The Child Mind BlogBrainstorm
ADHD Subtypes: Researchers Find Functional Brain Differences
Feb. 12, 2013 Harry Kimball
One of the criticisms leveled against certain psychiatric diagnoses like ADHD is that they are too indistinct—that in defining some disorders as "spectrum" disorders we risk pathologizing everyday behavior. If one kid with ADHD is hyper and impulsive, a critic might say, and another kid is just spacy, and a third kid is both, what's the disorder? You can't have your cake and eat it, too.
Well, new research from our own Dr. Michael Milham, director of the Center for the Developing Brain at the Child Mind Institute, has brought advances in brain imaging technology and methodology to bear on this issue with results that promise a future of more rigorous diagnosis and better understanding of neurodevelopment. A paper out earlier this month and co-authored by Dr. Milham in the journal Frontiers in Systems Neuroscience describes a project touching on everything from open science collaboration, the unique challenges in pediatric imaging, and the very nature of psychiatric diagnosis.
For me personally, one of the more interesting developments described in Dr. Milham's paper are the new approaches to minimizing movement "artifacts" during analysis of brain scans collected from multiple sites, of children of multiple ages, with or without ADHD. Essentially, he and his co-authors introduce new and better methods of getting imaging data from fidgety kids. This may sound banal, but when we consider that a lack of large-scale data sets from pediatric populations with psychiatric disorders is a signal hurdle to research in child mental health, its importance is clear.
Another conclusion in the paper might be picked up more quickly: that subtypes of ADHD, like inattentive-type or combined-type, manifest in the brain as distinct differences in connectivity when compared to each other and to typical brains. You should definitely check out the paper to see how the researchers made these distinctions, and how they relate to our growing understanding of how the brain talks to itself, and how these communication networks are implicated in mental disorders. But the grand takeaway is this: the different subtypes of ADHD are distinct but also with real basis in the biological functioning of the brain. And our imaging tools are beginning to let us discern between them—and one day perhaps diagnose the underlying illness.
This work is exciting for neuroscience, exciting for mental health research, and potentially transformative in terms of how we think about psychiatric disorders in kids. It is also representative of the Child Mind Institute's scientific mission, and shows an awareness of how far we need to go. This proof-of-concept research is exciting, Dr. Milham and his co-authors write. But—
It is only through the future creation of a large-scale datasets, with coordinated recruitment, deep phenotyping, multimodal data acquisition...and likely improved homogeneity in our subgrouping...that a fair assessment of the predictive potential of MR-based approaches will be realized.
We're not there yet, they caution. But there is a clear path—one that gets clearer every time research like this illuminates the biology of the brain and bolsters the science of neuropsychiatric illness.View Comments | Add Comment
'Silver Linings,' Mood Disorders, and Robert De Niro in Tears
Feb. 5, 2013 Caroline Miller
If you've ever loved someone who has been affected by mental illness, and maybe even if you haven't, I hope you'll take a look at the video of an interview Katie Couric did today with Robert De Niro, Bradley Cooper, and the director of Silver Linings Playbook, David O. Russell.
Russell sums up elegantly and affectingly why he wanted to make this movie for his son, who has a mood disorder. He talks about what it's like to have a child whose moods could "pull him down the drain or turn into a tornado" on a moment's notice, a son "who told me when he was 10 or 11 that life was so hard for him he didn't know if he wanted to keep going."
Russell says he wanted to make a movie that would help his son "feel like he's part of the world." And De Niro, asked what it meant to him to be involved in this very personal project, breaks down in tears, able to say very little except that he knows "exactly" what Russell is talking about.
The sweetest part of the interview is a discussion of the scene in the middle of the night when Pat, the bipolar character played by Cooper, has a meltdown. There's a lot of yelling and screaming and crashing, and a nosy neighbor with a video camera shows up at the front door to see what the ruckus is. De Niro, Pat's father, chases the boy away, in a protective fury.
That boy is played by Russell's son. And Russell wants you to know that scene comes from his own experience. "You have this chaos in your house that's so humbling. These reckonings of the soul, whether it's a marriage or a child, they always seem to happen in your pajamas at 2 am, and you look over at your neighbors and say, it's going down."
