The Child Mind BlogBrainstorm
A New Diagnosis for Explosive Children
Oct. 22, 2012 Caroline Miller
Chronically irritable and explosive children are the subject of a new disorder called disruptive mood dysregulation disorder, one of the biggest changes in the upcoming psychiatric disorder guide revision known as the DSM-5.
The disorder—DMDD for short—is the result of a long struggle in the psychiatric community over how to better understand and treat children with uncontrollable behaviors. These kids can be so difficult to manage—to keep them from harming themselves and other children, and even adults—that they are often put on antipsychotic medication or sent to residential treatment.
Children who are extremely irritable and prone to extreme outbursts have, for the last several decades, been diagnosed with bipolar disorder, though they don't show the classic symptoms, dramatic mood swings between depression and mania. Psychiatrists who work with these kids have been unsatisfied with the diagnostic choices and treatment options they have.
So the struggle has been to isolate and define this specific set of behaviors in a way that will lay the groundwork for more effective treatment, especially to help avoid overmedication. The Wall Street Journal chronicles the process and thinking that led to the new diagnosis in a very interesting story that lays out the back-and-forth that's gone on in the committee working on this issue, as well as the consequences, in terms of money and medications, that flow from any new diagnosis. Even names of new disorders have consequences, as the uproar against the first name proposed for DMDD—temper dysregulation disorder—demonstrates. Parents hated the name because, as one mother explained, "The use of the term 'temper' in the diagnosis connotes a bad personality," when what the child actually suffers is a "severe condition resulting from a dysfunction in the brain."
There is always a lot of skepticism greeting new disorders, as if psychiatrists are inventing things for themselves to treat, but as the Journal story makes clear, what everyone agrees is that these children are in severe distress, and there should be a high priority on finding better ways to understand what's happening to them.View Comments | Add Comment
'Falling': A Touching and Sensitive Play About Autism
Oct. 19, 2012 Michelle Kaplan
I recently had the privilege of attending Falling, a touching play that just opened off-Broadway at the Minetta Lane Theater in Manhattan. The play explores the challenges and painful issues that families can face when raising a teenage child with autism. Playwright Deanna Jent draws on her own experiences as the mother of an autistic son, and the result is genuine and moving.
In the play, the parents devote all of their time and energy to managing their 18-year-old autistic son—alternately endearing and angry, mentally limited but physically powerful—and their typically developing younger daughter is left to fend for herself. She carries a lot of resentment towards her parents as well as her brother, and it brings up the issue of how difficult it can be to give equal attention to your children when one child needs so much more support.
The play brings up the stress that raising a severely autistic child can have on a marriage, when parents have different opinions on how to best deal with rigid routines and aggressive behavior. What happens when one parent feels their child would be safer in a group home? What happens when extended family members don't understand or agree with the decisions that parents make about raising their children?
In one especially painful moment in the play the mom imagines what life would be like if her son was no longer with them, and her reaction is one of relief. It highlights the emotional double bind a parent can face, being overwhelmed by negative feelings towards a child while also unconditionally loving him. These feelings are not often admitted or accepted without judgment, and Jent is able to portray this in a very honest way.
Additionally, the play brings up the need for more services to support young adults with special needs who are aging out of the system in our society. I highly recommend Falling, as it is not only an exceptional theatrical experience, but also an educational one.View Comments | Add Comment
In October, 'Let's Talk' About Sex
Oct. 17, 2012 Harry Kimball
We like to say that talking to your kids about sex should be a "continuing conversation" between parents and children that starts young and evolves along with development. But not all parents can make that happen—which is why we are happy that Planned Parenthood has launched "Let's Talk Month" to encourage all parents to open a dialogue with their kids, no matter how long they've waited. It's never too late to start instilling good values concerning sex.
Planned Parenthood has a bunch of informative articles and videos with practical advice on how to talk to teens about sex, and in particular on how to get them to respond and to keep the level of discomfort as low as possible.
