Chicago offers an intensive mentoring program for high-risk teenagers.  At KIPP (Knowledge is Power Program) in the South Bronx, where there is a curriculum designed to teach character, and even a character report card, one student describes how the teachers were devoted to him and his fellow students. " They were like my second family, in essence...that's the vibe we all ended up getting, that we were like a family."

Yet another program is OneGoal in Chicago, run by CEO Jeff Nelson:

Nelson's belief is that underperforming high-school students can relatively quickly transform themselves into highly successful college students- but that it is almost impossible for them to make that transition without the help of a highly effective teacher. OneGoal has signed a unique partnership deal with the Chicago public schools that lets the organization work directly with individual teachers...the teacher sticks with the same class for three years...And when the students are freshmen in college the teacher keeps in close touch with them...providing support and advice."

Tough shows how relationships can be stressed not only for the very poor, but also the very wealthy.

Riverdale, a private school in a very different part of the Bronx from KIPP, offers an example of wealthy students who are similarly at risk. Referring to the work of psychologist Madeline Levine, he writes:

Wealthy parents today, she argues, are more likely than others to be emotionally distant from their children while at the same time insisting on high levels of achievement, a potentially toxic blend of influence that can create "intense feelings of shame and hopelessness" in affluent children. 

Stressed relationships of this kind may have a negative impact on character development. Riverdale's headmaster, Dominic Randolph, is concerned that students are lacking in important character traits.

Traditionally the purpose of a school like Riverdale is not to raise the ceiling on a child's potential achievement in life but to raise the floor. What Riverdale offers parents, above all else, is a high probability of nonfailure...The problem, as Randolph has realized, is that the best way for a young person to build character is for him to attempt something where there is a real and serious possibility of failure.

The book takes an interesting turn when, after focusing on a number of programs that measure their own success in terms of rates of college graduation, Tough reveals that he himself did not graduate from college. Clearly Tough is a highly successful person. This information led me to wish that more of the book had been devoted to exploration of the definition of success.

I thought of how Sigmund Freud defined mental health as the capacity to love and to work. I though about creativity and empathy as two qualities that are intimately tied to success. I found myself remembering Brandon Fisher, the manufacturer of drilling equipment who was recognized by President Obama in the 2011 State of the Union address for his critical role in the rescue of the Chilean miners.

These other aspects of success are mentioned in Tough's book. For example:

At KIPP, teacher Mike Witter explains to a parent, "The categories [of character traits] we ended up putting together represent qualities that have been studied and determined to be indicators of success. They mean you're more likely to to go to college. More likely to find a good job. Even surprising things, like they mean you are going to get married, or more likely to have a family."

A related body of research, coming from the fields of infant mental health and psychoanalysis, supports the notion that the way Tough interacts with Ellington will in fact lead to this broader definition of success. This literature, and in particular the work of leading researcher Peter Fonagy, refers to the central aspect of a secure attachment relationship,  a capacity that is unique to humans, as mentalization, or "holding a child in mind."

John Bowlby, considered the father of attachment theory, writes how in the setting of such a relationship a child becomes, "self-reliant and bold in his exploration of the world, cooperative with others, and also- a very important point-sympathetic and helpful to others in distress." 

Tough is applying his considerable talents as a journalist and writer to a critically important task. The question he asks is not only how children succeed, but also how the answer can inform meaningful social policy. He is bringing this issue to the forefront of public discussion.  I am thrilled to be in the company of Tough, as in my work I have also been asking:  What can we as a society do to promote healthy relationships, that in turn promote both character and success, from infancy through adolescence? Tough writes:

Parents are an excellent vehicle for those interventions, but they are not the only vehicle. Transformative help also comes regularly from social workers, teachers, clergy members, pediatricians, and neighbors. 

Tough tackles this issue in his whole body of work, including not only this book, but also his first book,  Whatever it Takes, about Geoffrey Canada and the Harlem Children's Zone, and his New Yorker article The Poverty Clinic about pediatrician Nadine Burke Harris' program.   I am eager to see what he does next.