Russell adds, "It was beautiful for my son to be the 'other guy' in that moment"—not the one melting down—as well as to find himself, momentarily, in Raging Bull. We would add that it was generous and lovely for this accomplished man to share his experience, and to recognize how many families fight every day to care for and protect struggling children.View Comments | Add Comment
JFK's Stirring Words on Mental Illness, 50 Years On
Feb. 5, 2013 Harry Kimball
We must fix mental health care in this country. And that is what President John F. Kennedy thought 50 years ago today when he passionately advocated for reform of the broken institutional mental health care system that, in his words, leads "in most cases to a lifetime of disablement for the patient and a lifetime of hardship for his family." He continues:
This situation has been tolerated far too long. It has troubled our national conscience—but only as a problem unpleasant to mention, easy to postpone, and despairing of solution.
President Kennedy was talking specifically about mentally impaired patients languishing in huge, inhumane hospitals. Those institutions have been closed, but the robust community care he envisioned to replace them hasn't materialized. The president hit many of the same points we make today: inadequately treated mental illness costs our economy billions of dollars. Most signs of psychiatric disorders appear in childhood. And yet we do not—not now, and not in 1963—treat these diseases with the same urgency as what he calls "diseases of the body." These "are beginning to give ground in man's increasing struggle to find their cause and cure," he wrote half a century ago. "But the public understanding, treatment and prevention of mental disabilities have not made comparable progress since the earliest days of modern history," he laments.
But I think we can take heart in JFK's words. His goal—deinstitutionalization—may not have been the whole answer, but it was achieved. And it was achieved by a combination of will and means. Listen to him: "The time has come for a bold new approach. New medical, scientific, and social tools and insights are now available."
Fifty years down the road we would do well to remember JFK's optimism and his resolve to change what needed to be changed. We are wiser now in many ways; let us borrow the strength from the past to put that wisdom into practice.View Comments | Add Comment
Stimulants and Suicide: A Tragic Story With Misleading Implications
Feb. 4, 2013 Caroline Miller
The very sad piece in the New York Times yesterday about a young man who committed suicide after serious abuse of stimulant medications was upsetting for a number of reasons. It's a terribly tragic story about mishandled medication, about the ravages of addiction, and about the powerlessness of parents to help adult children who are self-destructively mentally ill.
It is also verges on the kind of fear-mongering that is unhelpful to parents trying to provide the best support and care to struggling children. Families whose children have ADHD deserve, we think, a more even-handed assessment of the risks of the disorder and its treatments, as well as the circumstances leading to the suicide of Richard Fee.
Fee was a young man who, according to his father, had no symptoms of ADHD, but was able to convince a series of mental heath practitioners that he had the disorder and persuade them to provide multiple prescriptions for stimulant medications he was abusing. The story paints a painful picture of lapses in the mental health care system. Most painful of all was the portrait of his father practically accosting a psychiatrist who had been fooled by his son's fabrications and begging him to stop providing the prescriptions. It's appalling that he couldn't get the message across that his son was an addict, and that a series of mental health practitioners didn't do due diligence about how many prescriptions he had already filled.
But the story was also disturbing because the writer did painfully little to make it clear how far this kind of abuse of stimulants is from monitored use by children and adolescents who actually have ADHD. It suggests two misleading and frightening notions. First, that taking stimulant medication for ADHD puts kids at higher risk for addiction. Research shows that it doesn't. For kids with ADHD, medication is not a steppingstone to the kind of abuse Fee was engaged in.
The second misleading suggestion: that it's easy to take a little too much Ritalin or Adderall and end up in the predicament that Fee was in, addicted and at risk for the kind of psychotic, suicidal crash that ended his life. The fact is that stimulant medications are metabolized rapidly in the body, and when one takes them according to a doctor's orders the medication does not accumulate in the body. You have to do a lot of sustained doubling up on medications to accumulate enough amphetamines in the body to enable the crippling withdrawal symptoms that Fee is said to have experienced.
It's terrible that Richard Fee was able to manipulate a lax system to get enough medication to get into very serious trouble. It is terrible that Fee's caring and tireless parents knew their son was out of control and found themselves powerless to intervene on his behalf.
But it's also unfortunate that this story slyly inflates the risks of stimulant medications used appropriately by not acknowledging that Fee's abrupt change in personality, extreme behavior, and suicide may well have had other contributing factors. For a doctor with no connection to Fee to say that stimulants "in all likelihood" were the "primary issue" contributing to his suicide is irresponsible, and to print this statement is reckless. Fee was at a prime age for the onset several other major psychiatric disorders, and was also apparently abusing marijuana, which has also been linked to higher risk of suicidal thoughts, psychotic symptoms and depression. Did he have depression or mania or schizophrenia? We have no idea. Are stimulants fairly safe for people with ADHD under the close care of a physician and with the support of the family? Yes.View Comments | Add Comment
Victoria Azarenka: Panic Attacks and Armchair Diagnoses
Jan. 29, 2013 Harry Kimball
Tennis player Victoria Azarenka made news this past week—she won the Australian Open, sure, but more ink was spilled over her defeat of Sloane Stephens in the semifinals. Azarenka took a medical break in the second set, and some commentators think she used the time to rebound in a game that was slipping away from her. One went so far as to diagnose her supposedly unsporting behavior: "That was not an injury," Greg Couch writes for Fox Sports. "It was a panic attack."
