Adonis Diaries

Posts Tagged ‘attention deficit hyperactivity disorder

 Restless geniuses, a symptom of Attention Deficit Hyperactivity Disorder ADHD? The case of French author Rousseau?
 ADHD and bipolar too: an igniting couple

By the time the philosopher Jean-Jacques Rousseau arrived in Paris, aged 30, hoping to make his name with a new system of musical transcription, he had accomplished nothing of any note.

In the 15 years since fleeing his home city of Geneva – leaving friends, family and country simply to avoid a beating from the engraver to whom he was apprenticed – this spirited young man had bounced between northern Italy, Geneva and southern France, working as a servant, a surveyor, a secretary, a tutor, a music master, even for a short while training as a priest.

Time after time, he missed his big break.

At one point he was taken up by an illustrious family in Turin who, spotting his talent, aimed to develop him as a private diplomatic agent.

It was not to be: Rousseau fell under the spell of a clownish young friend and left to trek on foot back to Geneva, hoping to make a living along the way displaying his Heron’s Fountain, a hydraulic toy he had been given.

Rousseau knew better than anyone what was happening.

In his autobiography, Confessions, the description is clear: ‘To understand the full extent of my delirium at this moment you would have to know how easily my heart is fired by the least thing and with what energy it plunges into imagining the object that attracts it, however worthless this object may sometimes be,’ he writes. ‘A mere nothing will distract me, change me, charm me, fire me, and all else is forgotten. I can think of nothing but the new object of my passion.’

Rousseau calls it his ‘restless temperament… this vast chaos of sentiments… my idiosyncracies … traits of character… peculiar to me’. Today, we would call it Attention Deficit Hyperactivity Disorder (ADHD) or, using earlier terminology, just Attention Deficit Disorder (ADD).

For Ellen Littman, a clinical psychologist who works with the ADHD gifted, the signs are unmistakable. ‘Rousseau is really classic in both of those things: both in all of the parts of ADHD that can get in your way and all the parts that allow you to be brilliantly creative.’

Ned Hallowell, a psychiatrist who has changed the conversation through his best-selling books on ADHD, agrees: ‘It’s a slam-dunk. The characteristics are all there, including the positives: immense creativity, originality, a sense of a bold visionary mind, breaking new ground. And then, the frustrations of riding on the back of your racing brain.’

Aeon shared this link. April 18 at 7:00pm ·

His thought was non-linear, his mood was chaotic and his ideas struck like epiphanies – the qualities that made Rousseau’s life a bumpy road are also what created his restless genius.

How the man who sparked the French Revolution challenges stereotypes about ADHD:

Rousseau’s non-linear style of thought, restless spirit and chaotic mood swings…|By Aeon

Rousseau, who rivals Voltaire as the leading figure of the French Enlightenment, certainly broke new ground. His opera, The Village Soothsayer, performed when he was 38, made him, by his own account, the most sought-after man in Paris.

It so enchanted King Louis XV that he offered Rousseau a lifelong pension (which, to the astonishment of all, he refused).

His political books – chiefly The Social Contract, which argued that only the people, and not the monarch alone, have the right to set the laws in a just state – inspired both the French Revolution and the writers of the US Constitution.

His sentimental novel Julie, which describes a frustrated love triangle set in the foothills of the Alps, was one of the best-selling works of the 18th century.

Could this extraordinary output really have been achieved by someone with a condition which the American Psychiatric Association, in its latest Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), describes as a ‘neurodevelopment disorder’ leading to ‘clinically significant impairment in social, academic or occupational functioning’?

Could these works of genius emerge in the face of a diagnosis that psychologist Russell Barkley, the lead DSM cataloguer, says renders those who have it ‘not as creative or inventive’ as others of their intelligence?

For Littman, currently writing a book on successful people with the condition, the answer is a resounding Yes.

He rattled through charges against Rousseau: frequent masturbation; predilection for flashing genitalia at women; sending all five of his children to a foundlings home within days of their births

‘The wiring of the ADHD brain allows non-linear thinking, which has its advantages and disadvantages,’ Littman explains. ‘But to come up with new ideas, you have to be willing to move away from linear thinking and go outside of the box and look at stimuli and rearrange them in a new way. That is basically how all of our innovators and entrepreneurs work.’

