The Child Mind BlogBrainstorm
How Trauma Can Be Misdiagnosed as ADHD
July 7, 2014 Caroline Miller
Dr. Nicole Brown, a resident at Johns Hopkins Hospital in Baltimore, was troubled by the number of pediatric patients she saw who had ADHD diagnoses. She didn't doubt that some of them had ADHD. They were described by their parents as hard to manage and their teachers as disruptive and/or inattentive. But they were also kids whose homes and neighborhoods were marked by poverty, violence, and substance abuse.
Dr. Brown was frustrated that the standard treatments for ADHD—behavioral therapy and stimulant medication—weren't helping many of these kids get their symptoms under control. “I began hypothesizing that perhaps a lot of what we were seeing was more externalizing behavior as a result of family dysfunction or other traumatic experience,” she says.
Dr. Brown tested her hypothesis with a study that confirmed the link she observed: Kids who endured four or more adverse childhood events were three times more likely to use ADHD medication.
Dr. Brown's experience is detailed in an excellent piece in the Atlantic exploring the concern that kids who experience high levels of stress display symptoms that overlap those of ADHD, and that may be leading to misdiagnoses. Inattentive, hyperactive, and impulsive behavior can be the result of chaos, neglect or abuse, and many doctors prescribing ADHD meds may not have, or take, the time to find out what's happening to kids at home.
"We need to think more carefully about screening for trauma and designing a more trauma-informed treatment plan," says Dr. Brown.View Comments | Add Comment
Please Stop Fear Mongering About ADHD Medications
July 2, 2014 Brooke Garber Neidich
The New York Times ran yet another piece in the op ed section this week that takes a swing at ADHD medications, suggesting that adolescents who take them might be increasing their risk for anxiety disorders.
In the piece, Richard A. Friedman, a psychiatrist at Weill Cornell who is not a specialist in treating children and adolescents, wrote about the fact that teenagers are highly emotionally reactive, and their ability to regulate their emotions is not yet fully developed. They're better at getting anxious than they are at calming down. Researchers think that's one of the reasons they're especially vulnerable to anxiety disorders. So far, so good.
But then Dr. Friedman floated the hypothesis, in the form of two rhetorical questions, that stimulant medications, since they can increase symptoms of anxiety in some kids, might be triggering anxiety disorders. He writes:
Might our promiscuous use of stimulants impair the ability of adolescents to suppress learned fear—something that is a normal part of development—and make them more fearful adults? And could stimulants unwittingly increase the risk of PTSD in adolescents exposed to trauma? In truth, we haven't a clue.
Rhetorical questions may seem harmless, but as a parent, I know that this kind of speculation—when "in truth, we haven't a clue"—stimulates worry without giving us real information.
We know that a lot of kids who have ADHD also have anxiety, and good clinicians are very careful when prescribing stimulant meds for a kid who is also anxious. But there is no evidence at all—and ADHD meds are the most thoroughly researched type of medication in use for kids, including follow-up studies—that kids taking Ritalin or Adderall are more at risk for anxiety disorders than kids who don't take them. And what about the risk of developing anxiety as a result of struggling with untreated ADHD?
I don't like to see parents subjected to what seems to me to be fear mongering. The Times has in the last year or so run a number of pieces that suggest, again and again, and without evidence, that kids who take stimulants are more at risk for substance abuse in later life than other kids. In fact there is substantial evidence from long-term studies that this is not the case.
Of course I'm not in favor of "promiscuous" use of stimulant medications for every kid who is struggling with attention or behavior problems. That really does kids a disservice. But adding these unfounded worries about medication that is very valuable to many kids does both kids and parents a disservice.
Brooke Garber Neidich is the chair of the Child Mind Institute Board of Directors.View Comments | Add Comment
The Rock Names His Toughest Opponent: Depression
July 1, 2014 Harry Kimball
Dwayne "The Rock" Johnson isn't exactly weak, fainthearted, or indecisive. In fact, as described by Stephen Galloway in The Hollywood Reporter, he's "a 6-foot-5, 252-pound mountain of muscle, his arms hardened and honed, his chest as big as a bull's." He has quietly-well, not too quietly-come to dominate the box office with crowd-pleasing action spectaculars. And, like a lot of people, he has struggled with depression. Unlike some icons of masculinity, he is willing to talk about it.