Now, we don't know what really happened to Azarenka, whether her motives were pure, or even what Couch knows about panic disorder, which is in actuality a severely impairing psychiatric illness. I'm guessing he was using the term more generally—and incorrectly. "Azarenka was falling apart and didn't know what to do," he continues. "So she manipulated the injury timeout rules to freeze Stephens."
What we do know is that after the match, Azarenka said that before her medical timeout she "couldn't breathe" and she felt like she was "getting a heart attack or something out there." And we know that many people with undiagnosed panic disorder end up in the emergency room time and time again because their symptoms do feel like heart attacks—and that they can't really begin to address the disorder until someone notices that it is severe anxiety, and not a pulmonary issue, that is causing them distress.
It is normal for people to be anxious in a variety of situations—and particularly, I imagine, in the semifinals of a Grand Slam tournament. Couch accuses Azarenka of being a coward and a cheat. "She was so scared she couldn't get the ball onto the court," he concludes. But "panic breaks are not within the rules." I don't know-as many have pointed out, athletes are not above "diving" for an advantage. But I do know that if you feel like you are dying it's ok to get help, whether or not that feeling comes from a physiological injury or an anxiety disorder. Both of those things are real, and we should watch our language when we're saying something is "fake."View Comments | Add Comment
Living With Schizophrenia: A Success Story
Jan. 28, 2013 Caroline Miller
It's been on the most popular list on the New York Times web site for days, and no wonder. It's a great feel-good story. A woman in her 20s diagnosed with schizophrenia is told that she's not likely to be able to live independently, marry or have children, hold anything more than a menial job, or enjoy more than intermittent periods without debilitating symptoms. Thirty years later she's a law professor at USC who also teaches in the psychiatry department at UCLA, is married, and is the recipient of a MacArthur genius grant.
Part of the draw is just the headline,"Successful and Schizophrenic"—a conjunction of two words not seen together all that often. But it's a good deal more than a beating-the-odds story. Elyn Saks is one of a growing number of people with mental illness talking candidly about how they are able, with the help of excellent therapy and medication, to manage their recurring symptoms—the way someone with diabetes or arthritis manages their symptoms.
Saks cites participants in a study of high-functioning schizophrenics who report that they have trained themselves to recognize triggers to their symptoms and do things that help avoid them, like minimizing stimulation, or eating comfort food. One man, an educator, says he has learned to face his hallucinations and ask, "What's the evidence for that? Or is it just a perception problem?" Another, a nurse's assistant, says, "I'll listen to loud music if I don't want to hear things."
They're marvelously matter-of-fact about how they manage. One of the main things most of them cite for keeping them sane is work. As Saks puts it rather charmingly, "In other words, by engaging in work, the crazy stuff often recedes to the sidelines."
And—perhaps the most important thing—none of these people manage their illness alone. "Personally," Saks writes, "I reach out to my doctors, friends and family whenever I start slipping, and I get great support from them."
It's a very inspiring argument for not underestimating what kids with developmental and psychiatric disorders can accomplish—with the right treatment and support, and a focus on their strengths and talents.View Comments | Add Comment
Haunted by High School
Jan. 25, 2013 Caroline Miller
Whether you remember your high school years as happy or hellish, Jennifer Senior bets that the experience is still surprisingly vivid to you, lo these many years later, and the teenage identity you forged in those halls still has an inordinate (perhaps even ridiculous) amount to do with your adult identity. In her piece in this week's New York magazine Senior writes about the brain changes in adolescence, and why they make emotions more intense, and the business of finding your place so fraught.
It's a pretty irresistible look at the cauldron in which identity is formed in those arduous years. Senior argues that by quarantining teenagers in an environment filled overwhelmingly with their peers, we set the stage for aggressive, even desperate, competition for acceptance, status and power. "Most American high schools are almost sadistically unhealthy places to send adolescents."
But beyond that she argues that those experiences tag us long after we graduate and go on to bigger and (in most cases) better things. "During times when your identity is in transition," a developmental psychologist tells Senior, "it's possible you store memories better than you do in times of stability."