Most philosophers, drawled my university philosophy lecturer, ‘are kind and gentle souls: the kind of person you would bring to tea with your grandmother. Jean-Jacques Rousseau was a notable exception.’

He rattled through the charges against Rousseau guaranteed to hold an undergraduate’s attention: his admissions of frequent masturbation; his youthful predilection for flashing his genitalia at young women from dark alleys; his enduring yearning to be the sub in a sadomasochistic relationship; and, most damning, his sending all five of his children to a foundlings home within days of their births.

It was the most memorable 45 minutes of my four-year degree, but I found myself bristling in Rousseau’s defence. How could you so brusquely bear judgement on the character – even the soul – of a man on the basis of a handful of embarrassing acts?

Years later, when I read Confessions, I experienced a powerful sense of recognition. The experiences Rousseau described were terrifyingly familiar, particularly his social awkwardness and the fact that he often appeared rather dull-witted.

When moved by passion, I can sometimes find the words for what I need to say, but in ordinary conversation I can find nothing, nothing at all,’ he complains.

‘I know no constraint more terrible than that of having to go on conversing, on the spur of the moment and for ever … I do not know if this is because of my mortal aversion to all forms of compulsion; all I know is that the moment I am absolutely obliged to say something, I infallibly utter some stupidity.’

It was only last year, when I was diagnosed with ADHD myself, that I realised that it was this (and not, sadly, creative genius) that we had in common.

I had chanced upon an article on the working habits of philosophers that mentioned Rousseau’s ADHD, citing his complaint of not being able to read dense texts for longer than half an hour without losing focus.

I rushed back to Confessions to discover that the book is shot through with ADHD from start to finish. Take almost any of the diagnostic criteria from DSM-5 and you can find it discussed in detail.

‘How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?’ goes one of the questions in the diagnostic questionnaire developed for clinicians by Barkley.

‘I can hardly think at all when I am still,’ Rousseau writes. ‘My body must move if my mind is to do the same.’

‘How often do you make careless mistakes when you have to work on a boring or difficult project?’ asks the Barkley test.

‘I find the tedium of a long job so distracting that I spend more time scratching out what I have written than copying,’ Rousseau writes of his day job copying music manuscripts.

‘How often do you have difficulty unwinding and relaxing when you have time to yourself?’ Barkley asks.

‘I like, for example, the pleasures of the table… but I can enjoy them only when I am with a friend,’ says Rousseau. ‘It is no good when I am on my own, since then my imagination is so preoccupied with other things and I take no pleasure in eating.’

There is so much detail in Confessions that you immediately recognise a kindred spirit if you have been diagnosed with ADHD yourself.

Rousseau describes carrying a cup-and-ball toy in his pocket to fiddle with in the social situations he found so intolerable.

In later life he eccentrically took up weaving ribbons ‘as the women do’ to provide a similar distraction. He several times embarks on a journey intending to go to one place, only to end up somewhere completely different.

It is always encouraging for those with ADHD to discover talented figures wrestling with the same traits: the inventor Thomas Edison almost certainly merits a diagnosis.

The pop singers, Justin Timberlake, Justin Bieber and Robbie Williams all openly talk about theirs, as do high-octane entrepreneurs such as airline founder David Neeleman and Kinko’s founder, Paul Orfalea.

What makes Rousseau different is the detail with which he wrote about it, nearly 200 years before it got its medical name, turning his penetrating intelligence inward on himself, and analysing his ADHD traits in detail.

‘I feel my heart and I know men,’ he writes in the opening paragraphs of Confessions. ‘I am not made like any that I have seen; I venture to be believed that I was not made like any that exists.’

But he was wrong. Perhaps as many as one in 20 people – those with ADHD – were and are in important respects very much like him.

That someone with a condition associated with difficulty completing tasks could manage to write so many books (several of them rather long) should not be seen as evidence against Rousseau’s retrospective diagnosis. Instead, it reflects just how inadequate the label Attention Deficit Hyperactivity Disorder is.

Rather than being a deficiency in attention, ADHD is actually more an unevenness.

According to Littman, the brains of people with ADHD have an imbalance in the interplay between the neurotransmitters dopamine and norepinophrine, creating a situation in which an experience or activity must be more stimulating in order to draw and hold their attention or enable optimal focus.

