A critique of the runaway freight train that psychiatric diagnosis (followed by medication) has become. In this case kids are being put on speed. What is going on?
(A much shorter version of this article appears in Rethinking ADHD: From Brain to Culture, Editors: Sami Timimi and Jonathan Leo, publisthed by Palgrave-MacMillan. )
Abstract
A case is made that the symptoms of ADHD represent the behavior of children who have great difficulty connecting to expectations. In the classroom, they don’t feel part of the group. Unlike the other students, they aren’t doing what the teacher is directing them to do–they are somewhere else. Not just schoolwork; much of what they do seems to their parents as if they have no purpose. As a student, at best they fake it, go through the motions, behave as they are supposed to behave. However they can keep this up for only so long. Trapped, lost, helplessly anonymous, even if they began the morning with good intentions, once boredom and restlessness take hold, all bets are off.
Those who fear the consequences of making a disturbance drift off into daydreams, or look around the classroom for almost anything that might entertain them. They have ADD. Those with more spark, can’t sit still and make a lot of noise. They have ADHD. Depending on how well, or not well, they have been brought up, boys, more often than girls, can be particularly disruptive.
For most (though not all) of these children the explanation is not a biological defect in their brain. Bored trapped children have always acted this way. For as long as children have been forced to go to school, the challenge of how to motivate them so they don’t feel subjugated when they are asked to do something other than what they feel like doing, when the expectations of others is the agenda, has received a lot of attention . Parents soon learn that getting any child motivated to learn, work, and be responsible is often not easy. Enormous outpourings of parental time and energy may be expended trying to inspire, cajole, threaten, lecture, or bribe them, into sticking with what they are supposed to do.How do you get a kid to stop dilly dallying, gain self control, act with consideration for others, and like it or not, work at full capacity?
In the past a child with ADHD behavior was thought of as lazy. Now he or she has an out. “Experts” insist the problem is a brain disease. Judging from the enormous numbers of children diagnosed with this “disease” it means the brain, by far, is broken in far greater proportions than any other organ in the body,
For parents, whatever the emphasis, whether it is discipline, inspiration, or both, the key question is how do you instill an organizing purpose? Only this can give the child a sense of autonomy as he is doing what others expect of him. In the previous generation of parental philosophies, and in many cultures today (for example in many Asian cultures) successfully communicating this sense of purpose is considered a parent’s primary goal, the greatest gift that can be bestowed, the parent’s responsibility. This contrasts with the modern ideal of bestowing quality time, meaning fun, giving a lot of affection, giving a great deal of sugar to make (some would feel, very little) medicine go down. There are a lot of overweight children in modern America, accustomed to getting what they want without a great deal of effort.
The most striking evidence against the argument that ADHD results from a biological brain defect that interferes with their ability to pay attention, is the simple fact that most of these children have no difficulty keeping their attention focused on games. Many can sit for hours with video games that require extraordinary focus. Indeed, some feel their abilities with video games is characteristic. That isn’t to say video games are easy challenges for every child with ADHD. If the game is difficult, and the child lacks the confidence to ignore early frustrations and defeat, they will be on to another activity.
I evaluated a student who told me his mind completely fogged over when he had to read something for school. Without his medicine he could go over a page a hundred times and absorb nothing. “Really?” I asked, “You aren’t able to read anything?” “Well,” he told me, “there is one exception.” He was a fanatical mountain biker. Each month his mountain biking magazine arrived and he devoured that without medicine. Also supportive of this argument-unique charismatic teachers, who make educational material fun, will often succeed with these students.
Parents very rapidly learn that getting a child to move from point A to B is rarely a straight line. In America, every generation has a new philosophy of child rearing that advocates different strategies. Books, newspapers, and magazines are filled with good advice, which is a sure indication there are no simple solutions. Traditionally, it was assumed that the successful development of the capacity to learn how to work begins very early, with good habits inculcated as soon as possible, and later reminders repeated as necessary. Like spinach, cod liver oil, or manners at the table, parents had an agenda that clashed with their children’s will. They were considered failures if they could not win their children’s obedience. Whether Freud was correct that the first battlefield is specifically toilet training, or whether there are other, equally important, confrontations in which the parents’ and the child’s will collide, somewhere between 1½ and 3 conflict is unavoidable.