There is research that shows that being popular and attractive in high school, at least for boys, is predictive of greater earning power as adults. But an interesting thing happens when you look at girls—and this, I think, is an important takeaway from the piece.
A group of 10th graders were asked which of the five characters from The Breakfast Club they most considered themselves to be—Jocks, Princesses, Brains, Basket-Cases, and Criminals. (I know you're thinking, "This is science??" But bear with me.)
Girls who categorized themselves as Princesses when they were 16 were on the top of the pecking order at that point, but by the time they were 24 they had lower self-esteem than the girls who considered themselves Brains.
The researcher attributes that finding to the notion that Princesses had come to define themselves by their social success in the world of high school, while the brainy girls, for whom popularity was elusive, had to rely on said brains and the skills they could use them to develop as a basis for self-esteem. "Out of high school, they suddenly had agency," Senior writes, "whereas the princesses were still relying on luck and looks and public opinion to carry them through, just as they had at 16. They'd learned passivity, and it'd stuck."
To me, this reinforces the point that the most important thing to do to help our daughters build healthy self-esteem is to urge them to do things—acquire skills, explore interests, experience mastery—not to rely for their sense of self on how they look or how much other people like them.View Comments | Add Comment
School Bus Strike Hits Our Most Vulnerable Children
Jan. 21, 2013 Beth Arky
As the New York City school bus strike enters Week 2, it's clear that the 54,000 special-needs children and their already overtaxed parents are bearing the brunt of the walkout. It's important to understand that for many of these families, the school bus is not just a ride to school. It's a crucial piece of a support system for kids who can't just jump on the subway—in fact, they may not be able to walk—and parents who can't hold down jobs unless their children are in reliable, competent, and caring hands.
It's not unusual that the only appropriate school for a child with complex developmental delays and resulting behavior problems might be an hour from home, so thousands of parents are missing work to endure long, arduous commutes, or keeping their kids home. But the personal cost doesn't end there. As Marie Myung-Ok Lee writes in a candid and thoughtful piece in The Nation ("A Good Matron Is Hard to Find"), children and parents alike are also missing the continuity and calm provided by experienced drivers and matrons now walking the picket line.
Lee, whose 13-year-old son, J, has serious medical challenges and developmental disabilities, including autism, has come to depend on J's excellent driver and matron: "Our son indeed relies on them to be consistent, calm, patient and firm."
And that's not easy. "On bad days, our son can bite, head-butt, scream or pinch—fairly typical behaviors for autism, but they can be shocking when one first encounters them," Lee writes. And because of J's gastrointestinal problems, he can have toileting issues. "It can be difficult not to take such assaults personally or want to retaliate," she notes, "which is why experience and maturity needs to be taken into account."
While experience doesn't guarantee expertise and sensitivity, Lee says it improves the odds; J's driver and matron each have worked with special-needs children for 18 years. Like many parents, Lee considers them valued players on J's team: "We all work together to keep our son calm, but when he's not, they know what do to. No amount of training and video-watching can prepare a driver for what it's actually like navigating New York City traffic with the bedlam of one (or more) children throwing a tantrum behind her." She also applauds her driver's "great communication skills with parents; she calls when she needs our input on our son's behaviors or medical issues. She and the matron make our son feel safe, which in turn helps us to feel safe."
As the city and the unions continue their stalemate and questions arise about the cost of bussing special-needs students, Lee brings it down to the most human level: It's the children, "who have little voice and are often ignored or scorned in society," who are losing the most. Those who continue to attend school may be missing hours because of long commutes, while parents who are keeping their children home worry that they may regress as they miss out on the routine, socialization and therapies school provides.
Lisa Quinones-Fontanez, another autism mom, explains in an open letter to Mayor Bloomberg and Local 1181 why 7-year-old Norrin, whose school is 22 miles from the family's Bronx apartment, spent the third day of the strike with her at her job as an administrative assistant, rather than at school. She writes that she has already used up two vacation days staying home with him, her husband, a court officer, can't take time off; and she needs the rest of her days for doctor's appointments and IEP meetings. She also needs to keep her job, and she's worried about that. "This is beyond a stressful situation," she writes. We hope both the union and the mayor understand that.View Comments | Add Comment
Mood Disorders and Violent Video Games
Jan. 17, 2013 Caroline Miller
If you want to read a provocative, insightful piece on violent video games, mental illness, and mass shootings, you'll find it on Kotaku, a gaming site that's part of Gawker Media. The headline tells the story and sets the tone: I'm Mentally Ill, I Love Violent Video Games, and They've Never Made Me Feel Like Killing Anyone.