This neurotransmitter imbalance also leads to ‘novelty seeking’.

In fact, one variation of the DRD4 gene for dopamine receptors, called the ‘7-repeat allele’, has been associated with some forms of ADHD characterized by wanderlust.

Those with the so-called ‘explorer gene’ appear compelled to move between houses, cities, and countries (as Rousseau certainly did). People with ADHD continually scan their environments and minds to search out the stimulating thoughts and experiences that they need in order to fire up their brains and fully engage with the world.

This brings a higher likelihood of ending up in prison or addicted to drugs. But it also brings a compulsive fixation on what is surprising, dramatic, or controversial.

If, like Rousseau, you work in the arts, literature or philosophy, this is not a bad recipe for success.

When everyone else was composing formal French operas, Rousseau used lively Italian rhythms and mimicked natural patterns of speech for the music in his Village Soothsayer, making it sensationally new. When his fellow French philosophers were using reason to test the ideas and assumptions of 18th-century France, Rousseau went one further and applied it to those of the Enlightenment itself.

While this kind of mind might find it difficult to concentrate on mundane everyday tasks, many people with ADHD find that when something engages them they are deft at entering a state of immersive attention called ‘hyperfocus’.

Hallowell and others have identified hyperfocus with ‘flow’, the near selfless zone of artistic creation described by the Hungarian psychologist Mihaly Csikszentmihalyi.

The reports are backed up by brain scans: when confronted with a boring task, there is less activity than in people without the condition. But when they are hyperfocusing, ADHD brains light up to a visibly greater extent.

This must have happened to Rousseau often. In his Confessions, he describes writing his first opera, The Gallant Muses. ‘I made a tentative start on the first act and was soon overtaken by an ardour that was my first taste of the delights of creative fervour,’ he writes. ‘I composed rapidly, in the space of seven or eight hours, the best part of my first act.’

When I arrived in Vincennes I was in a state of agitation bordering on delirium …My feelings, with incredible rapidity, had soon risen to the same pitch of fervour as my ideas.

Perhaps the most important aspect of ADHD creativity is the way ideas strike like epiphanies, lighting up the brains of people with the condition in a rush of excitement and activity, almost compelling them to try to turn them into reality.

Rousseau describes stumbling upon the title of a prize essay competition in a newspaper while walking in the searing heat to visit his friend Denis Diderot in prison outside Paris. ‘Has the progress of the arts and sciences contributed more to the corruption or purification of morals?’ the question read.

‘The moment I read these words I saw another universe and became another man,’ Rousseau writes. ‘When I arrived in Vincennes I was in a state of agitation bordering on delirium.’

Diderot encouraged him to follow his urges and enter the competition. ‘I did so, and from that moment on I was lost,’ Rousseau continues. ‘My feelings, with incredible rapidity, had soon risen to the same pitch of fervour as my ideas. All my little passions were stifled by my enthusiasm for truth, for liberty, for virtue…’

People with ADHD often experience their new ideas as ‘mini-epiphanies’, but those Rousseau describes seem so powerful and transformative that Littman suspects ADHD, which is more of a cognitive than an emotional condition, is not the whole story.

‘I would say that more than 45 per cent of those who come to my practice also have some kind of bipolar thing going on, and that is my suspicion here,’ she says. ‘When you add bipolar, you’re simply adding the mood piece on top of it. The idea is larger and more exciting but it can also become more all-enveloping, and thwart good judgement to an even greater extent.’

Rousseau’s ADHD – though it wasn’t defined like that back in the day – became apparent to him the moment he left his relatives and family friends, where he was loved and free, for the constraints of his two unfinished apprenticeships.

‘The job seemed to me tedious, intolerable,’ he writes of his months with the clerk at the Geneva law courts. ‘The diligence it demanded of me and the constraints it imposed repelled me to the point where I never entered the clerk’s office without a sense of loathing.’

The clerk berated Rousseau’s uncle for the ‘dullness and stupidity’ of the teenager he had been sent, complaining he had ‘promised him a smart boy but had sent him an ass’.

Rousseau’s second apprenticeship, to an engraver, went still worse, with the boy starting to steal compulsively, read when he should have been working, and engrave pretend medals using his master’s equipment and materials.

