The Child Mind BlogBrainstorm
Flying Lessons and Exposure Therapy
May 6, 2013 Caroline Miller
Paul Graham is a Silicon Valley programmer, investor and enthusiast who runs a kind of training camp for tech entrepreneurs. Nathaniel Rich, who wrote about him in the New York Times, describes him as "infectiously giddy and hyperarticulate," part Bertrand Russell part PT Barnum. The story is about Graham's work nurturing start-ups and connecting them with investors. But what really got my attention was an anecdote Graham tells the writer at the very end of the story.
Graham, it seems, developed a severe fear of flying that made him miserable for more than a decade. Then he hit on what he described as a "miracle cure." I thought he was referring to behavioral therapy, specifically, exposure therapy. But it was flying lessons. That's pretty ambitious, I thought. Then I realized it was exposure therapy. Here's how the writer describes it:
He began with hang-gliding lessons. It was a gradual process. First he ran along flat ground with a hang glider strapped to his back. If there was any head wind, he would feel a sensation of lift but not enough to levitate. Next he walked 10 feet up a hill and ran down it, clearing the ground by several inches. He increased the height until, before he knew it, he was jumping off a 450-foot cliff. "By that point, you're not even worried anymore," he said.
Long story short, the glider led to about 30 hours of flight training in a Cessna. The training included one lesson in which the instructor shut off the engine and Graham landed the plane like a glider. Finally, he was ready to try what he called "the real thing." He flew on the shuttle from Boston to New York, and found it thrilling.
"It was like flying for the first time all over again," Graham told the writer. "Like starting over with a new brain. It felt fabulous. And I thought, Wow!"
I thought, what a great description of what happens in exposure therapy! From several inches to 450 feet to thousands of feet. It worked to conquer his anxiety because it was so gradual. That's exactly what children with anxiety disorders do in exposure therapy—start facing their fears in the smallest possible increments and work gradually to "real" situations that had been debilitating. Not any more.
From now on I'll think of it as taking flying lessons.View Comments | Add Comment
Launching Speak Up for Kids: A Conversation with Dr. Harold Koplewicz and Cynthia McFadden
May 1, 2013 Caroline Miller
Dr. Harold Koplewicz kicked off Speak Up for Kids today in a wide-ranging online conversation with Cynthia McFadden about the barriers to care that keep kids with psychiatric disorders from getting the help they need.
This year's month-long Speak Up campaign comes in the wake of the tragedy at Sandy Hook, and President Obama's call for a national conversation on children's mental health. Dr. Koplewicz notes that the fact is that mass shootings are very rare, but mental illness is very common.
The overwhelming majority of kids with psychiatric problems go untreated, he notes: Only 1 out of 7 Hispanic children who need treatment get it, 1 out of 5 black children who need it, and 1 out of 3 white children who need it.
What are the barriers to care? The No. 1 barrier is stigma. We have become accustomed to adults we respect—actresses, business executives, comedians, even First Ladies—speaking up about depression, and other disorders they've experienced, he notes. But parents are still very inhibited about sharing their worries about their children. And hiding those worries, hoping your child's problems will just go away, is the worst thing you can do for a child who's struggling.
The second barrier to care is limited access to qualified mental health professionals. Pediatricians aren't trained to recognize and treat psychiatric problems, and the average pediatrician in managed care has only 7 minutes to spend on a checkup for a child. Too many problems are overlooked, or kids are routinely medicated when they would benefit more from behavioral treatment.
The third barrier Dr. Koplewicz outlined is a shortage of research. We know more about the brain than ever before, but not nearly enough to achieve the breakthroughs in treatment we need. It's the last frontier, and progress will be slow unless we get a very significant funding increase.
To achieve that we have to treat these disorders above the neck with the same respect as other disorders, and stop making them the lowest priority. Psychiatry is the orphan of medicine, child psych the orphan of the orphan.View Comments | Add Comment
Do Soaring ADHD Stats Mean Overdiagnosis?
April 29, 2013 Dr. Harold S. Koplewicz
Recently the news has been full of reports that the prevalence of attention-deficit hyperactivity disorder in the child and adolescent population is dramatically on the rise. These have been based on analysis of CDC data from a nationwide survey in 2011-2012.
