Meaningful treatment requires identification of multiple causes of behavior
Posted Sep 29, 2014
When the American Academy of Pediatrics changed the guidelines for ADHD to expand age of diagnosis to include children from age four to 18 (from six to 12), that the number of cases would rise was, by definition, inevitable. The recent survey by the CDC 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 an invitation to speak at an international child psychiatry conference on 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. Central to deconstruction is time to listen to the story. Consider four-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 three 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.
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 four, 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.
Many refer to "faulty wiring" as a cause for "ADHD" Problems with specific areas the brain are known to occur in association with the symptom complex named as "ADHD." However, the field of epigenetics shows us that gene expression, and with that structure and function of the brain, changes throughout the lifespan. The wiring is not "fixed." With appropriate treatment, the wiring can change.
Perhaps more importantly, the term "ADHD" is now applied so broadly as to become meaningless.
The write up for the panel speaks of what is now called "ADHD" as a valid symptom complex, or set of behaviors that tend to go together. 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 is therapeutically misleading.
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. Long-term studies, however, show that these benefits do not persist and other serious mental illness may emerge. Such an approach is simply a silencing of children.
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.