The Child Mind BlogBrainstorm
The ADHD Lie Detector
Nov. 25, 2013 Caroline Miller
Bloomberg reports on an intriguing device that's apparently being used by an increasing number of doctors to weed out college students faking ADHD in order to score prescriptions to stimulant medications. It's called the Quotient ADHD System, and it collects data on a person's ability to "sit still, inhibit impulsivity and respond accurately to images on a computer screen." Developed at McLean Hospital, the psychiatric wing of Harvard Medical School, it uses motion detection technology, along with the patient's performance on a visual response test, to measure inattention, hyperactivity and impulsivity compared to other people of the same age and gender.
Some doctors swear by it—here's one who says it proved him wrong on several cases and here's a Time reporter who tried it—and the manufacturer claims that it's 92 percent accurate in identifying fakers. But it hasn't exactly taken the ADHD world by storm. After about 5 years on the market only about 300 are in use, according to Bloomberg.
Quotient wasn't developed, of course, to weed out students trying to score Ritalin or Adderall to boost their academic performance, but rather to improve diagnoses for the millions of children who have real problems. The goal was a test that would be less laborious and subjective than the scales now used to have parents, teachers, and children themselves measure how often they exhibit the behaviors that are symptoms of ADHD.
Those tests—like the SNAP-IV Teacher and Parent Rating Scale and the Child Behavior Checklist—are limited by the fact that answers can be skewed by preconceptions. That's why the Quotient people like to taut their test as "objective." But the bigger limitation in the use of scales is that too many doctors don't take the time to administer them, and hence too many kids are diagnosed basically by hunch—and on the hope that medication will help them do better. And when it comes to college kids, clinicians surely aren't asking for the multiple sources of information that are considered best practices when diagnosing kids.
Quotient has the appeal that it takes only about 20 minutes, and if it works to weed out the real inattention and hyperactivity from the fake, it could be useful for cutting down on abuse of the meds. But as Dr. Rachel G. Klein, professor of child and adolescent psychiatry at NYU's Langone Medical Center and a member of our Scientific Research Council, told Bloomberg, to be diagnosed with ADHD a child must show symptoms over a period of time and in several settings—not just at school, for instance, or at home. That fact that a child has symptoms of ADHD on a visit to a doctor's office isn't the basis for a sound diagnosis. We're all for developing objective tests, but the fact is that the science isn't there yet for us to make a diagnosis with a machine. Until we can, doctors should use the best evidence-based tools and the secret weapon of every good clinician: rigor.View Comments | Add Comment
Teaching Kids Under Stress
Nov. 15, 2013 Caroline Miller
A pair of excellent pieces in the New York Times recently highlighted the effects of mistreatment of children on their developing brains and behavior.
The bad news is that what's called "toxic stress"—frequent or continual stress on kids who lack adult protection and support—impacts the brain at the time it's developing its basic architecture. That makes kids vulnerable to anxiety and depression, as well as more physical ailments, later in life. The good news is that interventions that support kids in adverse situations, often by strengthening the role of parents and teachers in buffering stressful situations, can lower the risk of those problems developing.
For instance, programs that help parents tune in to what children are feeling and make themselves more emotionally available have shown to reduce the incidence of at-risk children acting out in school. And they also increase parental pleasure, the clinical director of one of these programs tells David Bornstein of the Times.
"There are millions of times that children are doing things that parents are missing or misreading," she adds, "and there's no joy or delight in their parenting. We want delight! Delight is protective. When a child feels loved and valued by a parent, it buffers the circumstances. We can't fix poverty but we can buffer the stresses."
There is also exciting evidence that training teachers to be more tuned in to the effects of toxic stress in children enables them to respond much more effectively to disruptive behavior in the classroom. Recognizing stress and helping kids who are overwhelmed to calm down and get mastery over their feelings reduces the kind of classroom outbursts that often end in suspension and get kids sent to the emergency room.
"Punishing children for misbehavior they don't know how to control," Bornstein writes, "is comparable to punishing a child for having a seizure; it adds to the suffering and makes matters worse." Instead, educators who are trained to recognize the effects of toxic stress understand that disruptive kids aren't necessarily being willful or defiant, and the best way to stop the behavior is to make them feel safe and help them build resilience.View Comments | Add Comment
Where are the support, concern, and homemade casseroles?