Shaming the child, inducing a fear of punishment, many of today’s forbidden parental attitudes were once comfortably practiced. They were never proudly proclaimed, but whether acknowledged or not, they were assumed to be necessarry. Spare the rod. Spoil the child. The trick was how to instill proper fear without breaking a child’s spirit. It was not unlike turning a wild bronco into a proud steed. How do you transform an often demanding, easily frustrated little package of misdirected energy into a young gentleman or lady, dedicated to feeling self satisfaction from a job well done, and bringing pride to his or her parents and teachers?
How do you prepare children to keep a cool head when a task is challenging, or competition is keen? How much guilt is useful before it backfires or, is received as ‘blah-blah blah’? Encouragement is essential but it can deteriorate into empty cheerleading, or worse, false happy talk that is thinly disguised nagging.
Keeping a step ahead of children is the first rule for both parents and teachers, but it isn’t always easy. Harnessing a force of nature is never a sure thing. When children dominate they can return to their natural state, a frenetic entropy that can be observed in schoolyards whenever they are playing a game without rules. Two or three generations ago, completely unsentimental views of children’s natural tendencies were commonplace, and acted on. For instance, grammar school students were asked to sit with their hands clasped on the desk straight in front of them. “Attention!!!!” sergeants in the army scream at their young recruits. Good first and second grade teachers usually had a certain firm tone that the students understood to mean “no more fooling around.” Here and there, even in the past, inspiring teachers could go easy on the rules and didn’t need a commanding voice. However, the average teacher policed the classroom for any signs of noise or movement. If needed, a sharp comment from them could snap a student out of his reveries. Evidence for the necessity of discipline was easy to find. In the event that a teacher stepped out of the classroom, chaos erupted like a volcano.
Connecting to a child at home so that he or she “listens” precedes the greater challenges in the classroom. If parents fail to accomplish this at home the problems will only get worse at school. There are numerous ways this can go amuck, particularly in modern times. It was once understood that children need a safe nest when learning to fly. Fathers and mothers used to stay together in loveless marriages, not always, because the family, per se, was sacred, but because divorce was considered too disruptive for the children. That is no longer the case. Unfortunately, marital discord in an intact family can be just as undermining. In some homes the tensions at home are so overpowering that there is little energy left for school’s requirements.
The difficulties are not always on the surface, and the results can be complicated Withdrawn depressed parents, broken by circumstance, can convey a helplessness that plays havoc with a child’s ability to feel mastery and concentration when meeting school’s challenges. Drugs, alcohol, incest, physical abuse a long list of horrendous home environments, can make school requirements irrelevant. Severe chronic physical illnesses in a family member can do the same thing. But the opposite can also occur. Occasionally, school becomes a haven, the one place where the child finds purpose. Often the explanation is a sensitive teacher who has taken a liking to the child and set them on their way to a career of accomplishments.
Poorly functioning day care centres can get a child off to a terrible start, especially if child care workers come and go, or children are moved from one centre to another. Some parents desperately search for the right place, hoping to approximate a stable underpinning that will foster the bonding that will be so crucial when effort is called for. In some families overwhelming pressures to excel can be brought to bear on a student. Repeatedly being a disappointment to one or both parents, can hurt deeply enough so that tuning out can bring relief from the anxiety and pain of trying and failing. On more than one occasion I have seen a situation when one of the two children is the star, and the other, almost by necessity has given up. Some parents are angry at the world, sometimes at teachers and authority figures in particular. If their children develop ADHD, teachers and principals better watch out. They will be blamed for not curing the child’s illness.
The problems can also be less dramatic. Every parent knows the appearance of a distracted child. The moment they start to lecture, one look at the child and they know he, or she, has gone to another place and time. Some loving mothers have great difficulty being forceful enough to get their children in line. It is not unusual to find ADHD children who misbehave with their mothers, ignoring all admonitions. As they get older they may get nasty. They do not behave this way with their father. They wouldn’t dare. It can also go the other way. Fathers are the sugar daddy and the mothers are the successful taskmaster. Some children, particularly in divorce situations (where parental guilt may be enormous) can wrap their parents around their pinkie. We also must mention the “baby of the family.” Standards get less and less with each child until finally the baby is overindulged, expecting to be given rather than asked to perform. The consequences become clear over time
Obviously, there are many ways that children can become a casualty of unsuccessful parenting. ADHD is only one of the by products. Because the impairment is similar regardless of what caused it, we may question whether it is appropriate to paint with broad brush strokes, to label the problem as a single ‘illness’. There are arguments for and against. But one unfortunate result of the illness model as an explanation for these kids is that doctors (or, ‘experts’ as they call themselves) have stepped forward with a simple ‘cure’. No surprises here. If all you have is a hammer every problem becomes a nail. By assigning a diagnosis, and supplying a sciency explanation for the phenomenon, the problem reduces to what doctors do. They give drugs.
