Attention Deficit/Hyperactivity Disorder

by Phil on March 31, 2009

Attention Deficit/Hyperactivity Disorder is defined as “a persistent pattern of inattention and/or hyperimpulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.” There is a requirement that the problem existed before age seven and that some of the problems are present in at least two settings. There also must be clear evidence that the inappropriate activity interferes with the individual’s social, academic, or occupational functioning. With regards to the actual diagnostic procedure, the APA lists eighteen behavioral indicators, nine under the heading “inattention,” six under “hyperactivity,” and three under “impulsivity.” For the diagnosis to be considered positive, the child must exhibit at least six problems from either the inattention list or the hyperimpulsivity lists.

Prevalence
DSM-IV-TR (2000) cites a prevalence rate of three to five percent for school-aged children, but even the most cursory familiarity with the reality makes it clear that at least in the U.S., the diagnosis is being assigned with increasing frequency with the passing of years. A CDC study from 2003, for instance, reports a 7.5% nationwide prevalence, the highest rate being in Alabama (11%) and the lowest in Colorado (5%).

Diagnostic Criteria
Attention Deficit/Hyperactivity Disorder is one of the most blatantly abused mental disorder diagnoses and is having an extraordinarily destructive effect within our society. To enable the reader to readily appreciate this matter, and facilitate a discussion, the APA’s eighteen criteria for this fictitious illness are set out below:
Inattention
a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b) often has difficulty sustaining attention in tasks or play activities
c) often does not seem to listen when spoken to directly
d) often does not follow through on instructions, and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
e) often has difficulty organizing tasks and activities
f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
h) is often easily distracted by extraneous stimuli
i) is often forgetful in daily activities
Hyperactivity/Impulsivity
a) often fidgets with hands or feet, or squirms in seat
b) often leaves seat in classroom or in other situations in which remaining seated is expected
c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults may be limited to subjective feelings of restlessness)
d) often has difficulty playing or engaging in leisure activities quietly
e) is often “on the go” or often acts as if “driven by a motor”
f) often talks excessively
g) often blurts out answers before questions have been completed
h) often has difficulty awaiting turn
i) often interrupts or intrudes on others (e.g., butts into conversations or games)

Not A Chemical Imbalance
As with most of the DSM diagnoses, no physical damage or etiology is required for a diagnosis to be assigned. Indeed, with regards to ADHD, DSM acknowledges that there “are no lab tests that have been established as diagnostic in the clinical assessment of” this disorder, nor are there any “specific physical features” associated with it. This is particularly noteworthy in that the notion that ADHD is caused by a malfunction in the brain is widely and actively promoted by psychiatrists and other mental health professionals. Parents, teachers, and other professionals, as well as the general public, are being told that the child can’t pay attention or sit still because of “a chemical imbalance” in the brain. The fact, however, is that there is no evidence to support such contentions, and it is just as reasonable, and far more plausible, to conceptualize the matter as plain, old-fashioned misbehavior. Certainly no one could dispute that problems in brain structure and chemistry can lead to problems in behavior, e.g. Hatfield-McCoy (or Von Hippel-Lindau) disease, but it is equally obvious that problems in behavior can and do occur in the absence of neurological problems. To infer neurological problems purely on the evidence of misbehavior is illogical, unwarranted, and even reckless.

Children who display the misbehaviors listed in the DSM criteria are clearly difficult to manage, and present problems in the classroom and possibly other settings. Parents and teachers are frequently all too relieved to refer these children to a psychiatrist and to accept the chemical imbalance explanation. The psychiatrist prescribes a pill, which by and large keeps the worst of the misbehavior under control. Once again, everybody is off the hook, and the psychiatrists and the pharmaceutical companies are making money.

At the risk of stating the obvious, just because a child doesn’t pay attention, does not mean that he can’t learn to pay attention. There is hardly a child in the world who would not prefer to be outside playing, rather than doing homework or sitting in class learning multiplication tables. Previous generations saw this clearly, and our parents and grandparents accepted the task of teaching their children the necessary skill of applying oneself to difficult and boring tasks and paying attention respectfully to authority figures. Today, tragically, if this training has been neglected, and the child reaches the age of six or seven without this skill, the entirely unwarranted assumption is made that he has a brain problem which prevents him from developing appropriately in this area. The far more likely assumption, that his training and discipline have been blatantly neglected in the home, is almost never even considered.

