The Child Mind BlogBrainstorm

  • Paris Jackson: The Wrong Thing to Say to a Teenager Who Is Suicidal
    June 11, 2013 Caroline Miller

    We were distressed to read about Paris Jackson's hospitalization last week after what is being officially called a suicide attempt. The daughter of an extraordinarily talented and self-destructive father, we can imagine that Paris might be in a very precarious situation emotionally. But she is also a 15-year-old girl not unlike the thousands of other 15-year-old girls from the most ordinary families in the world who make suicide attempts every year. Teenage girls experience very volatile emotions, and they lack the skills and experience to put them in perspective—a risky combination.

    In Paris's case, fortunately, her suicidal behavior didn't result in her death. But it did result in an outpouring of the worst possible responses from gossip sites pretending to be news outlets. Coverage at TMZ, for instance, reads like a list of what not to do when a teenager expresses suicidal feelings or behavior. (The ellipses, by the way, are theirs.)

    Law enforcement sources familiar with the situation tell TMZ ... based on the information the L.A. County Sheriff's Dept. has gathered ... "She wanted attention."  One source involved in the case tells us ... her call to a suicide hotline is compelling evidence "she wanted to be saved."  The source added, "It makes no sense if you really want to die to call a hotline, where the person on the other end will get an ambulance over to your house.

    You couldn't invent a worse message to send to other vulnerable teenagers: that we trivialize your pain and desperation, that we don't take your actions seriously, and that calling a hotline means that you aren't truly suffering. Unbelievable.

    Just as bad was the endless speculation about what prompted her action, from being bullied at school to being upset over having to testify in the wrongful death lawsuit involving her father to being told she couldn't go to a Marilyn Manson concert. And then Marilyn Manson got into the act in a concert Thursday, dedicating a song to Paris, and miming cutting himself with a huge knife.

    Marilyn Manson isn't exactly a role model for probity, but even for him this lapse in judgment is shocking. For a very thoughtful description of what it's like to feel suicidal I recommend an interview last week with comedian and actor Stephen Fry, who admits that he made a suicide attempt last year that would have been fatal but for a producer who found him unconscious in his hotel room.

    "You may say, 'How can anybody who's got it all be so stupid as to want to end it all?' " Frye said in the interview. "That's the point, there is no 'why?' That's not the right question. There is no reason. If there was reason for it, you could reason someone out of it."

    Fry, who is on the record about having bipolar disorder, said he often feels suicidal. "Sometimes it's the expression I imagine on my mother and father's face—both of whom are alive and happy—that stops me," he said. "But there are other occasions when I can't stop myself, or at least I feel I can't."

    We hope that the caring adults around Paris Jackson will make sure that whatever pain led her to this act gets serious attention, as well as the love and support she deserves. 

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  • School Cuts Suspensions by Asking Kids What's Bothering Them
    June 11, 2013 Beth Arky

    In the 1967 classic To Sir, With Love, Sidney Poitier plays an innovative teacher who helps some tough East London kids succeed both in school and at home by taking a personal interest in their lives.

    Fast-forward some 50 years and this type of positive approach remains the exception, not the rule. Middle and high schools are doling out suspensions at ever-higher rates; according to two recent reports, 2 million students were suspended during the 2009 school year, and boys of color and children with disabilities were suspended at much higher rates.

    So it's encouraging to learn about Lincoln High School in Walla Walla, Washington, which is bucking the trend with policies that keep kids in school and enjoying great success doing so. How great? Suspensions have dropped a whopping 85 percent. Given that Lincoln is an alternative school that takes on at-risk students whose behaviors have gotten them kicked out of other settings, its success rate is that much more remarkable.

    So how does it work? Let's say a student behaves negatively—maybe he hurls curses at a teacher. The go-to consequence in this time of increasing "zero-tolerance" is suspension; according to a 2011 report by the National Education Policy Center, 95 percent of kids are kicked out of school not for weapons or drugs but for categories including "disruptive behavior" and "other," which includes being "defiant"—a vague, highly subjective term—cell phone use, dress code violations, displays of affection.

    But this is not the case at Lincoln High; instead, teachers and administrators act quickly to stem escalation and try to find out what's going on in the student's life that might be causing him to act out. So principal Jim Sporleder might ask a student, "Wow. Are you OK? This doesn't sound like you. What's going on?" He gets even more specific: "You really looked stressed. On a scale of 1-10, where are you with your anger?"