We cannot entirely dismiss this approach. A small number of those labelled with ADHD, may have something physically wrong with their brains. An example, at the extreme, is mentally retarded or brain damaged children, who, for obvious reasons, have great difficulties sitting still for hours at a time and staying on task. Historically, neurologists believed that a minimal brain dysfunction was the culprit. They looked for minor neurological defects that might bolster their argument. It is not unreasonable to expect that some children, today labelled ADHD, may have a still undetectable genetic or biological problem, yet don’t have clear-cut neurological symptoms. But, ADHD has become a major social phenomenon, a catch all for most distracted children not paying attention in school, or doing as expected. It has long since expanded beyond neurologists and the idea of ‘minimal brain dysfunction’. Millions upon millions of children are now routinely labelled by their family paediatrician with ADHD. Indeed, by the time a doctor gets involved, a child’s teacher has probably made the diagnosis and knows the cure.
This would all be fine if solid research supported the argument that ADHD is a biological illness. But the evidence is sparse or ridiculously exaggerated. Not that there haven’t been thousands upon thousands of articles seeming to confirm that ADHD is biological. However, the fact is that the cause is still unknown (Surgeon General Mental Health Report; National Institutes of Health). Moreover, for an illness whose aetiology is repeatedly and confidently claimed to be biological, there is not a single biological test that can be used to determine whether or not a child has ADHD. Nothing in the urine, the blood, the spinal fluid, no X rays or CAT scans or MRI. Poppycock flourishes when we need answers to a problem, but don’t have them. It also is a tool of aggressive salesmen. Expert doctors trump the opinions of ordinary physicians who don’t have time to give long and complex thought to all of their patients’ problems.
The medical cure for ADHD patients’ inability to confront drudgery is stimulants, which have a long history of working pretty well for this purpose. Most of the drugs work similarly to cocaine. In the 19th century cocaine was the most popular miracle drug in the world, regularly used and extolled by the likes of President McKinley, Queen Victoria, Pope Leo Xlll, Thomas Edison, Robert Lewis Stevenson, Ibsen , Anatole France and a host of other renowned members of society.1 Sigmund Freud wrote the following about it, “You perceive an increase of self-control and possess more vitality and capacity for work.”2 According to the Sears, Roebuck and Co. Consumers’ Guide (1900), their extraordinary Peruvian Wine of Coca “…sustains and refreshes both the body and brain….It may be taken at any time with perfect safety…it has been effectually proven that in the same space of time more than double the amount of work could be undergone when Peruvian Wine of Coca was used, and positively no fatigue experienced.”
After he read this article, my son, who was then at Yale, told me that one afternoon he was complaining about the work he had before him, two finals and three papers that were due. His schoolmate piped in, “I got some Ritalin, want it?” The daughter of a friend said the same thing was going on at McGill.
They are not alone. Here is a headline from the NY Times:3
“Latest Campus High: Illicit use of Prescription Medication, Experts and Students Say”
“Ritalin makes repetitive, boring tasks like cleaning your room seem fun” said Josh Koenig a 20 year old drama major from NYU
“Katherinen Plyshevsky, 21, a junior from New Milford NJ majoring in marketing at NYU said she used Ritalin obtained from a friend with ADD to get through her midterms “It was actually fun to do the work,” she said.
Freud realized he had made a big mistake advocating the use of cocaine when he witnessed the horrible effects it was having on some of his friends. The downside of this miracle drug was also well described by Robert Lewis Stevenson who wrote Dr. Jekyl and Mr. Hyde during seven days and nights while he was high on cocaine. For many years, Stephen King wrote all of his novels while high on stimulants. He has said that the Kathy Bates character in his ‘Misery’ (a nurse who has literally imprisoned him) represented that habit.
Besides ADHD diagnosed adolescents, and their friends, who sometimes borrow their meds when they have to do chores that they dread, stimulants (”greenies”), according to David Wells (Wells et al, 2003), and more recently Mike Schmidt (2006) have long been part of the professional athletes’ equipment, helping them to step up to the plate with confidence. It changes their state of mind from a passive, reactive, position to a take charge proactive stance. Or as one basketball player put it, “Give me the ball. I can make the shot.” This taking charge, ‘I can do it’ feeling, when approaching tasks, is a key element in most people’s perception of whether they are up to a challenge, and whether it is ‘work’ or pleasurable.