Former Times
Almost all of the so-called diagnostic criteria listed earlier can be conceptualized as disobedience, laziness, defiance, and misbehavior, and the fact that the misbehaviors are not routinely seen as such is an indication of how far standards have been allowed to slip. The notion that a child of normal intelligence who leaves his seat in the classroom and wanders about the room at will, or climbs or talks excessively, or refuses to wait his turn, or interrupts or intrudes on others, is displaying symptoms of a mental disorder, borders on the bizarre. In former generations expectations were higher. Children who had the temerity to engage in such activity were quickly corrected (usually within the first few weeks of starting school) and readily acquired the appropriate level of self-discipline and control for an academic setting. As the child progressed through the successive grades, expectations were raised, and appropriate correction was provided for problems such as careless mistakes, not listening, not following through on instructions, and avoiding difficult tasks. It might be argued that classrooms in former times were over-regulated and regimented, but there certainly were not large numbers of children routinely misbehaving in the ways listed in the DSM criteria. So either some incredible change has occurred in the brain chemistry of our nation’s children across the last generation or two (which seems unlikely), or else the widespread and highly profitable prescription of psychoactive drugs to control this misbehavior is unwarranted. Nevertheless, these prescriptions have become the standard treatment for this so-called mental disorder.

Circular Explanation

The parent bringing a child to a psychiatrist and asking why he is so restless, why can’t he pay attention, etc., is told “because he has a mental disorder, a chemical imbalance in his brain that prevents him from functioning appropriately in these areas.” If the parent were to push the matter and ask “how do you know he has this disorder, this imbalance?” the only possible response is: “because he is so restless and inattentive.” The “explanation” is entirely circular, and in fact explains nothing. The problem behavior that the APA refer to as ADHD is not something a child has, but rather something he does. It is voluntary behavior which can be trained and modified using the normal methods of parental discipline and control. Parents of children who have been assigned this diagnosis, when confronted with this reality, usually protest that they “have tried everything,” but that their child is simply unamenable to any kind of normal training and correction. In fact, however, what is usually the case with parents in this kind of situation is that they have tried little or nothing in the way of creative discipline and correction, and routinely afford very little time and energy to the task of monitoring and directing their children’s activities. They tend to be extremely unconfident in parenting matters, want to “give” their children as much as possible, routinely fail to say “no” and to enforce sanctions even in situations where this is clearly needed. The mental disorder explanation actively promoted by the psychiatrists and pharmaceutical companies eases their consciences, and the drugs control the worst of the misbehavior. Tragically the child is given the expectation that he is damaged and that he can’t acquire the normal developmental skills in these areas without psychoactive drugs. He is also exposed to an array of side effects that sometimes make the original problem look fairly benign.

Although most parents of these children fit the profile outlined above, there are a few who do not want their children on drugs, and who resist the referral to psychiatric services. The Elementary and Secondary Education Reauthorization Bill, debated in the U.S. Senate and House in October 2001, contained provisions whereby schools could refer children to psychiatrists for mental health treatment only with parental permission. On their website at that time, the APA was actively encouraging readers to contact their political representatives and lobby for the deletion of that particular section of the bill. The question naturally arises as to why the APA would want to see these children without their parents’ permission. The psychiatrists say it’s to ensure that the parents’ resistance does not cause the child to miss out on needed services, but their track record in the marketing and lobbying area, and their ever-vigilant search for ways to expand their services, suggest that their agenda may also have had a more self-centered aspect.

Adult ADHD: A Marketing Success
In the context of marketing, it is worth noting that Attention Deficit/Hyperactivity Disorder is no longer considered exclusively a childhood condition. In recent years adults who exhibit these dysfunctional behaviors are being given the ADHD diagnosis by mental health practitioners, and are being encouraged to think of themselves as having a chemical imbalance in their brain. They are also, of course, being prescribed psychoactive drugs. Like their childhood counterparts, these adults are given the false message that their laziness, inconsideration, and lack of attention are perfectly acceptable, and that problems of this sort can be resolved pharmaceutically without any effort or difficulty on their part.