Nov. 14, 2013 Caroline Miller
Larry Lake's family has been through a lot. His wife had breast cancer. His daughter developed bipolar disorder and a drug and alcohol addiction. There was a serious car accident. Lake describes this series of events in Slate not because he wants sympathy, but to note a painfully acquired truth.
When someone in your family has a physical illness, including cancer, the outpouring of support and offers of assistance from friends is dramatic. Solicitous questions, links to stories that might offer helpful information, rides to radiation sessions, and, of course, lovingly prepared meals, more than they could possibly eat. "Leftovers piled up in the refrigerator, and soon the freezer filled up too," Lake writes, "this tsunami of food offerings an edible symbol of our community's abundant generosity."
But when the illness involved is mental, and the admission is to a psychiatric hospital or addiction treatment center, friends who are comfortable talking about cancer become speechless. The years of struggling to support their daughter through crises and rehab and relapse and more rehab were a much lonelier vigil, Lake writes, and quite without those lovingly prepared meals.
And when the family endures another crisis—another physical one—and the cards, offers of help and casseroles once again appear, it does make you want to cry for the fear and embarrassment and stigma that prevent generous people from stepping up when their friends are struggling with psychiatric and emotional problems. Do read the piece here.View Comments | Add Comment
Why Changing Autism Numbers Do Not Equal ‘Epidemic’
Nov. 12, 2013 Harry Kimball
Last week Dr. Bennett Leventhal, a psychiatrist whose considerable expertise includes the epidemiology of psychiatric illness, stopped by our office to give an overview of the state of autism spectrum disorders. Dr. Leventhal gave a wide-ranging talk on everything from causes to treatments to what's really going on with the so-called "epidemic" of new cases.
"Has the prevalence been rising?" Dr. Leventhal asked. "For sure it's been rising. When I was in training it was 4 per 10,000 live births. That's 0.04 percent. It's been going up and up and up, and in 2011 we published what I still think is the best paper on autism prevalence, which said the rate is 2.64 percent." But understanding why it's happening—and why it isn't—is a manner of soberly assessing the available information and make sure that everyone is "counting the right way."
Dr. Leventhal described the development of a standardized diagnosis in the 1970s, thanks to the advocates of the National Society of Autistic Children. In 1978, the organization developed criteria that would soon contribute to the autism diagnosis in the DSM-III, of 1980. "It's important to know how we got here," Dr. Leventhal said, "and it wasn't a bunch of smart guys sitting around—it was a bunch of moms who said, 'You scientists need to do things differently, you clinicians have to do things differently.'"
A key factor that contributed to the consistent increases in prevalence that continue to this day is education law. "This prevalence started rising in the 1970s," he said. "In 1975 Congress passed Public Law 94-142, the Education for All Handicapped Children Act, which said you can't throw kids out of school because they have a disability. And by the early 1990s the DSM-IV came out and those became the accepted criteria in schools. The vast majority of these increases in prevalence come from service data."
But there is another lesson to be had here. "The real critical point to remember is that there is a difference between prevalence and incidence. Prevalence is the number of people in the population who have a condition. And incidence is the number of new cases coming into the population. Increases in incidence represent epidemics—all of a sudden a lot of people have measles. But can you increase prevalence without having any more new cases? Absolutely, and it's really simple.
"How do you do that? The first thing is you can change the diagnostic categories," which have been getting consistently broader, said Dr. Leventhal. "You can change the way you do diagnosis, with better tools for diagnosis. You can increase awareness. And you can also find out that there were methods problems" in the past that artificially kept the prevalence down.
"The usual diagnosis of autism in the 1970s began at the age of 6 or 7 when a kid showed up in school. And then they stopped having autism at 16. Why? Because they left school and were sent to institutions or other places where they were called mentally retarded. So if you're only counting people between 6 and 16, the denominator stays the same and the numerator is small"—that is, the population at large is constant but the subset of people with autism is restricted to a strict age range. But when we understand that autism is a lifelong disorder, things change. "If you all of a sudden add kids from 2 to 6, the numerator goes up but the denominator remains the same." And if you add everyone with autism over the age of 16, "Voila," said Dr. Leventhal. "Your prevalence has risen without changing the number of people with the disorder. You're just counting everybody, and you're counting the right way."