It’s a story that will be horribly familiar to today’s parents of ADHD children. The solution Rousseau found for himself – running away from his city and country at the age of 16, and being taken in as a sort of toy-boy by a 29-year-old in France who had been permanently estranged from her husband – probably isn’t one most would wish for.

But it worked for him. His benefactress gave him the freedom he needed and soon he was surrounded by books and music, deeply engaged in a succession of passions – high-level maths, chess, philosophy, literature.

‘I have never managed to learn anything from any of my teachers,’ Rousseau explains in Confessions (making exceptions of his two boyhood tutors).

‘My mind, impatient of any constraint, refuses to subject itself to the discipline of the moment. Even the fear of not learning makes me inattentive. Anxious not to irritate my teacher, I pretend to understand; he continues and I understand nothing. My mind insists on moving at its own pace, and will not submit to anyone else’s.’

Rousseau’s success in catching up on his abandoned education by studying alone does not mean his ADHD did not continue to cause him problems into adulthood.

Readers always remember the bombshell intros: ‘Man is born free and everywhere he is in chains’ from The Social Contract, where he argued that only the people could be sovereign in a just state. Or ‘I am resolved on an undertaking that has no model and will have no imitator’ from Confessions.

But Rousseau couldn’t keep it up. The second part of Confessions, as he admits in the text, is not anywhere near as polished as the first.

And The Social Contract was originally to have been part of a larger, more ambitious work called Political Institutions. Confessions was intended to have a third part, to be completed during his exile in England. Neither got written.

Seated at my table, with my pen in my hand, I have never been able to achieve anything. It is when I am out walking among the rocks and the woods that I write in my head

Rousseau found the drudge work of writing agonising. ‘It is with unbelievable difficulty that my ideas arrange themselves into any sort of order in my head,’ he complains. ‘They circle there obscurely, they ferment to the point where they stir me, fire me, cause my heart to palpitate; and in the midst of all this emotion I see nothing clearly;

I cannot write a word, I must wait. Imperceptibly, the great movement subsides, order succeeds chaos, everything finds its proper place; but slowly, and only after a long and confused agitation.’

The initial part is ‘really unpleasant, and he describes it as unpleasant,’ Littman says. ‘Everyone wants to get to the part where you can hyperfocus. But before you can hyperfocus on something new, you have to allow in those new ideas and let them gel and come together in some amazing new way.’

Rousseau’s remedies might be familiar to those with ADHD. He was a prodigious walker. In his late 20s, he would rise early and roam the foothills of the Alps for several hours before breakfasting and settling down to his books.

‘There is something about walking that animates and activates my ideas,’ he writes. ‘Seated at my table, with my pen in my hand and my paper in front of me, I have never been able to achieve anything. It is when I am out walking among the rocks and the woods, it is at night, sleepless in my bed, that I write in my head.’

Now we know why. Exercise elevates the brain’s levels of dopamine, norepinephrine, and endorphins, making people with ADHD less impulsive, and better able to pay attention to what they are working on.

Rousseau also kept his mind alert by frequently switching between tasks. ‘After following a few pages of an author who must be read with attention, my mind wanders off and becomes lost in the clouds,’ he writes. ‘But if different subjects follow one upon the other, even without a break… I find that, without needing any rest, I can follow all of them more easily.’

This topic-switching is even more dramatic when viewed over a lifetime. He began his Paris career with four or five years as primarily an operatic composer, then spent four or five years as a radical political writer, then an educational theorist, then a sentimental novelist, ending his life with his Confessions.

Rousseau’s decision to follow rather than fight these impulsive seismic switches in direction is, in the opinion of Hallowell, a strategy people with ADHD today should learn from, however crazy it may look. ‘Follow your enthusiasms,’ he advises.

‘Otherwise you’ll just create friction. The ADD mind is like a toddler at a picnic, it goes where curiosity leads it. I’ve got ADD myself, and I’ve written 20 books about all kinds of different topics: whatever interests me.’

Where Rousseau spectacularly failed to manage his ADHD characteristics was in his private life. When reading Confessions, it is easy to forget poor Marie-Thérèse Levasseur, the near-illiterate seamstress with whom he lived for his last 33 years. Rousseau certainly did.

In middle age, he became infatuated with a much younger woman, which sent him into months of swooning fantasy. He then wrote Julie, a love novel so sentimental (and successful) that women across Europe sent him sensuous and devoted letters. At the same time, he had decided (apparently unilaterally) to stop having sex with Thérèse to prevent himself fathering further unwanted children.