We hear over and over that young people, particularly young men, lack viable role models who are open about mental illness and the need to get help. In this interview Johnson doesn't give specifics about how he recovered from episodes of depression, but his honesty is encouraging. "I didn't know what it was," he says of his first depression at age 18 following an injury that sidelined his football career. "I didn't know why I didn't want to do anything. I had never experienced anything like that."
Johnson places a high value on self-confidence, mastery, achievement. He describes the moment, as a child of struggling parents with a tough upbringing, when he decided to take control of his future. "What can I control with these two hands?" he asks himself. "The only thing I could do was train and build my body."
But despite his strength of purpose and success in overcoming challenges, he admits to being laid low by depression, and to depending on friends and family to get through it. And that's where his ambition and his honesty come together to make something special. He represents two kinds of strength-the strength to strive for outsized goals, and the strength to realize when you can't go it alone.View Comments | Add Comment
Is Sensory Processing Disorder a Real Condition?
June 25, 2014 Caroline Miller
This question is the headline on a story, surprisingly, in the New Republic. It's a good piece that lays out the overwhelming anecdotal evidence that some kids have problems processing sensory stimulation, leading to behaviors that range from irritability to inconsolable meltdowns.
It also lays out skepticism, in the psychiatric community, that these problems can best be understood as a disorder, and that the treatments that have been devised for them are legitimate or effective.
I'm glad to see this getting attention because I know many parents are frustrated by this rift, between the occupational therapists who diagnose and treat sensory processing problems and the psychiatrists and psychologists who may be treating these same kids for other conditions, like autism or ADHD. Among other things, it allows insurance companies to avoid paying for treatment.
As the article notes, what's needed is more standardization in how SPD is diagnosed, and more measurable outcomes for the interventions. Above all, what's needed is research, and that's kind of a catch-22. "It's hard to fund the studies because SPD is not a real diagnosis," notes Dr. Lucy Jane Miller, founder and director of the SPD Foundation, "yet it can't be a real diagnosis without more studies."
The story also lays out some of the more "out there" interventions that have been offered to parents. "A lot of it is myth and magic," notes Dr. Miller. What's real here is the need, both for understanding these kids and for helping them.View Comments | Add Comment
The Struggle to Find Treatment for Troubled Young Men
June 24, 2014 Harry Kimball
There is much in Benedict Carey's insightful New York Times piece on violently aggressive adolescent boys with psychiatric disorders that hits close to home for us. At the center of the story are an unnamed 15-year-old and his family, the Serpicos, all at wits' end despite high-class health insurance and proactive psychiatric care. He has attempted suicide and injures himself, attacks his mother, and abuses marijuana and prescription drugs. And he has no faith in treatment. "It's useless, all this stuff," he says. "It's a waste of my time."
Along with multiple diagnoses—from ADHD to bipolar to features of borderline personality disorder—he has been on multiple medications, including stimulants, antidepressants and antipsychotics, with little to show for it. Carey can't help but mention the possibility of a disastrous outcome for this teenager—another Newtown, another Santa Barbara—but to the reporter's credit he identifies a wider disaster that is already all around us.
"Most of these young men will never commit a violent crime, much less an atrocity," Carey writes, referring to the 1% of teens who are "young, troubled males with an aggressive streak." That doesn't mean they can be ignored, but how to pay attention eludes us. "The questions of how best to help them and how to pay for it are among the most intractable problems hanging over the system."
The Serpicos are lucky, or relatively so—they have secured coverage for their son's yearlong stay at a therapeutic boarding school. But a previous two-month stint at a residential facility seemed to do nothing for him. Although his parents seem optimistic—or must be optimistic—their son is skeptical. "Probably useless, too," he tells Carey.
