Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Wednesday, November 27, 2013

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.

6 comments:

  1. To improve care, and access to meaningful help, the SPD COMPONENT needs to be acknowledged in the DSM. ASD and ADHD often are co-associated, as you noted. But the sensory elements are possibly stand alone Dx, and need to be acknowledged by MDs, pediatricians, etc. The DSM is the holy grail for which support and services are rendered. Love that you acknowledge home life and family stress...they need the resources and training and help. Caught in a viscious cycle, arent they!

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  2. I have limited experience compared to you but want to share my perspective. I have been diagnosed with ADD as an adult(and PPD, PPOCD, and anxiety). I now stay home to manage my home and it is extremely obvious I have ADD. As I was growing up kids in my class were diagnosed and prescribed drugs. Overall their family lives were pretty horrible. I am sure lack of sleep, structure, and even the mental stress of dealing with adult situations all were major factors. For me I interrupted class, had a hard time focusing and excelling in the classroom setting and it was difficult to get work done unless someone be it a teacher or parent was always there to say history paper due tomorrow, spelling test in 2 days lets study(the agenda required by the school was SO helpful!) I too would have been getting the Fs and Ds that prompt the teachers to call parents. In my research it is literally that the ADD/ADHD brain is 'wired' differently and it is very genetic(My dad was also labeled ADD and never went on drugs for it). My therapist is pushing the drugs but I told her that although I am struggling now I have lived my whole life this way and do not want to resort to that. I started talking NOW foods true calm and true focus they are amino acids and they do help some. I heard about them in a book called The Mood Cure. They are not a miracle cure but help and are things found in foods anyway so I feel better about taking them

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  3. Thanks for all of the above comments. In response to the latest, there is certainly evidence that problems of inattention and hyperactivity have a genetic basis and are related to as you say "wiring of the brain." But brain structure and gene expression change in relationships, as is described in the discipline of behavioral epigenetics. Especially if intervention starts very young, there is opportunity to change the brain. Medication has a role to play in older kids, when poor performance in school can lead to problems of self esteem. and in adults where responsibilities require a certain level of functioning. The problem is with the use of the term "ADHD" which suggests a known disease process analogous to asthma or diabetes and tends to stop thinking. With diagnosis and prescribing of medication, examination of other factors contributing to problems of attention, impulsivity and hyperactivity tends not to happen.

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