The use of medication should not be dismissed out of hand. From a strictly practical standpoint, stimulants are very often helpful. But the propaganda surrounding their use, generated by ‘experts’, lacks intellectual integrity. Considering the controversial nature of this issue, who pays for experts’ work, should ordinarily disqualify them from claiming to speak objectively. Billions upon billions of dollars are at stake for drug companies, depending on whether or not ADHD is proven to be biological. Are those sufficient motives for their paid experts to, not only lose proper scientific caution, but become aggressive about selling a point of view that profits their sponsors? The former editor of the New England Journal of Medicine (NEJM), Marcia Angell, wrote an editorial entitled. “Is Academic Medicine for Sale?” (Angell, 2000). She followed this with an impassioned book, “The Truth About the Drug Companies: How They Deceive Us and What to Do About It” (Angell, 2004). The editor of the British equivalent of the NEJM, the Lancet wrote in the New York Review of Books, “Journals have devolved into information laundering operations for the pharmaceutical industry” (Horton, 2004).
Despite these criticisms recusing themselves has not been pursued by “experts.” Indeed, the opposite has been the case. They churn out article after article placing pressure on non-experts to follow their “guidelines.” The effect is, unfortunately, that most doctors (including some very nice, well meaning psychiatrists, family doctors and paediatricians) in the United States follow these guidelines unthinkingly, given that they are written by professors who hold prestigious positions in many of the finest universities in the United States. Medical practitioners, like everyone else, are very busy and must go on faith for many of their decisions. We can also not ignore groupthink, which has a way of determining acceptable and unacceptable points of view.
There is also a problem with the DSM IV paradigm.4 DSM IV was meant to define and categorize clusters of symptoms in a clear-cut way. While that has its merits, it has also encouraged an illusion that these clusters are like strept throat, a disease that can be cured with a drug like penicillin. There we understand the cause and the cure is a rational response to it. Despite the public’s general impression, and the assured pronouncements of the experts, we do not possess that kind of understanding in psychiatry in general and ADHD in particular. Modest, tentative formulations would be far more appropriate.
In good part, this chapter is a description of my upbringing (and I imagine many others like mine) and how we were motivated by our parents to forsake our more natural ADHD tendencies and do well in school. It describes a far from perfect environment, but one, nevertheless, that was culturally coherent. Purpose, and how one gets there, was clearly defined, a quality in far shorter supply in our more chaotic modern existence. It is much harder for parents to create this today, lacking a cultural milieu which fosters it. I believe my memories (and speculations!!) may be helpful as a contrast to current very different perspectives about how parents approach their children. One thing is clear. The problems that ADHD imply will not go away with a change in diet, tough love, soft love or any other bit of magic, even the magic offered by those claiming to speak in the name of science. For those primarily interested in the scientific issues, the first part of this article can be skimmed. However, the article’s main point of view is that bad science, science totally lacking science’s clarity about what is known and not known, is worse than sensible, if imprecise, literary speculations and reasoning.
A MEMORY
Fifty-three years ago. I’m ten years old and I am trying to listen to a sermon in the synagogue. The rabbi has a firm, sweet, modulated voice, commanding, wise, a radio voice they used to call it. The problem is I can’t listen. He fades right out. At best I’m good for two or three words, maybe a sentence but after that I’m gone. I’ve been stuck in the same seat for hours. I stayed with the rabbi for the first five minutes but now it is ten minutes after he lost me.
Very lightly my feet begin to tap on the floor. The sound is barely audible. A worshipper across the aisle, a man in his 50’s glares at me. Only silence is allowed in the synagogue. I stop tapping. I sit still. But not long after that I move around in my seat. At most the only sound I am making is from the wool of my jacket rubbing against itself. It doesn’t matter. The man’s anger goes up another notch. I sit absolutely still. But within a minute or two, unconsciously I stretch my fingers and crack one of my knuckles. This brings a look that could kill. He is joined by his wife who views me with utter disgust. They seem to have found a mission for the morning. Educate me in the ways of God. The first communication:
Or else!
It has never occurred to me to find out what “or else” might actually be. My parents wisely left that to my imagination, a far more effective tool than actual punishment. So I take their disapproving stares seriously. I try harder to listen to the rabbi, this time as hard as anyone could try to listen to another person.