Only three or four years after all of this – which he describes in his Confessions with barely a mention of Thérèse – does he notice ‘a growing coolness’ in her.

‘That’s really typical of ADHD, and to a much larger extent bipolar,’ Littman says. ‘That he did not even see the connection between stopping having sex with his wife and her being cranky is a real bipolar story. Everyone I see, I always see their significant other, and they all have that same exact complaint: “This person doesn’t listen to me, and they’re not here for me, and they’re all about themselves.”’

No master could have set a man with Rousseau’s temperament on the path to 60 years patiently engraving watchcases. The question is whether the steady job and family life he craved would have been more in reach today

Thérèse stuck by him to the end. Given her poverty-stricken background and that, in Rousseau’s words, she was ‘limited’ and ‘stupid’, unable to tell the time or recognise numerals, he may have seemed a good catch.

He had less luck hanging on to his friends. In Confessions, he falls out with or otherwise abandons almost everyone he ever gets close to. At the end of his life he harboured a succession of paranoid fantasies that his estranged friends were banding together in a shadowy conspiracy to isolate him; sometimes this involved religious orders such as the Jesuits or Jansenists.

Littman suspects that Rousseau underestimated the degree to which he made enemies by being compulsively provocative, both in person and in print.

‘It was the only way in which he could keep his brain active and stay in the room,’ she argues. ‘To him it doesn’t feel personal or adversarial, but the people who are experiencing him are experiencing attacks, and that’s how some of that persecution stuff starts coming in.’

The tragedy is that Rousseau did not seem to think the enormous literary fame he acquired in his lifetime made up for any of this. In Confessions, he idolises the simple, honest life he left behind when he fled Geneva. ‘Nothing could have been more congenial to my temperament nor more conducive to my happiness than the peaceful and obscure condition of a good artisan,’ he writes, blaming the bullying engraver to whom he had been apprenticed as a teenager for the ‘melancholy tale’, full of ‘miseries’, that was to follow.

‘I could have been a good Christian, a good citizen, a good father, a good friend, a good worker, a good man in all ways,’ he writes.

ADHD individuals can find it hard to take responsibility for their impulsive actions and may project blame onto others,’ Littman states.

And the truth is that no master, however benign, could have set a man with Rousseau’s temperament on the path to 60 years patiently engraving watchcases.

The question is whether the steady job and family life he craved would have been more in reach today. If he had been born in the modern US, or indeed in Switzerland, his ADHD would have been picked up in elementary school, his bipolarity probably somewhat later.

Rather than struggling to understand and manage his unruly mind, he would have been told he had a disorder and given treatment, probably stimulant medication such as methylphenidate (Ritalin) or dexamphetamine (Adderall) and later a mood stabiliser such as lithium, although that can be a difficult combination to manage.

It still would not have been easy, but would a Rousseau today have been better able to enjoy both good relations with family and friends and a fulfilling, creative life?

According to Littman, that normal life would have come at a price. ‘To what extent could you take the edge off it, make him a little more socially acceptable? Would he still have run with his ideas to that extent? Would there have been all these books? I think that ultimately it would have been sad, because I’m not sure that he would have been as driven or accomplished as much.’

Do childhood trauma affects health across a lifetime?

In the mid-’90s, the CDC and Kaiser Permanente discovered an exposure that dramatically increased the risk for 7out of 10 of the leading causes of death in the United States.

In high doses (of  childhood trauma ), it affects brain development, the immune system, hormonal systems, and even the way our DNA is read and transcribed.

Folks who are exposed in very high doses have triple the lifetime risk of heart disease and lung cancer and a 20-year difference in life expectancy.

And yet, doctors today are not trained in routine screening or treatment. Now, the exposure I’m talking about is not a pesticide or a packaging chemical. It’s childhood trauma.

Patsy Z and TEDxSKE shared a link.
Childhood trauma isn’t something you just get over as you grow up.|By Nadine Burke Harris

01:05 Okay. What kind of trauma am I talking about here? I’m not talking about failing a test or losing a basketball game. I am talking about threats that are so severe or pervasive that they literally get under our skin and change our physiology: things like abuse or neglect, or growing up with a parent who struggles with mental illness or substance dependence.  (Attention Deficit Hyperactivity Disorder)

For a long time, I viewed these things in the way I was trained to view them, either as a social problem — refer to social services — or as a mental health problem — refer to mental health services.

