The Child Mind BlogBrainstorm
Understanding ADHD With Non-Stimulant Meds
July 2, 2013 Harry Kimball
Last week Dr. Jeffrey Newcorn, a child and adolescent psychiatrist and professor at Mount Sinai Medical Center, stopped by the Child Mind Institute to give a presentation on advances in ADHD medication—specifically his research on atomoxetine (brand name Strattera), a non-stimulant compound that is seeing increasing use.
For me his most interesting point was that because stimulants are so effective at treating most cases of ADHD, the field has come to define the disorder—in the criteria listed for a diagnosis—partly by the targets of that treatment.
"Our criteria are really strongly built to things that stimulants make better," Newcorn said. "So there is a real premium on efficiency of processing, getting tasks completed, finding boring things interesting—the things that stimulants do better." But as a clinician and researcher, Newcorn sees two problems here. For one, there are many more dimensions to the disorder—as he puts it, "all the things about ADHD that we'd like to track better that aren't part of our criteria." And—relatedly, as he demonstrated—though most people with ADHD respond to stimulants, many don't. How to help them, he said, begins with understanding how they are different.
Newcorn's rationale for pursuing atomoxetine emerged from a widely known clinical fact: there are two classes of stimulants, and if one doesn't work well for a young person with ADHD, chances are the other class will. About 80% of patients will respond to either methylphenidate or amphetamine. Are those other 20% just out of luck? Not if you broaden your idea of what "response" is, and understand that the two classes of stimulants, though similar, work differently in the brain. Why can't something else work?
"It makes sense to look at atomoxetine," he said, which targets some of the same neurotransmitters as stimulants—but in a very different way and in different parts of the brain, as Newcorn illustrated with imaging studies. Its effects are also different, he postulated, serving more to "drive mental effort" and "increase" the signal as opposed to stimulants, which "decrease noise." And it can help people who have been labeled non-responders to treatment.
The upshot here is that all cases of ADHD aren't the same—and that Newcorn is blazing a trail into a future of personalized medicine. There is no place and no need anymore for a "one size fits all approach" to ADHD treatment, he said. Instead of settling on averages—on the sunny but still wanting 80% response rate for stimulants—we can and should figure out "which drug is best for which patients." Or, as he put it, "our goal is not to treat partial responders with something that doesn't work too well." And by thinking about ADHD in a more catholic way, we find that the tools to achieve a better goal may be in front of us.View Comments | Add Comment
Mental Health Shot Down With Gun Control
July 2, 2013 Caroline Miller
Back in the winter, when Congress was considering (however briefly) legislation reining in gun sales, some mental health measures were attached to the bill under discussion. The logic was that both initiatives were responses to the shootings at Sandy Hook Elementary School—measures designed to help keep children safer.
While the gun control proposals on the table—extending background checks to sales at gun shows, or limiting the size of magazines for semi-automatic weapons—proved too controversial to get serious traction in the Senate, let alone the House, the mental health measures had widespread bipartisan support.
So it's ironic that the defeat of gun control took the mental health bills off the agenda too.
"When we had the bill on the gun debate last month, I think the only amendment, that passed was the one on mental health," Senator Roy Blunt of Missouri told a reporter at Missourinet last month, noting that the mental health provision cleared the Senate 95 to 2.
The measure he was referring to is called the Mental Health First Aid Act of 2013, and it authorizes the launch of a demonstration program to support mental health first aid trainings nationwide on how to identify, understand, and respond to the signs of mental illnesses. It was introduced by Mark Begich (D-Alaska) and Kelly Ayotte (R-N.H.), and had eight other cosponsors from both parties, including Sen. Blunt.
That's a bill that would have been especially meaningful for kids struggling with psychiatric issues, since it would support training for adults who work with young people—teachers, scout leaders, church leaders, etc.—to help them identify, understand, and respond to the signs of psychiatric problems.
There are a number of other bills that were also proposed in the wake of Sandy Hook that also claimed bipartisan support, including one that would boost funding for local mental health centers. We have to wonder why interest in these bills disappeared as soon as gun control was declared dead—and we'd like to see them resuscitated.
Whenever gun violence erupts, mental health initiatives are touted as the one thing everyone can agree on—supporters of the NRA and the Gabby Giffords and Brady campaigns alike. But for members of Congress they seem to gain traction only as an alternative to gun measures. We'd like to see that across-the-aisle support amount to more than a way for politicians to appear to be proactive in the wake of tragedy.View Comments | Add Comment
Amy Winehouse and Bulimia
June 25, 2013 Rachel Ehmke
We thought we knew the Amy Winehouse story. The gossip press, obsessed with her self-destructive rampages, documented every boozy blowout and run-in with the law until she was a caricature of a celebrity in a downward spiral. That Winehouse was bulimic since her teenage years was less well known, although I remember seeing lots of "Scary Skinny!" style captions under paparazzi photos of the singer walking around Camden in her trademark ballet flats, often looking intoxicated.
Her eating disorder wasn't a secret, but it just didn't get the same attention that her drug use did, at least until now. This week her brother, Alex Winehouse, told the press that he blames bulimia for her death, not substance abuse. In an interview with the Observer he said, "She suffered from bulimia very badly. That's not, like, a revelation—you knew just by looking at her... She would have died eventually, the way she was going, but what really killed her was the bulimia."
I think hearing this comes as a shock to people because it deviates from the meteoric-rise-and-fall-of-a-celebrity story that we've internalized. Winehouse may have died at 27—putting her in the romanticized 27 Club of other musicians like Jim Morrison, Janis Joplin, and Kurt Cobain, who died tragically at that age—but her demons were around years before she got famous. It's a good reminder that substance abuse and addiction often don't come out of thin air. People who develop problems with substances often struggle with something else first—untreated depression, trauma, eating disorders—that don't get resolved so they begin self-medicating.