The headline grabber in this analysis is that as many as 1 in 5 high school age boys have been diagnosed with ADHD, and 11 percent of school age children overall. And these numbers have stimulated concern that too many kids are being diagnosed, and put on stimulant medication.
Whenever we see a surprising increase in in the prevalence of a diagnosis, two responses spring to mind: One is that diagnostic standards have been changed—weakened—so that kids whose symptoms wouldn't have met standards before are now being diagnosed. This is a claim that doctors are guilty of overdiagnosis, or misdiagnosis, or pathologizing normal behavior.
The other response is an increase in diagnoses means that kids who weren't getting the attention they needed are now getting it, because of increased access to care, better information, or a decrease in the stigma that has so long been attached to seeking mental health care.
In my opinion, both of these things can be true.
It's true that some kids are getting quickie ADHD diagnoses and, yes, prescriptions, by overworked and undertrained doctors. Not all kids who have trouble paying attention in school or behaving well in the classroom have ADHD, and it's sometimes easier to try medication than to investigate out what's really behind problematic behavior. A knee-jerk diagnosis is a disservice to kids whose problems are rooted in anxiety or depression or family crisis.
But it's also true that there's an increase in awareness among families, educators, and health professionals that kids with impairing school struggles or dangerous misbehavior really can, and must, be helped. Just washing our hands of kids who have problems and letting a lot of them drop out of school is not a viable option either for those children or for our society. They need to become successful learners in order to be successful adults, and we need them to be prepared, intellectually and emotionally, to form a prosperous and competitive new generation. That's one reason a lot more parents are hearing that they might want to have their kids evaluated—and that there are more diagnoses as a result.
It's important to note that while news organizations have done analysis on the raw data from the CDC survey, the CDC has not yet released their own study. And it's important to pay close attention to the methodology of these mass surveys, lest we overreact. The CDC survey is based on parent responses to questions I believe could possibly elicit misleading responses. For instance: "Please tell me if a doctor or other health care provider ever told you that [the child] had the condition."
Often psychiatry is accused of being an unscientific, disturbingly subjective enterprise full of clinicians desperate to label and then medicate people—the more the better. For one, most ADHD diagnoses are made by primary care doctors, not psychiatrists, and that it is in all of our interests to be very careful about who we diagnose and medicate.
But we should also be very careful about throwing around accusations of fraudulent diagnoses, claims that ADHD isn't a real disorder, and horror stories about stimulant medication use by school children leading to addiction. ADHD is a real brain disorder; it can create severe barriers to success in school, in relationships, in life; and kids who don't get treatment are at heightened risk for drug abuse, not the other way around.
The CDC survey is remarkable for its large size and how representative it is of the population. What we also need are studies of this size that report more specific and dependable clinical information if we are truly going to understand how ADHD and other childhood psychiatric disorders are affecting our kids, and how we as a society are meeting this challenge. I think that people on all sides of the debate would agree.View Comments | Add Comment
Autism Study Offers Models for Success at Multiple Points on the Spectrum
April 26, 2013 Caroline Miller
Dr. Catherine Lord and her colleagues have been studying the same group of several hundred children on the autism spectrum (or most of them, anyway) for 2 decades, since they were less than 3 years old. The results of that undertaking are remarkable in several ways. First, they've been able to identify important predictors of how children on the spectrum will develop, based on their very early behaviors as well as the kind of help they get—and when they get it. But second, they've acquired a very nuanced knowledge of these kids, not to speak of a passionate interest in how they have fared over the years, and how they're doing as young adults. And those individual portraits were the most surprising aspect of a guest lecture at the Child Mind Institute this morning by Dr. Lord, who is the director of the Center for Autism and the Developing Brain at New York-Presbyterian Hospital.
Of the kids still in the study, eight have done, as Dr. Lord put it, "spectacularly well"—at 19 they were in college, had part-time jobs, had social lives and girlfriends. They're almost off the spectrum, she said, though they were clearly on it at 9 and 14. At this point, she quipped, they seem less autistic than the University of Chicago or MIT physics department.
Another ten of the final group are also doing very well. At 29 they were going to college, but socially they were more challenged, more obviously autistic, more dependent on their families. This group has a higher level of depression than the top group. They're kids who have been quite successful channeling their talents and interests into an effective work or school opportunity, but are still living at home and struggling to have friends. The social deficits are the hardest things to change, she noted.