Success Through Effort
The notion of success through effort and perseverance has been fairly fundamental in western culture. Throughout most of our history successive generations have been encouraged to strive towards high standards in various areas, and there has always been the recognition that this is not easy. Habits of work and application have been encouraged formally and informally throughout our history. The ADHD diagnosis is a direct attack on the notion of success through effort and hard work. The fact is that most parents still take their responsibilities seriously, and teach their children to sit still, pay attention, etc.. Attributing the dysfunctional behavior of the children who do not receive this training to a mental disorder essentially belittles the efforts of the parents who have been successful in this area. It is noteworthy that the phrase “has difficulty” is used four times in the ADHD criteria: “often has difficulty sustaining attention…”; “often has difficulty organizing tasks and activities…”; “often has difficulty playing…quietly”; and “often has difficulty awaiting turn.” The assumption being made here is that the child who is misbehaving somehow has more difficulty acquiring the appropriate habits of discipline and self-control than the child who is behaving appropriately. This assumption is entirely unwarranted. The well-behaved child may, in fact, be experiencing enormous difficulty staying on track, but he continues to do so because he has received appropriate training, discipline, correction, etc., from his parents. The chronically misbehaved child, on the other hand, usually has never been exposed to the notion of success through personal effort, and has never received systematic discipline and training in these areas. He does not, in fact, experience any more difficulty waiting his turn than other children. He has simply never been required to make the effort in this or other areas.

ADHD and DisabilityIn 2006, more than half a million children in the US were receiving disability SSI from the Social Security Administration for mental disorders other than retardation. This was 49% of the total number of children receiving benefits for all disabilities. In other words, of all the children receiving disability benefits, 49% were awarded disability status on the basis of mental disorders other than retardation! In 2003, the percentage was 40%. This increase is part of a trend dating back to 1990, when new criteria for establishing childhood disability were put in place. The new criteria focussed on the child’s functioning, where the previous criteria were based more on proven etiology. The SSA website describes these trends in detail and offers this comment:

“A significant portion of the increase in awards involved mental disorders rather than mental retardation, with much attention directed at awards based on attention deficit hyperactivity disorder (ADHD) and various mental disorders manifesting themselves in maladaptive behaviors.”

An interesting sidebar in this area is that the welfare reform legislation passed in 1996 was expected to reduce the number of childhood disability awards. In fact, the number of awards continued to increase after 1997. It is clear both from the figures and from my personal knowledge of the system at the time, that Social Services departments were routinely referring their problem families to the mental health services, where the children could receive a “diagnosis” and be declared disabled. So they came off the welfare roles and went onto the disability roles. It is also my impression from this period that at least some parents were actively coaching their children in the ADHD symptoms to increase the likelihood of a disability determination. If the reader will glance back to the ADHD criteria listed earlier, it will be apparent that coaching of this sort would present no great challenge. What’s particularly interesting here is that a child who was successfully coached and encouraged to display these misbehaviors would really have ADHD. He would not be faking ADHD. The only requirement for a diagnosis is that the child misbehaves in the ways stated. If the child does these things, then he has ADHD, and if the misbehaviors are severe enough, then he will qualify for disability payments. Why he is behaving this way – or how he got to this position – is of no concern. SSI payments vary from state to state, but are usually about $500 per month per child ($640 in California; $476 in Alaska as of 2006.)

The abuse of these so-called diagnoses is a logical outcome of the APA’s spurious taxonomy. The APA’s position is that these misbehaviors are really symptoms of an illness, and that no other evidence is required to establish the diagnosis. Once this notion gains currency, it can be only a matter of time before someone says: “If my child is sick then why can’t he qualify for disability benefits?”