I have no better luck. A few sentences and I am gone again. I finger a cuticle on my thumb, rub it, start to pick at it. I nip at a tiny piece of the cuticle, which winds up tearing in the process. It smarts. It oozes cherry red. I suck on my finger, than take it out to see if blood is forming. It isn’t but I suck the finger again, just to be sure. The rabbi’s voice becomes passionate. He may be nearing his finale. Suddenly I can listen without difficulty.
I’m wrong. The rabbi is shameless. He is fond of mini crescendos, playing in the foothills before taking a shot at the lofty heights of the majestic.
Only a false ending is the one thing I cannot put up with. He won’t fool me again. I’m really gone. The person across the aisle glares at me more than he has all morning. What am I doing now? I have been 1000% silent and still. I have bothered no one.
There is no choice. I take on the expression of several of the most pious listeners in my row. Devotion emanates from them and by osmosis soon my expression resembles theirs. He has won. I have joined the others.
But my furtive eyes reveal the truth. They dart around the room.
High up the stained glass windows portray Moses holding the Ten Commandments menacingly above his head. He looks stern, just like the man across the aisle. However, the windows are very beautiful. Moses’ deep blue robe glows lit up by the sun. His eyes have a luminescent intensity that shoots straight out at the congregation. Straight at me. A serpentine black line twists and turns, wiggles its way across the window. On to the next panel, then the next, ‘til the line comes to an end. I find another line and follow it but that soon grows old. A hair is growing out of a mole on the back of the neck of the person in front of me. It’s gross but it’s kind of interesting. Until, it isn’t interesting. It’s just gross. I’m beginning to run out of ways to make the time go faster.
In a prison, rules are a very serious business. In the synagogue they are taken more seriously than any other place I know. Actually it is worse than prison. The silence rule doesn’t apply there. Here it is total. The only exception is when you pray.
No talking unless you are talking to God.
Rule two. You cannot get up and go somewhere else when you feel like it. Like it or not you must remain in your seat, stand when you are told to stand, sit back down when they tell you to be seated. And I have described how when you are seated you can’t move around. Which is torture. I like to move around. So do all my friends.
Being dressed up isn’t helping the cause either. I’m beginning to sweat. My starched collar is too tight around my neck. If I could open my collar that would definitely help. That isn’t allowed. This is God’s house. His rules. The only time I saw an open collar was when Mr. Gordon had a heart attack. The sick are allowed to do all kinds of things that everyone else cannot do. God is fair. He allows this. But I have no excuse, so the collar is to stay buttoned and tight. Rule 3. Rule 4, 5, 6; in addition to no noise, no whining, no questions. Unnumbered rule but the most important one; synagogue is a sacred place so act accordingly.
I whisper to my mother,
“What time is it?”
She puts her fingers to her lips.
I persist.
She mouths the words.
“10 AM.”
“Ten?” I whisper back.
“Shhh”
She turns back to the rabbi.
Two hours ‘til the services will be over. I look around for something else to do but I can’t find anything. I keep looking around. The man in front of me adjusts his skull cap. He’s wearing a watch. 10:02. Ten-o-two! Jeez. Only two minutes have passed.
I saw this movie on TV. The hero is alone in a dungeon. He’s not been outside his cell in twelve years. The only sound he hears is a drop of water every five or ten seconds. At times the hero (maybe it was Errol Flynn) studies each drop as it forms on the ceiling, exuding out of mildewed stones into a fully formed droplet. Drip. The process is repeated… Drip. Everyday the same, the same, the same. I estimate the drips in a minute: eight on average, times 60 minutes, times 24 hours, times 365 days. Over 4 million in a year, around 50 million over 12 years.
Drip.
Camera on a mouse positioned safely against the dungeon’s wall, slowly moving forward, sniffing, looking, listening for danger, eyes shooting pictures in every direction, whiskers acting like feelers as he moves forward. Our hero is delighted to have company. For Errol Flynn almost anything different would be like finding a pot of gold. Two hours is like two years when you’re 10 years old. Anything other than the sermon, or the hairy mole, the stained glass windows, or the wood grain of the seats in front of me. Anything not old would be gold.
It wasn’t always boring at the synagogue. Sometimes it was fun. We’d invent games. For example every time we got to the Shmonah Esrai, a very long prayer which is read silently, we raced each other to see who’d finish first. No cheating. You had to read every word. At one point you have to bow, knees first, then your chest parallels the floor, then down goes your head, then up comes your head back to the standing position. Some of the pious danced their bow, some bowed in a courtly manner. Others just did it business like. We would go so fast that we looked like we were part of a choppy Charlie Chaplin film. We zipped through the prayer ‘til finally, at the end, we were like race horses coming down the stretch. Mark won last time but this time I was going to beat him.