What these two groups of kids have in common is a positive trajectory on a whole range of autism and IQ scales from a very young age. Improvement starts early, she emphasized, but it's also very gradual over the period from 3 to 19. That improvement is linked to parents taking immediate action when they got the autism diagnosis, and getting kids into consistent communication skill-building programs.
Of course Dr. Lord is excited by that improvement, which she said gives her high hopes. But she also sees many kids in the rest of the remaining sample of 76, including those who are quite cognitively impaired, leading happy lives, and that gives her hope—and anxiety, too.
The hope comes from seeing how well they can do when they have highly structured families and other support in the community—schools, churches, jobs—that help channel their strengths into rewarding roles. She spoke warmly about one boy we see at 3, with his grandmother, who is still living with his grandparents at 19. He is cognitively impaired and has very little speech—single words, Dr. Lord said—but he is very fixated on being neat, and his grandparents worked with that to teach him to run the house. He had to be taught not to start the dishwasher until it's full, and not to remove your glass every time you put it down, without making sure you were finished with it. But he is essentially taking care of his grandparents now, and also has a part-time job at a bakery.
As a young child this boy was so socially aloof that if you stood in his path, Dr. Lord said, he'd just move you out of his way and keep going wherever he was going. "But now he's very socially directed," she said. "He wants to know what you're doing and what you want. He really wants to please you." And when his grandfather fell ill, the boy was obviously worried and concerned—not that he verbalized his feelings, but, she said, he made it clear how he felt by constantly changing the sheets.
The worry inspired by these kids' stories stems from the fact that their success is, as she put it, "highly dependent on context." She worries about what happens to them when they age out of supports—when this boy's grandparents are no longer there caring for him as he's caring for them. "We just don't have the infrastructure in this country to support them, even though we know they could do well."View Comments | Add Comment
New Voices on Babble's Autism Bloggers List
April 16, 2013 Beth Arky
For the third April running, the parenting website Babble is doing its part to raise autism awareness—and acceptance—with its Top 30 Autism Spectrum Blogs of 2013. The bloggers run the gamut: neurotypical parents of autistic kids, autistic parents of autistic kids, and autistic adults who aren't parents but provide a window into what it's like to live in a world geared to the typically "wired." All offer insight, support and invaluable practical advice to parents of autistic kids and, increasingly, children, teens, and young adults on the spectrum.
About a third of the bloggers on this year's list are on the spectrum, about the same number as last year. However, Joslyn Gray, who wrote the Babble story and was one of the panelists who chose the list, says, "I think overall, we are seeing more neurotypical people reading blogs by autistic writers, which is great.
"For me as a parent of two children on the spectrum, I was definitely thrilled to see so many autistic writers included," adds Gray, who also blogs at stark. raving. mad. mommy. "I want autistic voices heard not just because that's what's right, and what's helpful for all of us, but because I want my children's voices heard, too." On that note, she is happy that the panel included Rachel Kenyon, an Army wife and autistic parent of an autistic daughter and a neurotypical (NT) son, who blogs at Welcome to Stim City.
Among the notable additions: three mom bloggers of autistic kids who are themselves autistic: Jennifer at Asperkids, who Gray deems "an amazing resource, especially for parents of girls on the spectrum and tweens and teens on the spectrum"; Jean Winegardner at Stimeyland, whose "funny, honest, and self-deprecating" style led her to write, "I am like Buzz Lightyear: I am falling with style"; and Aussie Bec at Snagglebox, who offers up a blog that's "chock-full of resources, support, and information" for parents and teachers, including free downloads like 45 Ideas for Classroom Friendly Fidget Toys.
Julia Bascom of Just Stimming is one of the better-known autistic bloggers who prove you don't have to have children to provide valuable parenting advice. The newest entry in this category: The Third Glance. Gray writes that while the blog is written by a young autistic woman without kids who is working on her doctorate in science, it offers "powerful insights into growing up autistic." Because of that, "it's still one of our favorite parenting blogs because it helps you be a better parent."