Next Post:  Conduct Disorder and Oppositional Defiant Disorder

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  • Martin

    I really enjoyed this post on the so called belief in ADHD. How anyone can make up a disease and perpetuate it in children, many under the age of ten, is absolutely ridiculous. The worst part is the diagnostic criteria basically matches up the behaviors or most children I have seen including myself. I was hyperactive when I was a kid and many times would act out in school or at the babysitters. When I came into High School a lot of things began to change. I started running but at the same time also began to get less sleep. On average, I would pull 3-5 hours a sleep a night. Over time, I began to realize that many times when I would try to focus on things it would be hindered by what I called a mental block. I had trouble recalling certain things I studied and when I brought that up to my doctor he suggested I had what could be known as ADD. He said that he could set me up with a specialist and start me on Adderall. My parents being old fashioned, did not fall for it, and when I went into college I took a class on sleep. There, I learned how vital sleep was to a person, and in studying the effects of sleep deprivation I was surprised to see how they were similar to how I had felt in high school. We also had a class where we discussed how many children who suffer from Adjustment Sleep Disorder and Limit-setting Sleep Disorders usually have behavior similar to that of kid diagnosed with ADHD. On top of that, college allowed me to get into a better sleep routine and the effects I had in High School now seem long gone.

  • http://behaviorismandmentalhealth.com Phil

    Martin: Thanks for your comment. You touch on a wide range of issues. Firstly, you express a measure of amazement that the APA simply invent these so-called illnesses. I certainly share your sentiment in this area. I am equally amazed that the American public – normally a fairly skeptical group – have bought into the DSM system so wholeheartedly.

    You point out that most children can be seen as meeting the DSM criteria for ADHD. This is one of my major criticisms of the system. The criteria are so elastic that virtually anybody can be embraced.

    Your identification of sleep deprivation as a major issue is profound. In my view, lack of sleep plays a major role in many childhood problems. The APA position is that children behave dysfunctionally because they have mental illnesses. My position is that the reason for dysfunctional behavior is almost always something much more mundane, such as ineffective discipline, or, as you point out, insufficient sleep. Tragically, the APA has already trumped this position, by including lack of sleep as a mental disorder in its own right! And of course, the treatment is: sleeping pills. So the dysfunctional behavior is a mental illness, and the lack of sleep is another mental illness! And business is booming for psychiatrists and pharmaceutical companies.

    I am glad that your parents had the good sense to reject the “official” medical wisdom and that they didn’t send you down the “primrose path” of diagnoses and drugs. The pressure on parents to toe the line in this area is truly enormous. Parents are told that the child has an “illness” and needs “medication.” “If your child had diabetes, wouldn’t you want him to have insulin? Well this is the same kind of thing.” Etc., etc. The vehemence with which these spurious positions are promoted has to be seen to be believed. So your parents did well to resist this.

    Finally, you mention sleep routine. In my view this is a critical component of child-rearing, but one which is often neglected. Children are allowed to stay up very late perhaps to watch a TV show or to finish homework that should have been done earlier, etc. But they still have to get up early to catch the school bus. The results are as you describe.

    Once again, thanks for your comment. I’m glad things are going well for you.

  • guest

    Have you heard much about sensory integration disorder? I was wondering what your views on it might be.

    Also I know adhd is extremely over diagnosed and is not really an
    illness, but I do believe we are all different and some people may have
    WAY more energy than others. That excess energy makes it hard to fit
    into our cookie cutter society. Adhd is just a label that people tend to
    throw around all willy nilly, but I know many people who were given
    that label. The common denominator I have found was ‘energy’ they
    couldn’t get rid of. My husband was even put on riddlin.(I don’t know
    how to spell that). He always described it like he just got way more
    excited than most kids and it would build up. My friend she was
    ‘diagnosed’ she described it as balls of energy throughout her body that
    no matter what she did wouldn’t go away. My son would probably get
    ‘diagnosed’, which is not going to happen. He is about to be six and he
    told me “there’s alot of energy in there, but all the doors are shut.
    All these people had
    good disciple and parents. My friend was also
    a great student. All I am saying is maybe the diagnosis of adhd is a
    little ridiculous and overused, but maybe there are some people who do
    have “something” who never get the real help they need. Again love your
    site and thank you for reading this.

  • Phil_Hickey

    Guest,

    I haven’t come across the term sensory integration disorder.  I imagine there are many bona fide neurological conditions that might impair sensory integration, but I have no first hand information on this.