For instance, the study Dr. Leventhal mentioned above, which returned a staggering prevalence of 2.64 percent, was what's called a full population study of Korean youth, endeavoring not to just get a representative group but to test everyone in a community. By "counting everybody," the study was able to identify a "non-clinical" population—kids who didn't have autism diagnoses, and weren't getting services—who in fact met criteria for the disorder.
Dr. Leventhal is skeptical of the concept of an autism epidemic for a similar epidemiological rationale, and the culprits are usually methods problems. These plague every area of causal inquiry, he said, from genetics to environmental to social. Counting the right way may give us a higher prevalence—but counting the wrong way creates false hopes and false fears.
Dr. Leventhal is co-chair of the Child Mind Institute's Scientific Research Council, the Irving B. Harris Professor of Child and Adolescent Psychiatry, Emeritus, at the University of Chicago, and deputy director of the Nathan S. Kline Institute for Psychiatric Research. You can watch him speak about the hurdles to good, applicable research in developmental disorders like autism here.View Comments | Add Comment
Kids Serve Up Life Lessons on 'MasterChef Junior'
Nov. 8, 2013 Jessica Kashiwabara
Anyone who hasn't been watching the first season of MasterChef Junior is missing out on some talented and inspiring kids. The aspiring chefs competing for the $100,000 prize and MasterChef Junior trophy are between the ages of 8 and 13, but the kids use the same ingredients and equipment used in the adult version of MasterChef (though most need a step stool to reach them). The challenges haven't been watered down for the kids either, including a restaurant takeover at a high-end L.A. restaurant and challenges with hard-to-cook ingredients like snails, liver, and sardines. The judges include the notoriously tough and foul-mouthed (though not in front of the kids) host Chef Gordon Ramsay. Thankfully Chef Ramsay shows his softer side on the show, acting as a mentor to the children and offering his encouragement and guidance.
The best thing about watching the show is seeing how the kids blossom with each accomplishment. They are fearless and ambitious, coming up with daring dishes that have never been voluntarily attempted by adult contestants in past shows— macaroons, soufflés, chicken roulade, and other dishes I don't even know how to pronounce. You can see their self-esteem grow and their confidence in who they are expressed through their cooking. On his way out, my favorite competitor, 10-year-old Hawaiian shirt-wearing Jack, said, "I've learned so much about cooking, become way less shy and I've made a lot of great friends."
The finale airs tonight, with the top two going head-to-head—composed and confident Dara, 12, and front-runner Alexander, 13. In the previews, the finalists are already beaming with pride in their embroidered mini chef's jackets. Whoever wins, it's clear these kids have learned a lot. As 9-year-old Sarah, a fan favorite, says, "I've proved to myself that I can do much more than I thought I could." That's a lesson we all can learn from.View Comments | Add Comment
Brainhack 2013 Brings Together 50 Young Scientists
Oct. 28, 2013 Michael Milham
Over the past four days, I attended a unique event in neuroscience called the Neuro Bureau's Brainhack 2013 Unconference. Now in its second year, this event was first conceived and co-organized by Cameron Craddock, Director of Imaging at the Child Mind Institute's Center for the Developing Brain. The Brainhack brought more than 50 young scientists from four continents to Paris to collaborate.
What does this mean and why is it unique? Well, as to what it means—that was really up to the participants. That's why it's called an unconference. Some scientists showed up with projects they are working on, and asked for others to lend their expertise to make their vision a reality. Others brought valuable data and asked, "What would you do with it now that you have access to it?" Others worked to come up with original ideas in the moment, as part of a 24-hour experiment initiative, where they attempted to identify a question of interest, design an experiment and execute it. This year's effort attempted to probe the brain regions that support interpretation of the famous Rorschach ink blots.
The event also featured a series of 10-minute Ignite Sessions by more senior figures in the field, and some tool makers who took the opportunity to give tutorials—whether in the form of a talk or a friendly sit down with new users.