    Sporleder did his about-face after he learned the theories of John Medina, the best-selling author of Brain Rules. Medina writes, "Severe and chronic trauma (such as living with an alcoholic parent, or watching in terror as your mom gets beat up) causes toxic stress in kids. Toxic stress damages kid's brains. When trauma launches kids into flight, fight or fright mode, they cannot learn. It is physiologically impossible."

    "It sounds simple," Sporleder says about the new approach. "Just by asking kids what's going on with them, they just started talking. It made a believer out of me right away."

    This is not about giving kids a pass. There are still consequences, just not punishment, which many consider less effective as a way to shape behavior. Instead, Lincoln uses ISS—in-school suspension, "a quiet, comforting room where the student can talk about anything with the attending teacher, catch up on his homework, or just sit and think about how maybe he could do things differently next time." Sporleder and his staff also give kids the tools to recognize their reaction to stress and how to self-regulate their response to it.

    The approach is in stark contrast with traditional suspensions, which don't work well for kids who are already at-risk. "Studies show that one suspension triples the likelihood of a juvenile justice contact within that year," California Chief Justice Tani Cantil-Sakauye told the California Legislature last spring. "And that one suspension doubles the likelihood of repeating the grade." Meanwhile, according to the NEPC report, "research shows being suspended even once in ninth grade is associated with a 32 percent risk for dropping out, double that for those receiving no suspensions." 

    Given the cost to students, parents, and society at large when kids aren't encouraged to stay in school, Lincoln High offers an important lesson: When students are treated as individuals, when teachers and administrators take time to find out what's behind their behavior, what's happening in their lives that's affecting them in school, the results can be stunning. 

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  • Retro Toys and the Importance of Being Bored
    June 10, 2013 Rachel Ehmke

    When I'm shopping for presents for young children, toys from the Melissa & Doug company stand out. Melissa & Doug toys don't do anything—they don't light up, they don't moo, and they definitely don't have an on/off switch. What you see is what you get—dress up costumes, a child-size toolbox, plastic kitchenware and groceries. As far as I know, their only toys that make noise are the musical instruments. Melissa & Doug aren't the only company making toys like this—an article in Sunday's Times profiling the company also mentions Haba and Alex, for example—but their brand might be the most recognizable.

    In 2013, toys like this are decidedly retro. Handing kids the iPad or iPhone to play games is reflexive for many parents and these days even Lego has a line of video games. One mother interviewed in the Times story says she buys Melissa & Doug products as a kind of "rebellion against digitized toys," and acknowledges that they probably appeal more to her than her son. "The thing about Melissa & Doug toys, the problem with them, is they encourage you to be creative, which is great, but they also, speaking of it kind of concretely, are relatively one-dimensional," she explains. These toys are open-ended and require more work from kids. And without flashing lights and sound effects that provide constant feedback, they run the risk of being boring.

    Melissa Bernstein, the Melissa half of Melissa & Doug, is okay with that. "Parents are so scared of having their kids say, 'I'm bored.' It's synonymous with, 'I'm a bad parent,' and so they never allow kids to feel boredom, which equals frustration, and so kids don't get to the point where they have to dig deeper and figure out what to do." Which is really too bad because the inventiveness that comes from figuring out how something works or how to keep yourself entertained is an important childhood lesson that our kids are increasingly missing out on. Open-ended play teaches children how to think critically and creatively—it's how most of us learned how to solve problems, work together, and control our impulses. Contrast that with the hyper-structured modern idea of play, where kids follow rules to complete a task and are rewarded with a "level up." As Bernstein tells the Times, "When you're using a computer or an app, it's giving you all the information you need. It's a completely reactive experience."

    Learning how to be bored or frustrated and then how to self-regulate also helps kids build resiliency, something child psychologists consider essential to becoming a well-adjusted adult. Bernstein can attest to this personally. Growing up she described herself as lonely and miserable. In seventh grade she became anorexic. Her solace was her creativity. She wrote music and poetry and threw herself into arts and crafts. She told the Times that creating things "took me out of what could have been." "When I create it makes me so happy. I'm able to soothe myself." The ability to self-soothe is vital, but kids who are growing up in a constant state of occupation are getting fewer and fewer opportunities to learn how.

    Play in general is being threatened for American children, and the movement away from basic, open-ended toys is reflective of that. Recess and gym are disappearing in schools, a casualty of our national obsession over test scores. Our kids have full schedules, with sports, tutoring, and extra-curricular activities filling up their downtime, which has become a dirty word. When kids are at home, they're still kept busy. If parents need to do the laundry or make dinner without getting hassled, they turn on a video or hand kids the iPad. Our desire to have accomplished, well-rounded children (and to get dinner on the table) is laudable, but an important part of being well-rounded is being able to think independently and self-regulate. The lessons learned from imaginative play are real, and it's important that we not discount them.  