And then something happened to make me rethink my entire approach.

When I finished my residency, I wanted to go someplace where I felt really needed, someplace where I could make a difference. So I came to work for California Pacific Medical Center, one of the best private hospitals in Northern California, and together, we opened a clinic in Bayview-Hunters Point, one of the poorest, most underserved neighborhoods in San Francisco.

Prior to that point, there had been only one pediatrician in all of Bayview to serve more than 10,000 children, so we hung a shingle, and we were able to provide top-quality care regardless of ability to pay. It was so cool.

We targeted the typical health disparities: access to care, immunization rates, asthma hospitalization rates, and we hit all of our numbers. We felt very proud of ourselves.

But then I started noticing a disturbing trend. A lot of kids were being referred to me for ADHD, or Attention Deficit Hyperactivity Disorder, but when I actually did a thorough history and physical, what I found was that for most of my patients, I couldn’t make a diagnosis of ADHD.

Most of the kids I was seeing had experienced such severe trauma that it felt like something else was going on. Somehow I was missing something important.

Before I did my residency, I did a master’s degree in public health, and one of the things that they teach you in public health school is that if you’re a doctor and you see 100 kids that all drink from the same well, and 98 of them develop diarrhea, you can go ahead and write that prescription for dose after dose after dose of antibiotics, or you can walk over and say, “What the hell is in this well?”

So I began reading everything that I could get my hands on about how exposure to adversity affects the developing brains and bodies of children.

And then one day, my colleague walked into my office, and he said, “Dr. Burke, have you seen this?” In his hand was a copy of a research study called the Adverse Childhood Experiences Study.

That day changed my clinical practice and ultimately my career.

 The Adverse Childhood Experiences Study is something that everybody needs to know about. It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC, and together, they asked 17,500 adults about their history of exposure to what they called “adverse childhood experiences,” or ACEs.

Those include physical, emotional, or sexual abuse; physical or emotional neglect; parental mental illness, substance dependence, incarceration; parental separation or divorce; or domestic violence.

For every yes, you would get a point on your ACE score. And then what they did was they correlated these ACE scores against health outcomes. What they found was striking.

Two things:

Number one, ACEs are incredibly common. 67%of the population had at least one ACE, and 12.6 percent, one in eight, had four or more ACEs.

The second thing that they found was that there was a dose-response relationship between ACEs and health outcomes: the higher your ACE score, the worse your health outcomes.

For a person with an ACE score of four or more, their relative risk of chronic obstructive pulmonary disease was two and a half times that of someone with an ACE score of zero.

For hepatitis, it was also two and a half times. For depression, it was four and a half times.

For suicide tendency, it was 12 times.

A person with an ACE score of 7 or more had triple the lifetime risk of lung cancer and three and a half times the risk of ischemic heart disease, the number one killer in the United States of America.

This makes sense.

Some people looked at this data and they said, “Come on. You have a rough childhood, you’re more likely to drink and smoke and do all these things that are going to ruin your health. This isn’t science. This is just bad behavior.”

It turns out this is exactly where the science comes in.

We now understand better than we ever have before how exposure to early adversity affects the developing brains and bodies of children.

1. It affects areas like the nucleus accumbens, the pleasure and reward center of the brain that is implicated in substance dependence.

2. It inhibits the prefrontal cortex, which is necessary for impulse control and executive function, a critical area for learning.

3. And on MRI scans, we see measurable differences in the amygdala, the brain’s fear response center.

So there are real neurologic reasons why folks exposed to high doses of adversity are more likely to engage in high-risk behavior, and that’s important to know.

But it turns out that even if you don’t engage in any high-risk behavior, you’re still more likely to develop heart disease or cancer. The reason for this has to do with the hypothalamic–pituitary–adrenal axis, the brain’s and body’s stress response system that governs our fight-or-flight response.

How does it work? Well, imagine you’re walking in the forest and you see a bear. Immediately, your hypothalamus sends a signal to your pituitary, which sends a signal to your adrenal gland that says, “Release stress hormones! Adrenaline! Cortisol!” And so your heart starts to pound, your pupils dilate, your airways open up, and you are ready to either fight that bear or run from the bear.