As to why it is so unique—well, in a field that traditionally is known for working in research silos, the Brainhack explicitly fosters collaboration and sharing. Open science was on the tip of everyone's tongue as we shared ideas, approaches and data with one another, working as a collective. The challenge, of course, is how to keep this spirit going among scientists when they go home—avoiding unnecessary isolation of efforts and redundancy. In this regard, I believe events like the Brainhack will help to foster the development of a mindset in young scientists that actively works to tear down silos through usage of social networking and video technologies and build a new spirit of openness.View Comments | Add Comment
'Flipped' Classrooms Could Benefit Special-Needs Students
Oct. 25, 2013 Beth Arky
We were excited to read about "flipped" classrooms in two recent New York Times columns by Tina Rosenberg. The concept is simple: Rather than instruct students throughout the school day and expect them to put the material into practice in the form of homework, have them do the practical, hands-on work at school, under teachers' supervision and at their own pace. Then, have them pick up the concepts by watching videotaped lectures at home.
This approach, which is beginning to gain momentum around the country, allows for something parents of special-needs kids know is critical: the chance for individualized learning, based on a child's strengths and weaknesses, with added in-class support. Parents may chafe at Rosenberg's terminology—"slower" vs. "faster" learners—but the point is this: Children with diagnoses including learning disorders, ADHD and autism do absorb lessons at different rates and benefit from different learning styles to process and retain information.
The benefits don't stop there. Rather than teach a subject and then move on to another—whether or not everyone in the class has "gotten" the material—in a flipped classroom each student focuses on mastery at his own pace and advances when he is confident and ready.
Parents who feel just as burdened by homework as their children will also appreciate this style of learning, since the onus of working with kids on mastery shifts from the parent back to the teacher. Caregivers may be well advised to watch the videos along with their children so they can understand and help, but they no longer have to sit for hours prodding their struggling kids to get all the worksheets and projects done at home, during nights and weekends. The prospect of a less stressful home dynamic is something that might well have parents turning cartwheels.
Some special-needs students already benefit from aspects of this "flipped" classroom model thanks to smaller classroom settings and additional staff afforded by their Individualized Education Program (IEP) or, in some cases, homeschooling. It would be great to see this approach tested in more neighborhood schools, since it addresses the challenges of these students as well as their typically developing peers.View Comments | Add Comment
Where the System Failed Avonte Oquendo
Oct. 17, 2013 Beth Arky
As the search for Avonte Oquendo approaches week three, with police trying a new tactic—playing a recording of his mother out of emergency response vehicles in hopes the nonverbal autistic teen will hear it—questions mount over how he could have bolted from his Queens school. Meanwhile, advocates have begun searching for ways to ensure that such an incident doesn't happen again.
Avonte's brother, Daniel Oquendo—who has taken a leadership role in the search effort—met yesterday with Gary Mayerson, a Manhattan civil rights attorney concentrating on autism, to discuss the status of the investigation and security measures that should be implemented. (Autism Speaks and Mayerson & Associates have contributed toward the $70,000 reward money for Avonte's safe return.)
"I couldn't blame Daniel for being entirely absorbed in his brother's plight," Mayerson says, "but he's not. He's able to look outward to do good and protect other students going forward.
Mayerson outlines three layers of protection. First, there is the student's Individualized Education Program, or IEP. The attorney says a student like the nonverbal Avonte, a known wanderer who has been found in subway tunnels in the past, should have had goals and objectives on his IEP to deal with that issue, which would have included his own aide at the Riverview School. Instead, Avonte was placed in a classroom with one teacher, one aide, and six students. (Wandering, also called eloping or bolting, is a common autistic trait.)
The New York City Department of Education was "clearly on notice that he was a bolter," Mayerson says. "There also could have been a special alerts section saying that he has a history of bolting that is potentially dangerous or life-threatening and he probably does not understand the danger" of leaving school.
Beth Glidden Andersen, who blogs at Maternal Instincts about her 9-year-old son, Nik, who has multiple disabilities including nonverbal autism, agrees with Mayerson's assessment. She commented on Facebook that given that Avonte was known to elope, "there should have been 1:1 supervision full-time.