We are heartened when we see families like the Serpicos who have recognized serious problems and fought tooth and nail to get their children help, but we are also aware of all we don't know about severely troubled young people. "Some kids may benefit from these extremely costly services," a health policy expert tells Carey. But "we don't know which ones they are, and we don't have a good model for distributing those services, no matter who's paying." For these kids, these families, and all of us, it's time we devote more effort to figuring that out.View Comments | Add Comment
My Dad's Suicide Isn't 'Cool': Frances Cobain to Lana Del Rey
June 24, 2014 Beth Arky
When Kurt Cobain killed himself in 1994, daughter Frances Bean Cobain was just a baby. So when she read an interview in The Guardian in which singer-songwriter Lana Del Rey seemed to be glorifying the early ends of the Nirvana frontman and singer Amy Winehouse—and then shared her own death wish—Cobain took to Twitter urging her not to glamorize them.
"I wish I was dead already," Del Rey is quoted as saying. Cobain isn't having it. "The death of young musicians isn't something to romanticize," she wrote. "I'll never know my father because he died young & it becomes a desirable feat because ppl like u think it's 'cool.'"
"Well, it's f--king not. Embrace life, because you only get one life. The ppl u mentioned wasted that life. Don't be 1 of those ppl."
Both Cobain and Winehouse died at 27, from suicide and alcohol poisoning, respectively—the same age as Del Rey.
While The Daily Beast may feel Del Ray's statements are merely part of a ploy to sell her new album, Ultraviolence, and Rolling Stone reports that she expressed regret over the interview and claimed to have been misquoted, the damage may already be done. There are plenty of teens who pay attention to what high-profile entertainers say and are young enough to confuse marketing with meaning.
We hope Cobain's strong response drowns out Del Rey's casual fatalism, and that young people open their ears to the real effects of suicide and drug abuse and understand there is no glory in dying young.View Comments | Add Comment
The Trouble With Parenting Isn't the Kids
June 20, 2014 Caroline Miller
When Jennifer Senior (All Joy and No Fun) talks about parenting, she's not peddling another how-to-do-it-better manifesto (Tiger Moms, Panda Dads). She's taking a hard look at the stress and anxiety that are associated with parenting these days, and identifying some of the places the pressure comes from.
Senior focuses on the fact that some of the pain parents feel is relatively new, and some of it is culturally inflicted, including unrealistic expectations for creating perfect—and perfectly happy—children. It's also the result of profound changes in the economy that make preparing kids for the future an unusually fraught endeavor.
If you feel like taking a step back, not so much to smell the roses but to get a perspective on how we think about children, and how that affects how much we are able to enjoy being their parents, check out Senior's excellent TED talk here.View Comments | Add Comment
Company to Test Vyvanse Safety in Kids Under 6
June 16, 2014 Harry Kimball
It's interesting to hear that Shire, the maker of the Vyvanse stimulant medication for ADHD, has agreed to an FDA request that it evaluate the drug for children younger than 6. Kids under 6 may well be getting prescriptions already, but prior testing only looked at the effects in kids over 6.
This underscores one of the more peculiar aspects of the way a medication approved by the FDA for one illness or group of people can also then be legally prescribed for an entirely different disorder, or to treat a whole new demographic—kids, for instance.
This is a heartening development, given the considerable alarm recently over the rise in stimulant prescriptions, particularly for very young kids. The FDA taking an active interest in addressing concerns with sound science is fantastic. The fact that Shire has agreed to expend effort to answer questions that are very important to kids and families is also encouraging.
Of course, there is a lot more to this than just cooperation, I'm sure. In fact, the Financial Times reports that Shire will get another 6 months of lucrative patent protection out of the deal, at least. And other details aren't immediately clear, including how rigorous the trials will be.