The writer, Dennis Scimeca, is an articulate and startlingly frank gaming writer in his thirties who has bipolar disorder. And it's much more than a defense of the video games he has been a devotee of since childhood (though it is that). It's a close look at how games have interacted with his emotional life, both in the volatile years before he was diagnosed, in his 20s, and after.
Scimeca figures he suffered from bipolar disorder for more than a decade before he sought, and got, treatment, and he describes video games as one of the most important sources of pleasure and solace for a kid who was bullied and frustrated as a teenager. It's the skills challenge that made them satisfying, he says, noting that it's pretty hard for those of us who doesn't play to understand the appeal of what he calls first person shooters. "I was rubbish at playing sports as a kid, but I'm a pretty good FPS player and I feel a healthy sense of satisfaction when I beat a Halo 4 level at the Legendary (highest) difficulty level."
Of course he had revenge fantasies—everybody has revenge fantasies, he notes—but he says it wasn't just the fact that he didn't have semi-automatic weapons at his disposal that kept him from becoming Adam Lanza.
Even if I had been able to get my hands on guns in high school I doubt I'd have used them. I had a family who loved me, and friends who listened to my suicidal rants and slides into depression. These people comforted me.
Scimeca makes it very clear that it isn't just medication that helped him get control of his illness, but also his family and friends. And he's also clear that the real problem wasn't anger but emotional pain so extreme that he didn't want to "move or talk or even breathe." Without that support system and attention to his pain, and with access to guns, he imagines that the outcome could have been very different.
What might have made me a school shooter in some other reality would have been whether I was lonely, or whether anyone was paying any attention to the fact that I was in constant pain, or whether I could have easily laid my hands on a lot of guns, and I'm very glad that in my case none of those things were true.
In another post last fall Scimeca writes about why it's important to be open about psychiatric problems, and how long it's taken him to be able to be public about his own diagnosis. We appreciate his candor about living with a disorder that is so easliy and frighteningly misunderstood.View Comments | Add Comment
Aaron Swartz Suicide: Genius and Depression
Jan. 14, 2013 Caroline Miller
The death of Aaron Swartz, the 26-year-old programming prodigy and digital rights activist who committed suicide Friday, was stunning and upsetting. Swartz, who helped invent RSS as a 14-year-old and contributed to the creation of Reddit, was a passionate believer in the principle of open information. He was being prosecuted for allegedly downloading millions of academic papers collected by JSTOR, which sells digital access to scholarly journals, from the MIT archive. Swartz was said to be very upset about the charges, which carried a sentence of up to 35 years in jail and $1 million in fines. He was also said to be struggling with depression.
Mashable outlines the controversy over the criminal charges against Swartz, which his family calls “intimidation and prosecutorial overreach,” and some of the tributes offered by tech leaders, including this description of Swartz from a Harvard academic and activist: "A kid genius. A soul, a conscience, the source of a question I have asked myself a million times: What would Aaron think?"
What cuts even closer to the quick is the blog Swartz himself wrote in 2007 to describe his experience with the illness and depression that plagued him. I hope you’ll read it.
Swartz begins by apologizing for not keeping up with his blog, and admits that he’s been ill with several things, including stomach pain and migraine.
I have a lot of illnesses. I don’t talk about it much, for a variety of reasons. I feel ashamed to have an illness. (It sounds absurd, but there still is an enormous stigma around being sick.) I don’t want to use being ill as an excuse. (Although I sometimes wonder how much more productive I’d be if I wasn’t so sick.)
And he writes with painful eloquence about being depressed, about the pervasive sadness and the frustration of being unable to feel the joy everyone else seems to feel.
At best, you tell yourself that your thinking is irrational, that it is simply a mood disorder, that you should get on with your life. But sometimes that is worse. You feel as if streaks of pain are running through your head, you thrash your body, you search for some escape but find none. And this is one of the more moderate forms.
There’s more. But he comes back, in the end, to stigma, citing an economist who notes that depression, which affects 1 in 6 people, is the greatest impediment to happiness today:
Sadly, depression (like other mental illnesses, especially addiction) is not seen as “real” enough to deserve the investment and awareness of conditions like breast cancer (1 in 8) or AIDS (1 in 150). And there is, of course, the shame.
Swartz’s suicide is another reminder that genius is often no match for depression, and that the shame that inhibits both treatment and research can rob us all of great potential.View Comments | Add Comment