Also represented, of course, are the neurotypical parents writing about their special-needs kids. Among those joining returning bloggers like Sunday Stilwell (Adventures in Extreme Parenthood), the anonymous Autism Daddy, and Erica and Lisa at Laughing Through Tears comes Jim Walter, author of Just a Lil Blog. Gray describes Walter as a "self-deprecating" neurotypical dad who writes a "hilarious and poignant" blog about his daughters—one autistic, one typically developing—and wife, who is recovering from breast cancer treatments.
Marj, who has two boys at opposite ends of the spectrum, is behind the ironically titled Domestic Goddess, another of the list's newcomers. The panel loved the fact that the blog "isn't entirely about autism," Gray writes. "Blog posts are about the whole of family life. It's a great reminder that even when it feels like everything in life revolves around ASDs, ADHD, SPD, OCD, and IEPs, there's more to your family and your kids than a bunch of acronyms."View Comments | Add Comment
'Talk Therapy' Takes on New Meaning
April 12, 2013 Beth Arky
I come from a family of talkers, so it was only natural that I would be the mom who couldn't resist providing a running narrative as I wheeled my son around the neighborhood in his stroller: "Look at the daffodils, buddy. Hey, there's a Lab!"
I didn't take all that random (and often ridiculed) kind of talk too seriously, but more and more, policy makers are doing just that. In "The Power of Talking to Your Baby," Tina Rosenberg notes that there's a huge disparity as to how much language children hear, and studies show that it divides along socioeconomics lines, with parents in welfare families speaking to their children dramatically less than their working- and middle-class counterparts. The low-income children's language deficit is already apparent at 1; by 3, the gap has grown exponentially, creating lags in language, understanding and learning. By high school, Rosenberg writes, "it becomes a chasm."
Research shows, Rosenberg notes in her piece in the Opinionator section of the New York Times, that "the greater the number of words children heard from their parents or caregivers before they were 3, the higher their IQ and the better they did in school." TV talk did not help; it hurt.
Providence, R.I., will soon be launching the first major experiment to see if increasing language exposure at home helps poor kids succeed in the classroom. Last month, it beat out 300 other cities to win the $5 million grand prize in Bloomberg Philanthropies' Mayors Challenge. The Providence Talks program will train a network of nurses, mentors, therapists and social workers who regularly make home visits to pregnant women, new parents and children to provide a new service: creating family conversation.
While we know that wealthier, more educated parents talk to their children more, there was no clear reason why, at least until researcher Meredith Rowe arrived at a new theory in 2008: that poor women just didn't know it was important to talk to their babies. Rosenberg writes:
No one had told them about this piece of child development research. Poorer mothers tend to depend on friends and relatives for parenting advice, who may not be up on the latest data. Middle-class mothers, on the other hand, get at least some of their parenting information from books, the Internet and pediatricians. Talking to baby has become part of middle-class culture; it seems like instinct, but it's not.
Providence plans to begin enrolling families next January. If the effort to teach parents to speak more to their young children proves successful, it could provide an exciting model that could be implemented elsewhere comparatively easily, at a low cost. No one expects an even playing field in our society of ever-widening class differences, but we should be doing all we can to close the educational gap. So if it turns out that talking—not silence—is golden, I'm more than fine with that.View Comments | Add Comment
ADHD Affects Girls, Too
April 9, 2013 Rachel Ehmke
Stories about overdiagnosis and over-pathologizing are popular these days, in part because the new DSM is coming out next month. But very little ink is spilled on the people who don't get a diagnosis when they should, or only receive one later in life, after years of living with their symptoms. Maria Yagoda, who was diagnosed with ADHD in college, is one such person, and she writes in the Atlantic Wire that her story is a familiar one—especially if you're a girl.
ADHD is something of a guy's club. When we think of ADHD we tend to think of boys who are hyperactive and impulsive, but the disorder actually comes in several forms. Some kids are more hyperactive, others are more inattentive, and many have a combination of the two. In general girls are more likely to have the inattentive type of ADHD, which means that they are regularly overlooked because their symptoms don't match our idea of what ADHD "should" look like. Dr. Ellen Littman, who wrote Understanding Girls with ADHD and spoke to Yagoda for her piece, estimates that a shocking half to three-quarters of all women with ADHD are not diagnosed. Dr. Littman suggests that part of the reason girls are underrepresented now is because boys were so overrepresented in the early clinical studies of ADHD, which were based on the symptoms of "really hyperactive young white boys who were being taken to clinics." Girls' symptoms also tend to tend to peak in puberty, which means that symptoms that might not have been impairing functioning in grade school (when most boys are getting their diagnoses) suddenly become a problem.