    You make a good point concerning human “energy,” and I have no doubt that some individuals have more of this quality than others. Whether this is the result of genes, fetal environment, or learning is a more difficult question.  Probably a combination of all three. 

    But – and for me this is the critical issue – each child has to acquire sufficient impulse control to sit in a classroom and learn.
     
    Which brings us to the other very good point you made – the cookie-cutter society.  The purpose of school is to teach children reading, writing, arithmetic, history, etc..  But one of the effects of schooling is that children become conditioned to accept drudgery and routine as an integral aspect of ordinary daily life.

    This is simply a fact.  But it compels us to ask the next question:  is this good or bad?  Some people say it’s dreadful – we should be helping each child to find his/her individual direction.  Others say no – we must prepare children for the tedious drudgery of life!  Interesting stuff.  One could write a book on that topic alone.  In fact, I imagine people have.  I would come down somewhere in the middle.  Yes, we should encourage children to find their areas of passion – but we should also prepare them for the fact that (for most of us at least) there’s a lot of routine slog work in between
    the flashes of brilliance. 

    Back to ADHD.  For our classrooms to work, children have to obey the teacher’s instructions.  They have to pay attention to the teacher, work the lessons as directed, etc.. These are skills, and most children have acquired these skills in rudimentary form by the time they arrive in kindergarten.

    Now your point is that for some children (the high energy individuals) acquiring these skills is more difficult than it is for others.  And in this I agree with you.  But they still have to acquire the skills.  Which basically means that their parents may have to work harder than parents of other children to get them to the same place.

    But this inequality in basic disposition is true of virtually every human ability.  Some
    children have a kind of native ability in music.  Other children have to work very hard just to keep up with them.  Some are “naturally” good at sports, others have to struggle.  Some learn to read without effort.  For others it’s very taxing.  But
    there are basic skills we all have to acquire in order to have some success in
    life.  A surgeon experiencing a burst of high energy can’t just say to the team, “Hey, guys, I’ve gotta dissipate some energy.  Hold everything until I jog a lap around the hospital.”  He has to have the discipline to finish the job – or finish the shift or whatever – then do his jumping jacks.  I realize that this is a little facetious.  The point I am making is that a person who hasn’t developed this kind of discipline could
    never become a surgeon.  And this is the real tragedy of the pills.  In the old days, these “high energy” individuals were trained to sit still, pay attention, complete tasks etc..  And they could grow up to be successful surgeons, engineers, school teachers, etc.  Today they are given pills which make them more manageable, but often they never acquire the basic skills needed for success in any field.

    Once again, thanks for a very interesting comment, and best wishes.

  • Growing

    Phil,
    I agree with your thoughts on these issues – but its a hard subject to bring
    up with frazzled parents who have gone down the medication path for their
    children. I would appreciate your thoughts on predicament of 2 friends of mine;

    One is a mother of a 17 year old girl who was diagnosed with ADHD, autism and a lot
    of other stuff as a child. She has been medicated all the way but life has been
    hell for her mother, who had her own breakdown (and diagnosis), seemingly in
    response to the stress. The girl has been on many meds over the years and
    continues to be often reluctantly. Mother says she performs very well at school when medicated and expects she will go to university. The girl holds leadership positions in
    the school and does not have problems in that environment. At home it’s a
    different story; holes in the walls, mother physically attacked, doors have to
    be built with reinforcement and when she has a violent tantrum, the parents
    lock THEMSELVES IN to whatever room they are in, while havoc is wreaked in the
    rest of the house. (I find it interesting how the meds seem to work their magic
    in the school scenario but not at home). Mother excuses the behaviour as “part of
    her disability” to which I have endeavoured to be an honest friend and
    argue vehemently that even if it is a disability, it is inexcusable and
    unacceptable to beat up on mum (and why doesn’t this symptom of disability
    occur with other people?).