But I think the most interesting and important thing for parents that Planned Parenthood is providing is a statistic from a poll the organization conducted of about 1,000 teens and one of their parents. In general, almost all parents and kids said that they had spoken to each other about sex. But when you break it down, a disconnect emerges between what parents think they've talked about and what kids think. For instance, "49.9 percent of parents said they've discussed healthy and unhealthy relationships many times with their teens." That number for teens—who are the exact same children those parents were talking about—is just 31.5 percent.
Clearly, there is a lot of talking but not as much communication. So, even though it can be a little uncomfortable, it's very important that conversations about sex are clear, and that parents are forthright with their values and expectations. One way to achieve this is for parents to remember they are parents, not friends. A panel from the Freedom Institute explained this very nicely to our own Caroline Miller, and you can read about it here in a childmind.org piece on why frank sex talks are the most effective.
As Planned Parenthood New York president Joan Malin puts it in a piece on the Huffington Post, "Let's Talk Month is a great time to begin, or continue, the conversation." The poll shows that parents and teens are doing a pretty good job, but we can do better. Remember—though it might not seem like it, there is no one that influences a teen's attitudes about sex more than parents.View Comments | Add Comment
Lessons From Looking at Temple Grandin's Brain
Oct. 16, 2012 Harry Kimball
Though people with Asperger's disorder aren't all socially awkward geniuses, as the stereotype goes, interest in so-called "savants" on the spectrum remains. The most famous of these is arguably the animal scientist and advocate Temple Grandin—and now we know what her brain looks like.
Researchers at the University of Utah and other institutions used many different brain imaging techniques, as well as neuropsychological testing, to get an idea of what sets her brain apart from those "typical" people. The professor was compared against three controls, and some interesting structural differences emerged. (We should note that every brain is different, even if you aren't on the autism spectrum, and three controls is not the hugest sample group.)
According to the work presented at the Society of Neuroscience meeting and reported by the Simons Foundation Autism Research Initiative, Grandin's brain is larger overall than is typical, and has "enhanced" connections between brain regions associated with visual thinking as well as an oversized amygdala, the deep brain structure thought to be responsible for emotion. There are also "compromised" connections relative to controls, for instance, in areas tied to language and facial recognition. That we've reached this point in imaging technology and our understanding of autism is pretty remarkable.
I believe the lessons here are fairly simple, and one of them we knew already: Temple Grandin is an amazing person. It's not a stretch to assume that she has a relatively remarkable brain, and this research suggests that. But the other observation is that we now know enough to predict where the brain differences will likely be—that we know when someone doesn't act or think "typically," we're probably going to see some changes in areas that we're getting better at predicting.
The crucial caveat here is that no brain is "typical." It's sort of an old saw, but no person with autism is typical, either. And no person without autism is typical. We are all on a spectrum of humanity, and it's clear that some of us are closer to the center of the bell curve, as it were. And some of us are, for better or worse, outliers.View Comments | Add Comment
Why ADHD Pills Won't Help Kids in Poor Schools
Oct. 15, 2012 Caroline Miller
Dr. Nancy Rappaport has written a terrific piece outlining why it's important that kids not be given ADHD medications just because they're not doing well in school or are behaving badly. That is, without a real diagnosis of ADHD, by someone who believes it's a real thing.
She is responding to the piece that ran last week in the New York Times, in which a Georgia pediatrician describes prescribing the ADHD medication for kids who go to lousy schools as a form of "social justice." We can't fix the schools, he said, so we "fix" the kids.
It's a particularly bad idea, she writes, to use ADHD meds to manage distracted or disruptive kids in poor schools without an actual diagnosis because there are a lot of other reasons why those kids may be distracted or disruptive, and if they're not addressed, those problems aren't going to go away with a prescription for Adderall. In fact they might very well get worse.