Because the signs of ADHD are more self-contained in girls, their symptoms are often considered traits or personal failings, as Yagoda considered her own extreme disorganization, forgetfulness, and poor concentration. She managed to get by until college, when she went off the rails:
I was wrongfully allowed a room of my own, leaving me with no mother to check up on "that space between your bed and the wall," where moldy teacups, money, and important documents would lie dormant. I maintained a room so cluttered that fire inspectors not only threatened to fine me 200 dollars if I didn't clean, they insisted it was the messiest room they had ever seen (boys' included!) in their twenty years of service. Throughout college, I would lose my ID and keys about five times a semester. I'd consistently show up for work three hours early or three hours late. I once misplaced my cellphone only to find it, weeks later, in a shoe.
As Yagoda later learned, this is common theme. Sari Solden, author of Women and Attention Deficit Disorder, says:
Often, if girls are smart or in supportive homes, symptoms are masked. Because they're not hyperactive or causing trouble for other people, they're usually not diagnosed until they hit a wall, often at college, marriage, or pregnancy. A lot of the things that are simple and routine to other people—like buying groceries, making dinner, keeping track of possessions, and responding to emails—do not become automatic to these women, which can be embarrassing and exhausting.
Happily, Yagoda says that medication is now giving her a "more normal, settled life," which is another thing that makes her firsthand account so interesting. Not only is she a girl writing about her own experience with ADHD, she's also just plain writing about what it's like to have ADHD. We're used to hearing that ADHD isn't real, or that ADHD medications are academic steroids used for getting kids into the Ivy League and then law school. It's almost a novelty for the public to have a window into the disorder as it actually is, and see medication as it is actually prescribed and used. As a girl diagnosed with ADHD as an adult, Yagoda had to deal with a lot of preconceptions:
"Of course you don't have ADHD. You're smart," a friend told me, definitively, before switching to the far more compelling topic: medication. "So are you going to take Adderall and become super skinny?" "Are you going to sell it?" "Are you going to snort it?"
Yagoda, who was prescribed Concerta, was able to say no to all of the above. It's a refreshing counterpoint to the story you thought you knew.View Comments | Add Comment
A Sandy Hook Mom Talks About Stigma
April 8, 2013 Caroline Miller
Parents who lost children in the Sandy Hook shootings were, not surprisingly, a bit hard to watch on 60 Minutes last night, as they struggled with tears and tried to use their loss to achieve some meaningful change. Mostly they were there to support gun control legislation, including universal background checks and limits on the size of magazines for automatic weapons. But one mother, whose 6-year-old daughter Ana was gunned down, also zeroed in eloquently on the lapses in our mental health care system.
Nelba Marquez-Greene, who said she is a licensed marriage and family therapist, noted that the United States lags on the resources for psychiatric illness, compared to other countries where she has practiced. But then she added:
I think one of the barriers or one of the challenges is that there's a whole lotta stigma attached to getting help. The fact that you have to go to a therapist or a psychiatrist or a psychologist, and then get a diagnosis for your child, that can be very humbling and scary for parents. I can't speak specifically for what happened with Adam Lanza and his family. As a mother, my heart breaks for Adam Lanza's mother.
It's often lack of resources that keeps kids from getting care, but it's also often lack of connection and support. Nancy Lanza seems to have struggled for years to get her son into a setting that would enable him to thrive, but the two of them ended up appallingly isolated. And the consequences were tragic, for them and Lanza's victims.View Comments | Add Comment
Are there more child psychiatrists or taxidermists in the US?
April 8, 2013 Caroline Miller
Okay, it's probably not a question you contemplate every day (unless, that is, you live in Brooklyn, which is a hotbed of hipster taxidermy these days). But it's one way to put in perspective the dramatic barriers we face to getting all kids who are struggling with psychiatric disorders the care they need to reach their potential. And if you take our Children's Mental Health Quiz you'll find out the answer, along with some other rather surprising comparisons. Everyone who takes the quiz earns us $1, thanks to our friends at Hunter Boot, to help us help more families in need.View Comments | Add Comment