    The second friend is a single, legal guardian of her nephew. He has been
    diagnosed with ADHD and clinicians are currently seeking to define his
    condition more as the meds they have given him are not working. He is also
    classed as “learning delayed” and having poor attention but I have
    watched him focus inordinately on working out how (and succeeding) to unlock an
    “out-of-bounds” door with a jammed lock that even I struggle with. I
    have spent time with him and he is indeed a wild, impulsive and non-stop, if
    affectionate child. This mother also is suffering with the stress of it all.
    She is looking forward to finding the meds that will give her relief but also
    for skills to manage the boy. The “logical consequence” type tools do
    not have much bearing on the child and he has recently started kicking his
    mother when she presses him too hard. She lets a lot of bad behaviours
    – and that all important routine – go, because it becomes so draining
    to attend to them all and she has no strong recourse that will make an impact
    on him. ( I currently have a kitten for whom I have found a jet of water from a
    spray bottle is an excellent learning tool to stop her diving into the fridge
    or jumping on the table, etc. My friend says she needs an equivalent tool for
    her boy!) I have suggested a lock on his bedroom door (would probably need
    locks on windows as well) so that she can leave him there for 10 minutes or so
    to cool off when all reasoning fails or when he gets violent, but
    because of her guardian status she is worried that the Child Welfare
    authorities will remove him from her if they regard that as too harsh (-even too nervous to ask about it for fear of their judgement).

    I would like to be able to give her some advice that could help her avoid the
    path that the first described mother has gone down. But all the research I have
    done on managing these behaviours brings up the soft, reasoning type
    tools that are simply unrealistic with kids who seem to have no
    personal restraint and a willfullness from hell. It seems to me that
    these children are destined to spend their lives chemically restrained (and
    never learning the self discipline so necessary for a happy life) or, if
    they ever stop the meds as adults their inability to manage frustrations is likely to see them restrained in a padded room- which will be far more unpleasant than the 10 or so minute interludes locked in their own bedroom as children, followed by a caring parent explaining consequences to them.

    I agree with you that a really, REALLY strong structure and routine would be very
    helpful, but this can require a huge amount of monitoring energy and dare I say
    a large amount of self discipline (and what I would term “wise love” ) on the part of the parents also. As the two mothers in question have their own psychological issues, I’m not sure that they are particularly strong in these areas. If you have any ideas I could pass on, or any links to examples of effective logical consequences or similar that might be realistic for this sort of child, I’d be grateful.

  • Phil_Hickey

    Growing,

    You are raising the million-dollar question. My general position is that psychiatry’s destructiveness goes way beyond the obvious adverse effects of the drugs. They have created an ethos/culture where virtually every human problem (including childhood misbehavior) is an illness which needs to be “treated” with drugs. When misbehavior is chemically mitigated, the child, as you point out, often doesn’t acquire the discipline and self-control needed for success. Similarly, when people ingest the so-called antidepressant drugs for an extended period, they often lose, sometimes permanently, the ability to experience joy. Also with craziness, when this is simply masked with major tranquilizers, the person never learns to function successfully in society.

    As psychiatric hegemony expands, we are seeing increasing numbers of people in these kinds of predicaments. In my view, this problem will reach truly staggering proportions in the next 10-20 years.

    With regards to the children that you mention, the most plausible explanation for the misbehavior is ineffective parenting, though, I agree, this is sometimes hard for parents to hear. Because I don’t know the children personally, the best I can give you are some general thoughts and ideas.

    With regards to the 17-year-old girl, the fact that she functions fine in school suggest that there is no disability of any kind.

    The likely source of the problem is ordinary childhood temper tantrums that were not properly dealt with, and have now escalated to a disastrous level. There may be other sources, but given the general picture that you’ve presented, that seems the most likely. I’m assuming that there’s no history of anyone perpetrating heinous acts against the child, for which the child is now retaliating?

    For me, the general issue here is that it is not possible to talk infants into behaving appropriately. Infants and young children acquire the habits of appropriate behavior because they discover that this pays off better than misbehavior. The role of the parent is to make sure that they make this discovery within a loving and caring context. Love and respect from the child come later.

    The million dollar question is: what can one do when a child reaches the age of 17 and hasn’t internalized the discipline of a normal 3-year-old in the home context? And sadly, the answer is probably: not much.

    If there are periods of calm, it might be possible to engage the girl’s interest in change, though I imagine this has been tried, without success. It might be worth trying again because ultimately, remediation without the girl’s cooperation is almost impossible.

