Connecting the dots to discover the cause of "ADHD"

A reader of my previous post asked how I "connect the dots" from supporting newborns and parents to "ADHD" treatment. He states that, "trying to figure out the cause will not help any kid today." This comment motivated me to clarify what I mean by cause, as I think finding out the cause will help every kid today.

What I mean by "finding out the cause" is to give parents the space and time to tell their story, to make sense of their child's symptoms.  The aim is not to determine if the child has enough symptoms to meet diagnositic criteria for a DSM defined disorder, but rather to support  parents' efforts to find a coherent narrative. It involves starting with at least 1-2 full hour visits with both parents.  I put "ADHD" in quotes because by giving the symptoms a name, as in "ADHD evaluation" we narrow our thinking before we even start. Ideally we listen to the family's story with an open minded curiosity.

The story often starts with a fussy or colicky baby. Even before this, there may have been stress in pregnancy which is known to be associated with advanced motor development and behavioral dysregulation in the newborn. Postpartum depression and/or anxiety may have been present. Supporting a dysregulated baby is particularly challenging when a parent is affected by depression and/or anxiety. These babies often continue to have symptoms of dysregulation into the toddler and preschool years, with frequent tantrums, "not listening" or "explosive behavior." There is often a strong family history of "ADHD," substance abuse or other mental illnesses. This history is closely linked with current relationships. For example, if one parent has "ADHD," the child's behavior may be especially dysregulating for that parent. One parent who does not have "ADHD" may blame the other parent, resulting in marital discord. The child may have significant sensory processing challenges. The child may be developmentally immature and the youngest in a structured preschool program. Sleep disurbance on the part of both parent and child has a significant role to play in development of symptoms.  There are as many variations to this narrative as there are families. Clinicians also need to be attentive to the fact that child maltreatment is a rare cause of "ADHD"  that we do not want to miss, and must be considered.

 Once parents have the opportunity to make sense of their child's symptoms,  "what to do" follows naturally. Medication may, in a few cases, be indicated, particularly if a child's self esteem is suffering due to academic demands. But more often than not, the "what to do" is elsewhere. For example, a parent may need to do his own therapy to address troubled past relationships. A parent may take up yoga to manage the dysregulation her child's symptoms precipitate, so that she can remain calm in the face of his difficulties. Sleep disruptions are often part of the story and must be addressed. Marital counselling may be necessary. A good occupational therapist, who helps the family to manage the child's unique challenges in the context of relationships, can be invaluable.

Time, space and a nonjudgmental listener are essential first step in evaluation of any child with behavioral symptoms. The "why" must come before the "what." Then the "what to do"will follow naturally.