Sure, there is a lot to be cynical about when it comes to pharmaceutical marketing and the interplay between government and big business. But in this case it certainly seems like a gap in the system was recognized, consumers were listened to, and proactive action was taken. Shire insiders tell the Financial Times that establishing "firm data on safety and efficacy" for Vyvanse in younger children "was in the public interest." I'm happy for the time being thinking that we can all work together for that purpose.View Comments | Add Comment
Teen Overcomes Anxiety to Compete on ‘America’s Got Talent’
June 13, 2014 Beth Arky
When Anna Clendening competed on America's Got Talent this week, she brought her music and a whole lot of courage. Before launching into a heartfelt rendition of Leonard Cohen's "Hallelujah," the 20-year-old shared her story of being bedridden as recently as four months ago by a crippling anxiety disorder, panic attacks and depression that first manifest themselves when she was 14.
"It felt like my mind had given up on me," she said in a segment that has since gone viral. "I didn't see a future. I just didn't want to be here anymore." She credits therapy, her parents and, like so many others with mental health issues, finding something she loves to do with helping her battle her issues.
Talent judge Howie Mandel, who was diagnosed with OCD and ADHD as an adult, told Clendening, "People really don't know what it takes and how much suffering it is. For you to even show up today is so amazing." He encouraged her further, saying, "There isn't anybody alive that at some time doesn't need help in coping."
The singer got a standing ovation and Mandel was so moved he hugged her despite his fear of germs. She also received countless accolades in online comments and on social media. Erin Roberts Jones, who writes about autism and anxiety on her Mutha Lovin' Autism Facebook page, posted, "This hits so close to home. What an inspirational young woman for all of us dealing with anxiety and panic attacks. Just wow."
Clendening is far from alone. By mid-adolescence girls are more than twice as likely to be diagnosed with a mood disorder as boys. Teenage girls who participated in an online conversation about anxiety hosted by the Child Mind Institute and Amy Poehler's Smart Girls stressed it's important to face your fears to overcome your challenges. We applaud Anna Clendening for bravely stepping on that stage as she gets the help she needs.View Comments | Add Comment
Audra McDonald and ADHD Medication
June 11, 2014 Caroline Miller
If you're tired of hearing people equate ADHD medication with lazy parenting, you'll enjoy Belinda Luscombe's open letter to Audra McDonald in Time. Luscombe was responding to McDonald 's comment, in accepting her sixth Tony Award Sunday night, that her parents' unwillingness to put her on stimulant medication led to her stunning success in musical theater.
"I want to thank my mom and dad up in heaven," McDonald said, "for disobeying the doctors' orders and not medicating the hyperactive girl and finding out what she was into instead and pushing her into the theater."
Luscombe is, of course, glad things worked out well for McDonald, and sure that the immensely talented singer didn't mean to put down parents who do decide to give kids ADHD medication. But that's certainly the effect of comments like this.
What bothers me is why McDonald thinks parents who try medication don't also try to help their kids find out what they are good at and passionate about. Of course they do. Who said it was either/or?
Luscombe has a son with ADHD who was having a very hard time with learning. "We've tried the theater, sports, music, wearing him out, getting him more sleep, meditation, diet, being super-disciplinarian, being not too disciplinarian, art, bribery and shouting," she writes. "But the thing that worked best, that enabled him to learn to read and stopped him from getting into trouble at school, was medicine."
What works for one kid doesn't necessarily work for another, and parents of kids with ADHD deserve more support, not more anxiety.
UPDATE: Tiime has posted a response from Audra McDonald to Luscombe's letter, acknowledging that the needs of each child have to be considered individually, and filling in a little more detail about her parents' decision. They were "struggling with the question of how best to help their struggling, unhappy, hyperactive child," she writes, when they happened to see a troupe of children performing at a dinner theater, and thought "it might be a good outlet for my energy, an oasis for my emotions and possibly a place for me to build some desperately needed confidence."
It turned out to be a "life-changing decision," she writes, and one we can well imagine her strong feelings about. The response is worth reading, and the turning point she describes is one we hear about a lot from adults who have struggled with attention problems. Finding a passion that will be the focus of your life can be transformative, whether medication helps you find it, and succeed at it, or not.View Comments | Add Comment