    It might be possible to empower mother to take a firmer stand, set some appropriate boundaries, goals, etc. But, again, I imagine it’s been tried. It also needs to be acknowledged that any efforts in this area will almost certainly precipitate escalation in the girl as she redoubles her efforts to get her own way through the tried and true methods that she’s always used. Given the level of turmoil at present, any escalation would involve considerable risk.

    Incidentally, mother probably does need some help in the personal empowerment area, regardless of the problem with the child.

    You mention that the parents (plural) lock themselves in the bedroom during the rages. I can understand mother being scared, as she’s being beaten. But is father powerless also?

    Holes in walls – reinforced doors. Are there safety concerns? Is it time to ask social services to help?

    It would probably be helpful for parents to keep a journal in which they log each tantrum: dates, timing, triggers, severity, damage done, context, etc… This might provide some clues as to the significance of the rages. It also might provide some ideas as to the payoff for the child. The obvious payoff, of course, is control – but there may be others.

    Parents might want to consider calling the police – a drastic step – but perhaps overdue. Of course, then matters will go out of their hands. So not a step to be taken lightly.

    Has she always been like this or is it recent? Is she doing drugs? Caught up in some destructive peer-pressure stuff?

    Physical restraint is appropriate with a raging infant, but is problematic with a 17-year-old. The danger of serious injury is very real – for restrainer and restrained.

    It might be helpful if the girl were to talk to a counselor either individually or with her parents, but it is very easy for these kinds of interventions to degenerate into parent-bashing sessions.

    Finally, it is possible (though probably unlikely) that the rages are being triggered by some chemical in the home. I worked with a family once in which a 14-year-old boy was having severe rages at home. His hobby was building model airplanes, and he spent long hours in his room with oil paints, dope, solvents, etc., and no ventilation. Solution: window fan. I think something of this sort is unlikely in this case – but there are a great many chemicals in modern homes (and often little ventilation): carpets, laundry detergents, etc… You mention that she takes “meds” for school – perhaps at home she’s experiencing withdrawal symptoms?

    With regards to the second case – the nephew – you didn’t mention his age – but I’m assuming he’s younger.

    I’ve been retired for a long time, but during my career I worked with a great many families who were in this kind of situation. One of the messages I tried to communicate to parents was that parenting – no matter how much love and caring one brings to it – always involves conflict also. And the great paradox is: that if the child wins, he loses. Parents always understand this in an intellectual way, but some parents seem to be almost incapable of applying any kind of sanctions or discipline They coax, they wheedle, they bribe – and all the while the child rules – then one day the parent blows, and over-disciplines – followed by apologies, guilt, self-recrimination, etc. – and child still rules.

    In my work with these families I tried to empower parents to break this pattern, – to accept that loving their child isn’t the same thing as being their child’s friend, etc. I’m sure you’re familiar with all this.

    One of the things I found most helpful was asking the parent to identify other parents who seemed to “have it together” in this area, and to ask these parents for advice, coaching, mentoring, support, etc… There was always some initial resistance (washing laundry in public) but it was always striking how much the approached parents were happy to cooperate.

    Your description of the situation inevitably raises the question of restraint. This topic always reminds me of Silas Marner putting Effie in the coal-hole and then relenting and tying her to the loom. There is a place for restraints (e.g. playpens, etc.) for small children, but it becomes problematic as they get older. Locking him in the bedroom has merit, but might precipitate an escalation: you did this to me, now I’m going to do this to you…etc… Also, there are safety concerns with locking a child into a room. I’m not saying that she shouldn’t try it – just that it’s complicated and the results are hard to predict.

    The sad fact is that the basic skills and habits that we’re talking about here really need to be instilled at a very early age – certainly by 3 or 4. After that, it’s very difficult.

    All my comments on the 17-year-old girl apply here also, including some help for aunt to develop some sense of empowerment.

    I’m not sure if the child was orphaned, legally removed from parents, or what. But there might be some historical issues there that have some bearing. Counseling might be helpful to provide the child an opportunity to talk about things that are on his mind. But trying to counsel the child to behave and stop hitting his mother is unlikely to achieve anything. The “soft reasoning type of tools” are indeed unrealistic. They can even be counter-productive, in that they can appear to validate the child’s position.