For example, a child who has experienced trauma has many of the same symptoms as ADHD—"the hyperactivity, the disorganized approach, the distraction, the frequent mood changes, the anger, the reactivity," explains Dr. Rappaport, a Harvard professor of psychiatry who focuses on kids' mental health and schools. Undiagnosed learning disorders may cause a child to tune out, or to act out in frustration. These kids need a very different kind of help to do well in school—and life.
It's troubling to acknowledge that we have to put the word "real" in front of diagnosis, to distinguish between a knee-jerk prescription and a serious assessment of a child's behavior. Dr. Harold Koplewicz makes this point, and explains the difference, on a roundtable video on Huffpost Live. He also makes the point that the majority of kids who have behavior problems in school don't have ADHD, and the one-pill-fits-all approach does a serious disservice to those who really do have the disorder, and do need the medication.View Comments | Add Comment
ADHD Medication: A Pill for Failing Schools?
Oct. 9, 2012 Caroline Miller
The New York Times has a provocative and compelling story on the front page today about the use of ADHD medications. It will be widely shared—and widely misinterpreted.
The story is about the growing use of ADHD medications to help kids struggling in school—kids, that is, who don't have ADHD. A lot has been written about middle class kids cribbing Adderall to help them score better on tests, or scoring their own prescriptions to enhance their chances of making it into an Ivy League college. But this is about a different set of kids: those whose schools are underfunded and whose parents can't afford the non-pharmaceutical support they need to enhance their school performance.
In the story we hear a lot from Dr. Michael Anderson, a well-meaning pediatrician near Atlanta who routinely prescribes ADHD meds to kids essentially because they're struggling in school. "I don't have a whole lot of choice," he tells the Times reporter. "We've decided as a society that it's too expensive to modify the kid's environment. So we have to modify the kid."
Dr. Anderson sees it as an issue of social justice, of "evening the scales a little bit" for these kids who would otherwise almost surely be failing in school—in schools, that is, that he perceives as clearly failing them.
Whoa. We need to establish some facts here. Kids who are failing in or behaving badly in school don't necessarily have ADHD. It does a serious disservice to both kids who do have ADHD and kids who don't to prescribe it as a fix for bad schools.
ADHD isn't a disorder that just happens in school—to qualify for a diagnosis, a child must exhibit extreme inattention, hyperactivity and impulsivity in several settings, not just the classroom. It's what we call a global impairment, and it's not responsible or competent to see stimulant meds simply as a tool to improve school performance—or to compensate for a lousy school.
We know it happens, and we worry that it happens much more to kids whose families don't have the resources to get other kinds of support they might really need—tutoring, behavioral therapy, smaller classrooms, better-trained teachers, consistent structure.
We worry along with one school superintendent who speculates that what's happening is a doctor who "sees a kid failing in overcrowded classes with 42 other kids and the frustrated parents asking what they can do. The doctor says, 'Maybe it's ADHD, let's give this a try.' "
This story also fuels the myth that ADHD medication is dangerous. The unsubstantiated suggestion that these meds can lead to lifelong addiction is irresponsible. There is a clear body of evidence that taking ADHD meds in childhood and adolescence does not increase the risk of addiction or abuse, and in fact they are among the safest, most effective, best-studied, and least easy-to-abuse psychotropic medications we have.
So what we have here is a sympathetic pediatrician arguing that when a kid is struggling in school, trying ADHD meds might be the most cost-effective thing he can do to help. "I am the doctor for the patient, not for society." It may be cost-effective, but we'd argue that it's not good either for the patient or the society.View Comments | Add Comment
NBA Player Royce White Gets a New Travel Plan for his Anxiety
Oct. 9, 2012 Rachel Ehmke
Royce White, the NBA rookie recently drafted to play for the Houston Rockets, is catching attention again because of his anxiety, this time after he requested permission to travel to close road games by bus due to his fear of flying. While White has already gotten on several planes with his new team over the summer, flying is stressful for him, and he says he'd prefer to avoid it whenever possible as part of a "more healthy work environment."
