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.

Buddhism, brain science, and parenting: towards an integration

In the past week I had two profound yet seemingly polar opposite conversations about how to promote healthy development.

The first was among fellows and faculty of the UMass Boston Infant Parent Mental Health Post-Graduate Certificate program (IPMH) about a new study, The Effect of Poverty on Brain Development, published in the current issue of JAMA pediatrics. Using brain imaging techniques, researchers showed that the children raised in poverty had smaller volumes of specific areas of the brain. They describe how the "caregiver" can "mediate" against the effects of poverty. The effects on the brain were less in the setting of "caregiver support." The group was addressing the ways in which this study fit with the abundance of new research in developmental psychology, neuroscience and genetics.

In conversation with the IPMH group, made up of many brilliant and often like- minded colleagues, who I affectionately refer to as "my peeps," I expressed concern that the exclusive focus on "brain science," where parents are referred to as "mediators," the emotion is excluded. It can become a way to distance from, or even leave out, the passion inherent in these profound love relationships.

Perhaps even more worrisome, I said, is that by making the discussion primarily about poverty, there is a risk of creating a kind of "us-them" mentality.  Certainly there are plenty of well-off families raising children in an environment of high stress and emotional neglect. Similar to the focus on "brain science," it becomes another way of distancing from the problem. 

I shared with the IPMH group my recognition that pointing to the value of listening, of creating an environment of respect for all parents and children, is seen by many as "soft." For example, I felt very alone when one pediatrician referred to my work, in a none-too-kindly tone as, "that baby whisperer stuff."

I knew I was not alone when the second conversation occurred a few days later at  a workshop at Austen Riggs entitled The Interplay of Psychoanalysis and Buddhism: Partners in Liberation. It was all about emotion and interconnectedness.

In a post a number of years ago, I wrote about receiving a letter from a reader who had been "awakened by the tradition of Zen Buddhism" and found my that my work, as described in my book Keeping Your Child in Mind ( see excerpt below), resonated with his experience.

Being understood by a person we love is one of our most powerful yearnings, for adults and children alike. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. For a young child, this understanding helps develop his mind and sense of himself. When the people who care for him can reflect back his experience, he learns to recognize and manage his emotions, think more clearly, and adapt to his complex social world. 

When families come to see me in my pediatrics practice for “behavior problems,” both parents and children feel estranged and out of control. They are disconnected, angry, and sad. I help them recognize each other. Meaningful change happens when we share these moments of reconnection. 

While I do not know very much about about Buddhism, I have been greatly influenced by psychoanalysts D.W. Winnicott and Peter Fonagy. I attended the workshop because I was curious to learn more about the relationship between Buddhism and psychoanalysis. In particular I was interested in the place of mourning, for I have increasingly come to recognize that meaningful change, and with it the joy of connection, occur most often when parents move through moments of profound sadness.

Workshop leader Joseph Bobrow spoke with a kind, gentle manner while conveying a sense of quiet authority that was calming and containing. He described the Buddhist notion of "re-authoring our suffering" of "representing our suffering in safe circumstances without shame" so that the story can "take its place in a hierarchy." He described "riding the waves of affect" to "transmute them in to the waves of life." He spoke of "transmuting sorrow" so that it does not "hijack" us." He spoke of how the therapist's "presence of mind," is what  calms, regulates and heals the patient.

When parents are flooded with stress and feeling overwhelmed by their child's behavior, I may ask them to slow down and describe in great detail a specific moment of disruption. This can be very difficult to do. Listening to Bobrow speak about meditation and Zen Buddhism, I heard many links to this process. Meditation can be about noticing how we become derailed by patterns of  thought and behavior. Similarly, by slowing things down, parents become aware of how their child's behavior provokes them, and how they may unintentionally attribute meaning to their child's behavior that is markedly different from the child's true intention.

If a parent recognizes in his response to his child's behavior a surge of rage that is linked to a memory of his own father slapping him across the face, the tears may start to flow. Now we have an opportunity to, as Bobrow said "use the suffering to turn straw in to gold." For in the face of this realization, of this "riding the wave of affect" this father can "re-author the suffering" and in doing so separate his own experience from that of his child. It is just this slowing down that helps him to see his child as himself. In turn the child, himself feeling recognized and understood, becomes calm.  This "meditative" process can be what underlies the moments of profound joy and connection between parent and child that follow.

My two experiences this week seem at first glance to be worlds apart.  I wonder if a piece Bobrow wrote on his Huffington Post blog following the Newtown shooting might point in the direction of integration.

We are helpless, we want it fixed, and become prone... to either-or thinking. But there is no silver bullet. Silver bullet, compartmentalized thinking is the problem. Cumulative trauma compromises the capacity for making connections, for holistic reflection. At it's extreme, the other becomes "not me," so I can eliminate him or her with impunity, Intellectually, it's like bubble living: psychology here, culture there, economics somewhere else. Climate? Fuhgetaboutit. We must grasp our fundamental interconnectedness, and with it the intimate and often unseen interplay of psychological and cultural forces and social and political action.

 I wonder if a third conversation, including both my IPMH colleagues and Bobrow, would lead to some real progress.

Authoritarian parenting vs. parenting with authority

Authoritarian parenting, as in "my way or the highway," and its opposite, permissive parenting with lack of limit setting, may be linked with difficulty with emotional regulation in children. In contrast, an "authoritative" parenting style is associated with an enhanced capacity for emotional regulation, flexible thinking and social competence. An authoritative parenting stance encompasses respect for and curiosity about a child, together with containment of intense feelings and limits on behavior.

Parental authority is something that in ideal circumstances comes naturally with the job. It is not something that needs to be learned in books from "experts." In fact our culture of  "advice" and "parent training" may unintentionally undermine that natural authority.

But what might cause a parent to lose that natural authority? Stress is far and away the most common culprit. That stress might be in part coming from the child himself, if, for example, he is a particularly "fussy" or "dysregulated" baby. It might come from the everyday challenges of managing a family and work in today's fast-paced culture, often without the support of extended family. It may come from more complex relational issues between parents, between siblings, between generations.

When I work with families of young children, my aim is to help parents reconnect with their natural authority. By offering space and time to listen to their story, including addressing the wide range of stresses in their lives, my hope is that together we will make sense of, or find meaning in, their child's behavior. Armed with this understanding, "what to do" usually follows naturally.

I have learned that it is important to be explicit about this approach. As I write on my website:

Parents often come to a pediatrician with expectation of advice and judgment. Our culture may support this expectation by our reliance on “behavior management” and increasingly on medication to treat “behavior problems” in children.

Some guidance about "what to do" may naturally enter in to the conversation. But I have found that premature "advice," without full understanding of the complexity of the situation, can often lead to frustration and failure. In contrast, when a parent has that "aha" moment of insight, the joy and pleasure that comes from recognition and reconnection, for both parent and child, can be exhilarating.