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  • White House Conference Kicks Off With Plea for Openness
    June 3, 2013 Caroline Miller

    President Obama launched a White House conference on mental health this morning with a surprisingly down-to-earth message. He ticked off some sobering statistics about people suffering from psychiatric illness—for instance, we are losing 22 veterans a day to suicide—and he talked about federal initiatives to do a better job helping them. But his message was mostly to individuals, especially vets, who might be listening to his voice: "Just as you would take care of yourself and those around you in battle, you've gotta do the same thing off the battlefield. You're not alone. You are surrounded by people who will support you and care for you."

    He sounded the themes repeated throughout the first session: to anyone out there who is struggling, please seek help. If you know someone who is struggling, please help them get care. Mental illness is treatable. There is hope.

    Secretary of Health and Human Services Kathleen Sebelius also addressed the challenge of making it more comfortable for people suffering from psychiatric illness—and here we would add parents of children with psychiatric illness—to ask for help. "Mental health needs to be an issue talked about openly and freely without fear of being judged," she said.

    Glenn Close, one of five professionals and activists on the day's opening panel, said some interesting things about stigma. People think there's no longer stigma surrounding mental illness, she said, since most people understand that mental illness is in fact an illness like any other. "But the truth is stigma has hardly budged." As a result there is a surprising amount that we don't know about people we work with and are friends with—even people in our families. She first realized this, she said, when her sister called her up one day and said, "I need help because I can't stop thinking about killing myself." Close was stunned. "I am ashamed at what I didn't know about my own sister," she said.

    For Close, that was the beginning of her commitment, through her organization, Bring Change 2 Mind, to getting people to tell their stories about living with mental illness. "The way to change somebody's attitude is to have them actually meet someone and hear their story," she said.

    I'm with Close on that. It's pretty hard to imagine that people could continue to dismiss children's problems or blame them on parents, as so many do, if you'd met the families I've gotten to know at the Child Mind Institute.

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  • Sen. Rockefeller Makes Concussion National Issue
    June 3, 2013 Michael Rosenthal, PhD

    If you are the parent of a school-aged child who plays sports, you've probably been affected by concussion in some way.  Your child may have had one, or perhaps one of his or her friends.  The school might have had you sign a form about concussions or given a presentation about how to identify the signs and symptoms and what to do if you're concerned your child may have been injured.  You may have also noticed changes in how games or practices are run, or what kind of headgear the kids are wearing. This attention to concussion is the result of local activism but also of concerned legislators, and I'm happy that US Senator Jay Rockefeller of West Virginia recently made it a nationwide issue by introducing a concussion safety bill in the Senate.

    The history of legislative approaches to the problem of youth concussion really began with the unfortunate circumstances of a young man named Zack Lystedt and the work of an attorney named Richard Adler. In 2006, then 13-year old Lystedt suffered repeat concussions while playing junior high school football, leaving him permanently disabled. Adler supported Zack and his family through his recovery and went on to draft legislation designed to protect youth athletes.  On May 16, 2009, the Lystedt Law was passed in Washington State, requiring that athletes under the age of 18 who are suspected of having sustained a concussion are removed from play and not allowed to return until cleared by a medical professional.  The law also mandates concussion education for athletes, parents, and coaches.  A majority of states have adopted similar guidelines, and we have seen a major shift in how these injuries are understood, recognized, and managed.

    Lystedt and Adler have made an enormous impact on youth sports, and no doubt saved lives.  But there is still a tremendous amount of work to be done, especially in educating the public about the different aspects of concussion safety, including prevention. Last month Senator Rockefeller introduced the Youth Sports Concussion Act, which mandates universal safety standards for helmets and clamps down on companies making deceptive claims about their products. As a clinician, one of the most common questions I get from parents is about some new helmet that claims to be "concussion-proof."  My response is generally the same: Show me the data!  In the midst of this concussion craze, some companies are exploiting the fears of parents in an effort to sell products that may actually give a false sense of security and put kids in more danger.  Senator Rockefeller's bill is a timely and essential step towards cementing the legacy of Zack and Richard and, ultimately, keeping kids safe as they play the games they love.

    Michael Rosenthal, PhD, is a pediatric neuropsychologist with expertise in the evaluation and treatment of children and adolescents from pre-school through early adulthood, particularly when complex questions exist about autism spectrum disorders and concussion or mild traumatic brain injury.