And that is wonderful if you’re in a forest and there’s a bear. (Laughter) But the problem is what happens when the bear comes home every night, and this system is activated over and over and over again, and it goes from being adaptive, or life-saving, to maladaptive, or health-damaging?

Children are especially sensitive to this repeated stress activation, because their brains and bodies are just developing. High doses of adversity not only affect brain structure and function, they affect the developing immune system, developing hormonal systems, and even the way our DNA is read and transcribed.

For me, this information threw my old training out the window, because when we understand the mechanism of a disease, when we know not only which pathways are disrupted, but how, then as doctors, it is our job to use this science for prevention and treatment. That’s what we do.

So in San Francisco, we created the Center for Youth Wellness to prevent, screen and heal the impacts of ACEs and toxic stress.

We started simply with routine screening of every one of our kids at their regular physical, because I know that :

1. if my patient has an ACE score of 4, she’s two and a half times as likely to develop hepatitis or COPD, she’s four and half times as likely to become depressed, and she’s 12 times as likely to attempt to take her own life as my patient with zero ACEs.

2. I know that when she’s in my exam room.

For our patients who do screen positive, we have a multidisciplinary treatment team that works to reduce the dose of adversity and treat symptoms using best practices, including home visits, care coordination, mental health care, nutrition, holistic interventions, and yes, medication when necessary.

But we also educate parents about the impacts of ACEs and toxic stress the same way you would for covering electrical outlets, or lead poisoning, and we tailor the care of our asthmatics and our diabetics in a way that recognizes that they may need more aggressive treatment, given the changes to their hormonal and immune systems.

So the other thing that happens when you understand this science is that you want to shout it from the rooftops, because this isn’t just an issue for kids in Bayview.

I figured the minute that everybody else heard about this, it would be routine screening, multi-disciplinary treatment teams, and it would be a race to the most effective clinical treatment protocols.

Yeah. That did not happen. And that was a huge learning for me.

What I had thought of as simply best clinical practice I now understand to be a movement.

In the words of Dr. Robert Block, the former President of the American Academy of Pediatrics, Adverse childhood experiences are the single greatest unaddressed public health threat facing our nation today.”

And for a lot of people, that’s a terrifying prospect. The scope and scale of the problem seems so large that it feels overwhelming to think about how we might approach it.

But for me, that’s actually where the hopes lies, because when we have the right framework, when we recognize this to be a public health crisis, then we can begin to use the right tool kit to come up with solutions.

From tobacco to lead poisoning to HIV/AIDS, the United States actually has quite a strong track record with addressing public health problems, but replicating those successes with ACEs and toxic stress is going to take determination and commitment, and when I look at what our nation’s response has been so far, I wonder, why haven’t we taken this more seriously?

13:14 You know, at first I thought that we marginalized the issue because it doesn’t apply to us. That’s an issue for those kids in those neighborhoods. Which is weird, because the data doesn’t bear that out.

The original ACEs study was done in a population that was 70 percent Caucasian, 70 percent college-educated.

But then, the more I talked to folks, I’m beginning to think that maybe I had it completely backwards. If I were to ask how many people in this room grew up with a family member who suffered from mental illness, I bet a few hands would go up.

And then if I were to ask how many folks had a parent who maybe drank too much, or who really believed that if you spare the rod, you spoil the child, I bet a few more hands would go up.

Even in this room, this is an issue that touches many of us, and I am beginning to believe that we marginalize the issue because it does apply to us. Maybe it’s easier to see in other zip codes because we don’t want to look at it. We’d rather be sick.

 Fortunately, scientific advances and, frankly, economic realities make that option less viable every day. The science is clear: Early adversity dramatically affects health across a lifetime.

Today, we are beginning to understand how to interrupt the progression from early adversity to disease and early death, and 30 years from now, the child who has a high ACE score and whose behavioral symptoms go unrecognized, whose asthma management is not connected, and who goes on to develop high blood pressure and early heart disease or cancer will be just as anomalous as a six-month mortality from HIV/AIDS.

People will look at that situation and say, “What the heck happened there?” This is treatable. This is beatable. The single most important thing that we need today is the courage to look this problem in the face and say, this is real and this is all of us. I believe that we are the movement.