White, who has generalized anxiety disorder and OCD, explained, "It's honest to just say, 'I have some anxiety.' It's a whole different level of honesty to say to the Rockets, 'I have anxiety, and this is what I need to do to be healthy and can you accommodate me?' I felt that it was necessary to take that step."
White's skill is undeniable—people are already speculating that he'll have a spot on the NBA All-Rookie team—but he's always been upfront that he brings his anxiety along with his talent. This makes him a fascinating figure in sports, since athletes are often conditioned to mask their fears and weaknesses. But White does his best to be candid, both because he says he wants to be a role model for kids and because he believes getting the support he needs will make him a better player. Fortunately it looks like he has found a team that thinks the same way. The Rockets knew about White's anxiety and fear of flying before they drafted him, and they have agreed to let him drive to games whenever possible. Here's wishing them luck.View Comments | Add Comment
'Bell Rung': NFL Players Discuss Concussions in a New Documentary
Oct. 4, 2012 Michael Rosenthal, PhD
I attended the premiere of Bell Rung, a provocative documentary co-produced by retired football player Dorsey Levens about concussions in the NFL. Mr. Levens interviewed several players and friends of his who experienced multiple concussions and now, several years later, are feeling the ill effects of these injuries. Many complained of persistent headaches, problems with attention and memory, and heightened emotionality and mood swings in their personal lives.
To many kids, Dorsey Levens and the players featured in Bell Rung are heroes and their words and actions carry an enormous amount of influence. This is important, because all too often they hear their favorite NFL players minimizing concussions as "dings" or "just part of the game." And when an idol talks nonchalantly about routinely playing through his injuries, this approach to the game can easily become internalized. In contrast, the players in Bell Rung were not shy opening up about their experience with concussions—some claimed to have suffered 20 to 30 over their NFL careers—and talked introspectively about their decisions to play through injuries, their limited awareness of risks, and the toll it may have had on their health. One of the players discussed his reaction to the suicide of NFL star Junior Seau and wondered if he might be heading down a similar path. The film provoked a strong reaction in the audience, many of whom had questions about how to safeguard their own children.
The answers are many and promising: New state laws have been passed mandating concussion education for coaches and other school personnel, and rules put in place dictating when a student-athlete should be pulled from play and when he or she is cleared to return. Youth sports organizations are adopting new system-wide policies designed to reduce exposure—Pop Warner has made changes to the way practices are run to limit amount and intensity of contact, US Lacrosse is exploring headgear options for its female athletes, and USA Hockey has eliminated body checking in 12 and under male players. Kevin Guskiewicz and his colleagues at the University of North Carolina are teaching football players at many different levels of play how to tackle safely using proper technique. The CDC has partnered with several organizations to create free tools designed to educate parents, coaches, athletes, and other health care professionals about concussions. And a number of researchers, educators, and clinicians around the country are exploring new technology that could help identify concussions early and treatment techniques designed to shorten recovery times.
With Bell Rung Mr. Levens is certainly playing his part in keeping kids safe, too. I hope more role models step up to influence a younger generation of athletes that it's smart to take care of your brain.
Dr. Rosenthal is a pediatric neuropsychologist who is an expert in identification and treatment of children with concussion or mild traumatic brain injury.View Comments | Add Comment
Porn OK, Malware Not So Much: Dad to Teen
Sept. 28, 2012 Harry Kimball
For the past few days the internet has been buzzing over a letter, posted to the social news site Reddit, that a dad wrote to his 13-year-old son after finding pornography on his computer. The gist of the note, left on the son's desk: It's cool. Be careful about computer viruses. I won't tell your mom.
People have been more or less supportive of the anonymous dad, who seems particularly concerned about his investment in the $1800 machine. "I'm not mad or anything," Dad writes. "It's life and I did it too. I just want you to know that most of those sites are places that can and will ruin your computer...There are viruses and other scamware that can completely ruin a computer and I can't afford to buy you another 1800 dollar machine because you went to a site that fried it."