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  • Salon Owner Has Tantrum Over Crying Autistic Child
    June 3, 2013 Beth Arky

    Many autistic children are prone to unpredictable meltdowns, triggered by everything from transitions to changes in routine to sensory issues, turning something as mundane as a haircut into a stressful experience. When they have them in public, they and their parents are often judged harshly.

    Such was the case last week for Ashley Bays and Grayson, her 2-year-old autistic son. As Bays explained in a local TV news interview, Grayson is "terrified of people touching his head and his ears, and the sound of the clippers." So even though the Michigan mom has been bringing Grayson to the same stylist at MSpa for more than a year in hopes of establishing a routine, he cries every time. But during this visit, owner Michelle Mott turned the already difficult situation into a nightmare by yelling at the upset child and distraught mom, forcing them out of the salon.

    It could have been just another painful incident for a struggling mom if not for Vanessa Hunt, who witnessed the episode and recounted it in a searing Facebook post. Undoubtedly bolstered by the strong online special-needs community, the update went viral, leading to coverage by national media. A week after Hunt posted, there have been more than 40,000 Facebook shares.

    In her post Hunt, who was at the spa getting a birthday manicure with a friend, decried the "severe tongue lashing" the owner meted out, but perhaps more importantly, she expressed empathy for the mom and the little boy. She wrote that the crying child reminded her of her son's first haircut. "It was seriously painful to watch seeing as I have been there more than once myself and it's very hard when your child is having a tantrum in public. The last thing you need is a woman yelling at you for it."

    And she expressed that empathy directly: "Jess and I walked outside to see the hairstylist finishing the little boy's haircut on the lawn. The mom still crying and cradling her precious son. We hugged her and cried with her too."

    We applaud people like Hunt and Houston waiter Michael Garcia, who refused to serve a patron after he made disparaging remarks about a Down syndrome child eating with his family. They are spreading a message of understanding and acceptance, of standing up and doing the right thing, even if it appears Mott learned nothing; her main reaction to the online firestorm has been to take down MSpa's Facebook page and issue a statement that the matter was handled "appropriately."

    But it isn't the anger that's the most important thing here. It's the message that children who can't be counted on to behave typically don't have to be isolated from the community, and that most people (though not all, obviously) have enough generosity and warmth to cut them a little slack. It's one of the most important things we can do for them and their parents, who, you can be pretty sure, are doing their best to make these experiences work for everyone.

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  • PANDAS, OCD, and a Bomb Plot
    May 28, 2013 Caroline Miller

    An Oregon teenager was charged with aggregated attempted murder today for plotting to blow up his high school. Seventeen-year-old Grant Acord was caught with an arsenal of bombs and bomb-making material secreted under the floorboards of his bedroom, along with checklists and diagrams with which, it is alleged, he hoped to outdo the Columbine killers. 

    The already disturbing story took another painful turn today when his mother reported that he was suffering from PANDAS. That's the rare and controversial form of acute-onset OCD that is linked to strep infections. PANDAS—it stands for pediatric autoimmune neuropsychiatric disorder associated with streptococcusis a syndrome which can come on virtually overnight, after a child has contracted a strep infection. Symptoms include tics and the severe obsessions and compulsions associated with OCD, as well as a host of disorienting behaviors, including intense separation anxiety, sleep disruption, handwriting changes, trouble eating, panic attacks, irritability and emotional outbursts. Parents describe their children as suddenly unrecognizable, and conventional treatment for OCD doesn't work effectivelyyou can read more about it here.

    It's troubling whenever an act of violence is associated with a particular psychiatric disorder, because it's easy for people to stereotype other people with the disorder, wrongly, as prone to violence. In this case it's particularly troubling because parents of kids with PANDAS are already in a very tough spot because of dissent within the mental health community about how to treat PANDAS, and whether, in fact, the disorder actually exists.

    Acord's mother's attorney has been quick to use the disorder to build a defense, telling the press that the teenager is "very mentally ill" with PANDAS. As Dr. Jerry Bubrick, the head of the Child Mind Institute's OCD program, puts it, "That statement will do nothing but increase the stigma about a condition that is already so misunderstood."

    Dr. Bubrick says that although a small percentage of kids with PANDAS may have explosive episodes in which they are violent, "it tends to be more impulsive and situational, and the child is usually remorseful afterwards. That is very different than premeditating a violent attack, which involves conception, planning and precision. Although both are expressions of anger, their intentions are very different and should conceptualized differently."