"There is so much we don't know about Avonte and how he, specifically, functioned in his school environment," she wrote. "My son has many of the characteristics attributed to Avonte; at school he has more independence than he would if we were out in public. But that's because his school is exclusively special-needs students and everyone knows him. They give him opportunities to develop skills in a safe environment."
Mayerson's second point: Avonte's IEP should have had a behavior intervention plan that would tell teachers what to do if he went for the door of the classroom, let alone the school building. Finally, there have to be much-improved security measures in place. "There should be protocols so that people who are leaving the building have the legitimate authority to do so," he says.
The Riverview School—a special-needs program—shares space with a middle school and a high school with typically developing students. The schools share common spaces, including auditoriums, gymnasiums, libraries, and cafeterias. It's believed that Avonte eloped while transitioning between lunch and the classroom.
Mayerson disagrees with New York City Police Commissioner Raymond Kelly's exoneration of the school safety officer who saw Avonte before he bolted. Kelly said they looked at the security videotape and "she directs the young man to go back upstairs [when] he's just at the front door. He goes down the hall and actually exits the building from a side door. You see nothing after this juncture that shows the conduct of the school safety agent was inappropriate or there was any misconduct involved."
But the Oquendo family's attorney, David Perecman, questioned why a side door would be unlocked and unguarded in a school with autistic students. Not only that, "it's an omission issue," Mayerson says. "It's what she didn't do after challenging Avonte and saying 'Where are you going?' She doesn't say, 'Wait a minute, what if this is one of those nonverbal kids?'" In other words, was it simply enough to tell Avonte to stay and to not have some one follow him back to his classroom?
Jennifer Aronson Sellar has had experience with schools like Avonte's: Her nonverbal 7-year-old son, Hugo, who has multiple disabilities including an autism diagnosis, attends such a setting in Brooklyn. She wrote on Facebook that the bigger issue of schools like Riverview is whether staff outside the special-needs program understands the kids' needs. "Very few people even know what elopement is and that this population is at risk for escape," she writes. "I doubt the guard had any knowledge or training for this particular population."
Also yesterday, advocates at a Google hangout presented by ICare4Autism (The International Center for Autism Research and Education) echoed Mayerson's thoughts. Dr. Joshua Weinstein, the founder of ICare4Autism and Hear Our Voices, a school for autistic children in Brooklyn, said his school has cameras inside and outside the building and in the classrooms, as well as "panic doors" that sound an alarm if a child runs out. He adds that there's always an instructor with each student, walking them in and out of the school, going from activity to activity, and during fire drills, lockdowns, and outings.
Weinstein advises parents to find out what the safety procedures are at their children's schools, especially if there's inclusion and a wide span of grades. If they find fault with the plan, they need to advocate for change. He adds that the public needs to be aware of autistic behavior, including wandering, and be able to respond and notify the authorities.
Stephen Mark Shore, an ICare4Autism board member and himself on the spectrum, added, "We need to educate both the individual with autism on how to be safe as well as first responders who may encounter someone with autism." Shore has helped the New York Police Department produce a training video so that first responders may better know how to interact with autistic children, teens, and adults.
He also cited the work done by Dennis Debbaudt of Autism Risk & Safety Management, which offers autism training and resources for law enforcement and emergency first responders, as well as parents, educators, and the autism community. For instance, Debbaudt has an autism emergency plan on his site to help caregivers; it also includes a contact form to get as much info possible about the bolter quickly into the hands of first responders.
All the advocates cited GPS tracking technology, including wristbands, as a key way to keep wanderers safe.
As for the 45 minutes to hour it took before the school notified Avonte's family that he was missing, Sharie Manon, director of strategic alliances for ICare4Autism, said that as a mother she'd rather be called early; if it's a false alarm, so be it. Shore added that it's worth exercising "an abundance of caution. If they find [a child] under the couch, looking for a quiet place, that's a good outcome. And in situations where the child has eloped, the earlier we can get on this, the better off everybody will be."
Avonte was last seen wearing a gray striped shirt, black jeans and black sneakers. He is 5-foot-3 and weighs 125 pounds. Anyone with information is asked to contact the Police Department's Crime Stoppers hot line at (800) 577-TIPS.View Comments | Add Comment