    It’s also important to keep expectations realistic. Even if parents become instantly empowered and skillful in these areas, it takes a lot of sustained effort to see progress. I used to encourage parents to think in hundreds: after 100 functional interventions, they might begin to see some improvement; after 200 they’ll begin to feel some relief; and after 300, things might just be to the low end of normal.

    Of course, the psychiatric solution to all this is to “diagnose” the child with disruptive mood dysregulation disorder, and prescribe a neuroleptic drug. It will certainly subdue the child, but the cost is horrendous.

    Sorry I haven’t been much help – but these are perhaps the most intractable kinds of problems that we deal with.

    Best wishes.

  • Growing

    Many thanks Phil,
    You have made a number of helpful points that I will pass on.

  • Ailleurs

    Dr. Hickey, I have decided to try picking up all that will sink in on this issue of pscyhiatry’s ultimate worth. Surely, as practiced one way of seeing it is as it would apply to the concept of managing mostly unskilled labor detachments, for the purpose of rumor control and creation. In our society, everyone should work, should want to do their best, and should get help if they can’t stay focused on that. Every recovery assessment for psychiatric illness says that, including what either APA uses, I’d bet. Of course, like what Ruth Benedict pointed out years ago in Patterns of Culture that is still undeniably true: the culturally endorsed monomaniacs and megalomaniacs and narcissistic elitists who produce, consume, and overdo their allegiance to how success and conformity matter, and are the successful looking ones, are not those psychiatry will take the diagnostic look at. That oversimplifies her lovely breakdown of rational perspective inherent in the project of psychiatry to her understanding of it, but I am looking to see that text again and more like it.

    Likewise, it all seems so obvious what Academics, mainstream psychological service providers, and psychiatrists could do to amplify their responsiveness to real needs in a more helpful, less problematic way. Psychiatrists, for example one, could admit that their work has got to be as focused on psychological intervention as for psychologists, and admit that the drugs they might offer people feeling bad enough to want to try them, just don’t attack any known disease, emphasizing that they need the person to understand that if they want the drug for trying it. They would have to learn to defer at the limits of their training and workload to better prepared psychological specialists, and to take pride in their wise judgment in this sense as part of what doing psychiatry means–or else. None of this perfectly normal way of conducting yourself in business or as a member of the helping professions remotely resembles what I have seen from all but-certainly, fewer than five six psychiatrists (thinking carefully) out of perhaps the hundred I’ve run into. The same idea applies for the big name ones (and they’re all Dr. Spock) that get our lazy media’s carte blanche most of the time.

    As you can see, we might as well start discussing alien spaceman in our government today than even try to imagine realistic good self-governance, as far as I can see in the filed as it exists. On that note, let me say that my real curiosity just always is why they can’t take their admittedly good in theory-only notions of how to offer kind attention to desperate, outcast, and defeated people and act like reasonable service providers with a little more courtesy and restraint. The sufferers I met in hospitals would all have gone bananas to hear what the doctor thought might be worth trying given their latest ideas of input he would need for helping them. What new, different, or easier to keep up with thing, what could feel better and might be worth trying in their lives. I have never seen anything like this or heard any normal sales pitch like ‘…Now let’s talk about getting you out of here today or as soon as you feel like you can keep this good informative explanation of what kind of help would work for you We also have other services that you may like outside. You are really patient with us and our limited knowledge and somewhat grandiose schemes, Jan, Bill, or Gary.’

    I can’t really get started on imagining reform measures that seem more technical just yet, or more able to put emphasis on what I have mostly seen from these mad doctors, which is just gross ineptitude in so much as carrying out the easy approach afforded them with a fictitious run of disease profiles.

  • Phil_Hickey

    Ailleurs,

    I agree. There is, in my view, no hope of rapprochement with psychiatry as long as they insist that all significant problems of thinking, feeling, and/or behaving are illnesses, best treated by drugs. And they have made it clear by their actions and their words that they have no intention of retreating even one inch from that position.

    Best wishes.

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