Instead, the dad offers a few suggestions for "safe" porn sites and a tacit offer of an open door, judgment-free. "I won't tell your mom and I'm not gonna make a big deal out of this. In fact I'm not gonna make any size deal out of it. If you don't wanna talk about it that's fine and I completely understand." (Perhaps one of the most contentious parts of the letter, at least to online readers, is the decision to exclude Mom from the discussion. "The husband / father made the unilateral choice for his wife / mother of their child," one Huffington Post commenter protests. "Only she can state whether or not it's important to her." Not so fast, says another. "If a man can't side with his son, who can he side with?")
Another red flag that went up for commenters was the missed opportunity to discuss how far from reality both the sex and the people in pornography are, and how this disconnect can encourage inappropriate sexual attitudes, a point CMI psychiatrist Al Ravitz made yesterday in an appearance on Huffington Post Live. The author responded to this criticism on Reddit. "I also talked to him about porn not being like real life and that women aren't objects like they are portrayed in porn."
It's tempting to focus on the pornography and weigh the response—enlightened? Naive? Unfair? But this misses the point the dad brings up almost in passing at the end of his letter. "I would like you to not be back here so much though. You literally spend all of your time back here." Excuse me?
Let's put aside the issue of pornography for a moment and focus on a larger one: screen time. There are debates over the effects of almost everything a kid—or an adult—can do on a screen: watch frenetic TV shows, play violent videogames, interact on social networks, text, sext, you name it. But we know one thing for certain: when kids are tied up by a screen, they aren't doing other things critical to their development. This includes hanging out with friends, getting physical exercise, and being part of a family.
"I'd like to see you more often," Dad pleads. "I like doing stuff with you and miss it." There are a lot of things going on with a 13-year-old, and this father deserves applause for being open, honest, and practical about sexuality, and for realizing that his son naturally desires some independence and autonomy from his parents. But these words above indicate that Dad also knows—maybe unconsciously—that spending your young life in front of a screen isn't great for his kid or for the family. I hope that this issue comes up in their next conversation. It's not as sexy a topic as porn, and maybe even harder to talk about, but it is a critical one for families to address.View Comments | Add Comment
Lady Gaga Fights Bulimia (and the Fat Police)
Sept. 27, 2012 Caroline Miller
Lady Gaga has put on some weight, and, not surprisingly, she's catching flak for it. The Daily Mail, among others, published a bunch of unflattering photos of her on stage at a recent show in Amsterdam, and quoted a fitness expert who had calculated, from those photos, that Gaga was about 30 pounds "meatier."
The stories were obviously, if not surprisingly, crass—"The fat Lady Gaga sings," read one headline—and Gaga countered with some pictures of her own, only slightly more exposed than she is on stage, but appealingly defiant: "This is what I look like off stage and out of costume," they seem to say. " Here's the real thing. Take a good look."
But what got (and deserved) more attention than the photos was the caption: "Bulimia and anorexia since I was 15." Gaga has talked about bulimia before, but what is different this time is the tense: Unlike almost every celebrity who talks about having an eating disorder, she's not talking about something comfortably in the past. She's not telling us that now she feels great about her weight and her healthy relationship with food. Eating disorders don't go away overnight, and by acknowledging her reality Lady Gaga is helping to legitimize anyone who has ever struggled—and is struggling—to recover from one.
In true Gaga fashion she's also launching an offensive against the fat police and asking fans to join her by posting similarly raw photos of themselves. The goal, as she puts it, "is to inspire bravery and BREED some M$therf*cking COMPASSION." Or, to put a little Gaga gloss on it: "May we make our flaws famous, and thus redefine the heinous."
I can't say whether the love fest and outpouring of photos on her site will really help others struggling with negative feelings about their flawed (ie, normal) bodies. But we love Gaga's creative efforts to use her over-the-top celebrity to help her young fans. And, of course, we love her honesty.View Comments | Add Comment