Alex Winehouse's interview is also welcome because bulimia tends to be a very private thing that individuals and families struggle with quietly. Hearing people talk publically about it—and how dangerous it can be—is important. "We all knew she was doing it but it's almost impossible [to tackle], especially if you're not talking about it," her brother said. The Winehouse family has formed a foundation focused on drug and alcohol abuse and also recently donated money to Beat, an eating disorder charity. Alex told The Guardian "We had to support eating disorder charities because no one talks about it."View Comments | Add Comment
ADHD and Substance Abuse: Are Meds Really to Blame?
June 24, 2013 Nancy Konigsberg
This is a guest post by Nancy Konigsberg, an occupational therapist and applied behavioral analysis therapist who has a son with ADHD.
Every time I see an article debating the benefit and/or consequences of giving children stimulant medication for ADHD I take notice. When I read recently that that researchers found a link between ADHD and substance abuse, but no link between medication specifically and substance abuse, I wanted to know why, and why people were speculating that the use of stimulant medications might contribute to substance abuse.
This matters to me personally because my son has ADHD and he takes stimulant medication. But I am also a pediatric O.T. and I recently completed a post-graduate program in Applied Behavior Analysis. What my professional experience and education have taught me is that a disorder does not define behavior. The principle of behavior analysis is that behavior has a function—a child acts in order to get something tangible, or get attention, or to escape something, for instance. Behavior is either strengthened or diminished by the history of reinforcement. Whatever consequence immediately follows a behavior reinforces (negatively or positively) that behavior. If a child is having a tantrum and the parent says "I will give you a treat if you stop tantrumming" and the child stops and gets the treat, the tantrum was just reinforced. That is, the child understands that having a tantrum results in getting a treat.
Until my son was in first grade, when he started on stimulant medication, I would get calls and complaints about his behavior on almost a daily basis. He was thrown out of programs and demoted. It's not that he was badly behaved per se. It was just that he couldn't sit still, he couldn't follow directions and that he had a hard time adjusting to a group environment. Almost the minute he started the meds, his life started to change. He could listen and attend and interact appropriately with his peers. This allowed him to do well academically. And it wasn't just in academics that he started to excel. He was named "outstanding music student of the year" and "most improved swimmer" on the swim team. Prior to taking the medication he had difficulties with motor skills. It seems that the medication allowed him to process information much better. Slowing him down allowed him to learn. And when he learned, he started to succeed. When he succeeded he got rewarded with commendations, trophies and good grades. The reinforcement of recognition and praise keeps my son on track.
This makes me wonder about the link between ADHD and substance abuse: whether those kids who have ADHD and don't get positive feedback turn to drugs because of their history of reinforcement. When children aren't behaving appropriately or aren't doing well in school they usually hear criticism instead of praise. If all they ever hear is "Why can't you do better?" or "Why did you get detention?" or "Why can't you do anything right?" they develop poor self-esteem. They don't get feedback that will keep them on a good path. Their history of reinforcement is one of negativity. Ultimately, they seek approval from peers or escape or just a means to feel good. They achieve this with substances such as drugs and alcohol.
The study linking ADHD and substance abuse itself offers evidence for this hypothesis. The researchers noted that children with comorbid ADHD and ODD/CD (oppositional defiant disorder/conduct disorder) may be much more at risk than those with just ADHD. They observed that the ODD/CD might be the problem rather than the ADHD. They also noted that there is evidence that parental maltreatment is more likely to independently predict substance abuse problems than childhood ADHD. The point here is that the history of reinforcement might be the most relevant factor in contributing to future substance abuse.
Why do I bring all of this up? It is easy to form misconceptions when we hear that children with ADHD are three times more likely to develop substance use problems than typical children. And it is easy to shy away from trying stimulant meds when you hear that they may be related to addiction. But the ADHD or stimulants might not have a causal relationship with substance use. It may well be that it is the history of reinforcement for a child which is much more predictive of future behavior.View Comments | Add Comment
Noticing Bullies Inside the Family, Too
June 18, 2013 Rachel Ehmke
We think of bullying as something that happens in the schoolyard or, increasingly, online. But what about bullying that happens at home?
A new study in Pediatrics claims that kids bullied by siblings experience negative mental health effects, much like any other kind of bullying. But another more subtle point the authors are making is that children even can be bullied by siblings.
We tend to downplay it when siblings get aggressive, which makes sibling bullying "under-recognized and under-estimated," says Corinna Jenkins Tucker, PhD, lead author of the study. Which makes sense. We think of sibling fights as a common, innocuous thing, and they often are. I grew up with an older brother who sometimes kicked soccer balls at my head, for example. But even when he was picking on me, I knew that he basically liked and even respected me, which makes all the difference in these interactions. For children who are actually being victimized, it's a different story.
One of the reasons we're disturbed by Internet bullying is because we know how far-reaching it is. In 2013 you're never far away from the Internet, which means kids are never far away from their aggressors-they follow you home on your phone and your computer. Similarly, getting bullied by a sibling is another serious violation of the sanctuary that home is supposed to represent. Imagine needing to share a bunk bed with your tormentor.
So, if parents take anything away from this Pediatrics study, maybe it should be a renewed sense of awareness. It's good for siblings to be rambunctious and competitive, but the sustained, victimizing bullying techniques from the playground shouldn't fly there, so they definitely have no place at home. The ability to empathize is important, and it's one that we need our kids to exercise wherever they are.View Comments | Add Comment
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.View Comments | Add Comment
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.View Comments | Add Comment
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.View Comments | Add Comment
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.View Comments | Add Comment
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.View Comments | Add Comment