Attention deficit hyperactivity disorder…Diagnosis of grieving Human

The news that 11% of school-age children now receive a diagnosis of attention deficit hyperactivity disorder — some 6.4 million — give the chill.

Ted Gup, an author and fellow of the Edmond J. Safra Center for Ethics at Harvard University, published this April 2, 2013

“My son David was one of those who received that diagnosis.

In his case, he was in the first grade.

Indeed, there were psychiatrists who prescribed medication for him even before they met him.

One psychiatrist said he would not even see him until he was medicated.

For a year I refused to fill the prescription at the pharmacy. Finally, I relented. And so David went on Ritalin, then Adderall, and other drugs that were said to be helpful in combating the condition.

In another age, David might have been called “rambunctious.” His battery was a little too large for his body. And so he would leap over the couch, spring to reach the ceiling and show an exuberance for life that came in brilliant microbursts.

As a 21-year-old college senior, he was found on the floor of his room, dead from a fatal mix of alcohol and drugs.

The date was Oct. 18, 2011.

No one made my son take the heroin and alcohol, and yet I cannot help but hold myself and others to account.

I had unknowingly colluded with a system that devalues talking therapy and rushes to medicate, inadvertently sending a message that self-medication, too, is perfectly acceptable.

My son was no angel (though he was to us) and he was known to trade in Adderall, to create a submarket in the drug among his classmates who were themselves all too eager to get their hands on it.

What he did cannot be excused, but it should be understood.

What he did was to create a market that perfectly mirrored the society in which he grew up, a culture where Big Pharma itself prospers from the off-label uses of drugs, often not tested in children and not approved for the many uses to which they are put.

And so a generation of students, raised in an environment that encourages medication, are emulating the professionals by using drugs in the classroom as performance enhancers.

And we wonder why it is that they use drugs with such abandon. As all parents learn, and to their chagrin, our children go to school not only in the classroom but also at home, and the culture they construct for themselves as teenagers and young adults is but a tiny village imitating that to which they were introduced as children.

The issue of permissive drug use and over-diagnosis goes well beyond hyperactivity.

In May, the American Psychiatric Association will publish its D.S.M. 5, the Diagnostic and Statistical Manual of Mental Disorders.

This voluminous book is called the bible of the profession.

Its latest iteration, like those before, is not merely a window on the profession but on the culture it serves, both reflecting and shaping societal norms. (For instance, until the 1970s, it categorized homosexuality as a mental illness.)

One of the new, more controversial provisions expands depression to include some forms of grief. On its face it makes sense.

The grieving often display all the common indicators of depression loss of interest in life, loss of appetite, irregular sleep patterns, low functionality, etc. But as others have observed, those same symptoms are the very hallmarks of grief itself.

Ours is an age in which the airwaves and media are one large drug emporium that claims to fix everything from sleep to sex.

I fear that being human is itself fast becoming a condition. It’s as if we are trying to contain grief, and the absolute pain of a loss like mine.

We have become increasingly disassociated and estranged from the patterns of life and death, uncomfortable with the messiness of our own humanity, aging and, ultimately, mortality.

Challenge and hardship have become pathologized and monetized.

Instead of enhancing our coping skills, we undermine them and seek shortcuts where there are none, eroding the resilience upon which each of us, at some point in our lives, must rely. Diagnosing grief as a part of depression runs the very real risk of delegitimizing that which is most human — the bonds of our love and attachment to one another.

The new entry in the D.S.M. cannot tame grief by giving it a name or a subsection, nor render it less frightening or more manageable.

The D.S.M. would do well to recognize that a broken heart is not a medical condition, and that medication is ill-suited to repair some tears.

Time does not heal all wounds, closure is a fiction, and so too is the notion that God never asks of us more than we can bear.

Enduring the unbearable is sometimes exactly what life asks of us.

But there is a sweetness even to the intensity of this pain I feel. It is the thing that holds me still to my son.

And yes, there is a balm even in the pain. I shall let it go when it is time, without reference to the D.S.M., and without the aid of a pill.

A version of this op-ed appeared in print on April 3, 2013, on page A27 of the New York edition with the headline: Diagnosis: Human.
Note: And billion of people go hungry, suffer malnutrition…and die of curable diseases before the age of 5.




October 2022

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