    Parents of kids with PANDAS already face daunting confusion as well as skepticism from those clinicians and researchers who don't consider the link between PANDAS and strep conclusively proven. Despite efforts to resolve the conflictincluding a new broader category called PANS (pediatric acute-onset neuropsychiatric syndrome) that does not specify the link with strep or any other form of infectionthe teams are still far apart. The ongoing controversy makes treatment extremely difficult for parents to obtain, and we hate to see any more challenges added to their lives, and those of their children. 

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  • Two Psychiatrists Discuss the Changes (and Controversies) of DSM-5
    May 28, 2013 Caroline Miller

    At childmind.org we've had our heads bent over the DSM-5 this week, chasing down the changes we've been expecting in diagnoses that affect children. We should have the details reflected in the updated disorder guide in the next week or so. But in the meantime, an excellent piece on childmind.org considers both the reasoning behind the changes, and some of the important objections that have been raised about the DSM-5 recently.

    The new piece is a very incisive conversation between Drs. Bennett Leventhal and David Shaffer, two eminent child and adolescent psychiatrists, that took place Friday for Speak Up for Kids. The doctors discussed the updates on diagnostic thinking included in the DSM-5, and the widely publicized charge that the DSM itself is invalid because it is based on clinical observation and studies, rather than on brain research. You know, the quip about how the brain didn't read the DSM.

    Dr. Shaffer sums up the history of the DSM, from its prewar origins in an effort by the Department of Defense to categorize the mental disorders suffered by veterans of the Armed Forces, to an effort to standardize what had been rough classifications into more and more precise descriptions. The gradual iteration of DSM criteria (this many symptoms, over this period of time, with this effect on functioning) was done, he notes, not to pathologize more behavior but to make it possible for researchers to be able to effectively identify subjects for their studies and, not incidentally, to make diagnosis something that many different professionals could do.

    Changes in the DSM are made, he says, when new information calls into question the validity of criteria and their effectiveness in clinical setting. One example is the important new diagnosis disruptive mood disregulation disorder. It's a response to what Dr. Shaffer describes as a real crisis in child psychiatry—an escalating number of kids being given the diagnosis of bipolar disorder when they don't meet the criteria applied to older-onset bipolar disorder: episodes of mania. These kids are chronically irritable and prone to meltdowns, and their need for help is urgent. But they don't follow the typical course of bipolar disorder into adulthood, and the medications used to fight bipolar disorder don't work well for these children. Bipolar disorder is a very serious, lifelong diagnosis to give to parents, especially, he notes, "when the evidence was so weak."

    Creating a new diagnosis, he says, is the first step to studying and rethinking approaches to helping these children. Rather than developing adult bipolar disorder, many of them develop anxiety disorders as they get older. It may be more fruitful, he hypothesizes, to think of them as very anxious children. Children with early-onset anxiety fight very hard to control their environments in order to manage anxiety and feel safe; the smallest change in plans or deviation from their expectations can make them melt down. Instead of treating them with antipsychotics, it makes sense to treat them with antidepressants and other medications that are effective for anxiety. And it could change the therapeutic approach, as well—to exploring and treating the anxiety, if that's what's making them very upset and very aggressive, with behavioral therapy.

    Drs. Shaffer and Leventhal go through the other big changes in DSM-5 as well, and if you're wondering about the rationale, I recommend listening to the whole talk here. But they also offer some interesting thoughts about the controversies that have surrounded the changes.

    Specific changes, Dr. Shaffer notes, are always debated fiercely within the mental health community, with some advocating against the updates. He argues that some of the many professionals who lobby against changes in the DSM have a vested interest in seeing the criteria remain the same—books, rating scales, research projects all face updating or rethinking when the DSM changes. Some worry about schools and the insurance companies—whether they will accept the changes, rather than whether they will allow professionals to do a better job understanding and helping kids. Just something to keep in mind.

    To the charge that psychiatrists are bent on medicalizing more and more of human behavior, he notes that half of the members of the committees who worked on the updates for DSM-5 are professionals other than psychiatrists. He also notes that no one is allowed on the working committees who has pharmaceutical ties or is receiving pharma research funding.

    Both doctors noted that the prevalence of mental illness isn't likely to change, but the updates may bring some different symptoms into the discussion of a disorder, and hence "make people who use it more sensitive to certain symptoms." If your child's diagnosis has changed, do you need to get a new diagnosis? That depends, Dr. Shaffer said, on two things: "Has the diagnosis been useful?  Has it led to effective treatment?" If the answer to those questions is yes, he said, don't worry about DSM-5. Your current diagnosis will be grandfathered in. If treatment is not working, you might want to see your clinician about how the changes affect your child.

    And to the charge that the DSM is a "philistine endeavor" because it isn't based on brain science, I think it's safe to say that both doctors look forward to advances in brain science that will yield treatment applications, but at this point those applications are few, and the DSM is an enormously valuable tool for identifying, investigating, and treating mental illness.

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  • Sesame Workshop's Advice for Families Going Through Divorce
    May 28, 2013 Rachel Ehmke

    Divorces are hard on kids. And because 50 percent of all first marriages end in divorce, and two-thirds of those marriages involve children, Sesame Workshop—the people behind Sesame Street—have pledged to help families going through divorce stay as resilient and strong as possible. As part of their effort, JoAnne Pedro-Carroll, PhD, a clinical psychologist who specializes in divorce, joined Sesame Workshop and Speak Up for Kids last week to share some of her expertise.

    Dr. Pedro-Carrol focused on some of the risk factors that can prevent kids and parents from moving forward healthily, and some resilience factors that can help. She said one of the biggest risk factors is conflict, which unfortunately is also something very natural at the end of a relationship. Dr. Pedro-Carrol notes that ongoing conflict is "like a toxin" for children, especially when they're stuck in the middle. To help children stay healthy, she advises that parents present a united front as best they can and shield children from any bickering that might be going on behind the scenes. For couples struggling with this, she recommends, "renegotiating the relationship with a former spouse to that of business partner" in the business of raising your children.

    The second biggest risk factor she mentioned is poor quality parenting. Even when parents are trying their best, the added stress and pressure of a divorce does take its toll, and parents often "don't have the patience or ability to set limits" says Dr. Pedro-Carrol. Setting limits might not even feel right to sensitive parents who are trying to make kids feel better during a tough time. But limits actually give kids a sense of security, she said, particularly during a time when everything else in their life seems to be changing. Dr. Pedro-Carrol notes that staying emotionally responsive to kids is important, too. Divorce brings up a variety of feelings for kids, and it's important for kids to know that all feelings are okay-but not all behaviors are. Finally, Dr Pedro-Carrol also told parents going through a divorce not to overlook their own limits, either. "Parents are able to give their best to their children only when they take care of themselves," she said.

    To listen to the entire Sesame Workshop talk, and to learn about some of the materials they have put together to help families going through divorce, click here. 

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  • 30 Years Later: Following Kids With ADHD Into Adulthood
    May 20, 2013 Caroline Miller

    Dr. Rachel Klein has been following a group of some 200 boys with ADHD for more than 30 years. I should say boys with the symptoms of what we now call ADHD, because the diagnosis didn't exist in 1970 when she and her colleagues began the study. The boys were around 8 at the start, of average or higher intelligence, and hyperactive and inattentive both at home and at school. Those who exhibited aggressive or anti-social behavior, which we'd now call conduct disorder, were not chosen for the study, to keep it focused on the outcomes of ADHD alone. They were compared to a control group of kids who were described by teachers and parents as behaving typically.

    It's a remarkable study because of the detailed interviews and data collected from these children well into adulthood. The boys were interviewed again when they were 18, 25 and 41. Dr. Klein, who is director of the Anita Saltz Institute for Anxiety and Mood Disorders at the NYU Child Study Center, reviewed the findings during a visit to the Child Mind Institute Friday.

    The kids with ADHD overall fared worse in school, in jobs, in family stability, and with the law, than the control group. But one of the one of the key findings is that 60 percent no longer qualified for an ADHD diagnosis at 18—and those kids who outgrew their symptoms fared differently over the long term than kids whose ADHD symptoms persisted. 

    Of the kids in the original ADHD group, the 40 percent who still qualified for the diagnosis at 18 were much more likely to have developed two new problems during adolescence—anti-social personality disorder and substance abuse disorders—than those who had outgrown their ADHD, or the control group. And they were most likely to develop them in the same order, in what Dr. Klein called a "developmental cascade": ADHD heightens risk for anti-social personality disorder, which in turn heightens risk for substance-abuse disorder.

    But the good news is that the interviews at 25 and then 41 showed no heightened risk for new anti-social or substance abuse disorders after the checkup at 18. There are still clear disadvantages that continue into adulthood for the group in which the ADHD persists-but they all started in adolescence. As Dr. Klein put it, "If you've made it through adolescence, you've made it, relatively speaking."

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