I finished. My head popped up to look around at the others. Yes! I won! They were still at it. It was like finishing an exam early, triumphantly bringing it to the teacher, trying not to look show-offy, but sneaking a look at the other students still nervously scratching out answers with their pencils.
The adults in the congregation also sought victory in the Shmonah Esrai. Lips moving silently, the faithful reverently bent their knees. Down again, up again, they swayed to a familiar rhythm brought from Eastern Europe many years before. These were modern men dressed to the nines, white on white shirts, gold cufflinks and tie-pins, hair in place, Vitalis carefully applied.
They were visiting an earlier time and place. A soft echoing moan, almost a melody could be discerned. They prayed, chanting as their fathers had chanted, and as their grandfathers and their great grandfathers had chanted. Dovened in exactly the same way, the same voice, the same beat, the hum, -in this process the voices of father and grandfather were returned to their sons. The dead visit us in recognizable physical characteristics, the same eyes, the same lips, the same smile- my father and youngest son both lift their right eyebrow in response to a quip. Prayer was the most sacred place to meet. Their children’s imitation reincarnated the departed. Father and son, father and grandson were together again, together in obedience, together in their sway.
It wasn’t just family. It was tribe. Every Shabbis the same ancient words were repeated exactly the same way, with the exact same rhythm, repeated as they had been repeated for five hundred, perhaps a thousand years. The next generation would also do it that way, and the next generation and the next, each part of a chain, doing their part to keep it going, make it continue exactly the same forever.
It was a glimpse of eternity. The inspired were transported. The scattered, fleeting impressions of daily life dissolved. The noise of everyday life can easily engulf the unwary. If only during this prayer, everyday troubles were left behind. It was like the inevitable insight at a funeral when the noisy, aggravating, unjust pursuits of the real world become illusion, placed in perspective as the nonsense they are in the larger scheme of things.
Our temple had been lovingly built. It brought the faithful a chance to visit with God. They reminded themselves of his magnificence. They sang songs of praise. They pleaded with him.
Fortunately for us kids the issue was who could finish the Shmonah Esrai fastest. No cheating; you had to read every word…
There were other pleasures. Some of the prayers had beautiful melodies. They were sung in Hebrew, in His language. I didn’t understand a word. With the exception of my mother no one I knew could speak Hebrew. But we knew how to read it, and how to sing it. Joining with the others, singing out, the rush of a crescendo could bring goose bumps, and with it a needed sense of conviction. It is true. God lives. He rules! That was worth singing about.
And sing we did, in sweet loving unison. Quite to my satisfaction I could operatically nail the high notes. Sometimes, hearing my voice ring out, I felt almost like the cantor himself (though no match for Art Garfunkel, 12 years old and already a legend at the synagogue, the only one of us to be the private student of Cantor Koussevitsky.) Art Garfunkel’s soft, sad, almost heartbreaking voice seemed to come from another realm. I heard an elderly woman whisper to her neighbor that God had given this voice to the world as a gift, the sound of heaven miraculously emerging from a small frail boy. He was to be, if only during a song,a bridge over troubled water.
But the sermons. Any sermon, even the best sermon, within 10 or 15 minutes I usually had had enough. I had no maneuvering room. I was trapped.
It reminded me of the study periods in the auditorium at school. Like assistant principals all over New York City at the time, Mr. Burke was hired muscle. He stood in front of the auditorium making sure we understood that he was going to nail us if we were anything other than serious. We needed to be reminded every day that standing behind our women teachers was power, real power. It gave bite to their bark. Mr. Burke watched us very closely. You didn’t want to go to his office. Stories of his punishments had been repeated many times among the students. One look and you knew they were true. The tight wrinkles across his forehead told you. So did his barely disguised clenched fists. Daring you. Daring you to make trouble.
There were only two choices when his eyes moved in your direction, look like an angel, or stare at the ground. It would never occur to us to wonder about the source of Mr. Burke’s need for revenge. Why was not important; it was a given. The main thing was making sure he didn’t turn his fury on you. Brazenly looking him in the eye, even for a moment, would be asking for it. Certainly doing what heavy weight championship boxers do before the handshake, staring each other down wasn’t an option. Mr. Burke did the staring. You had to sit very still. Whispering to your neighbor was a punishable offense.
Sermons were uncomfortable even without Mr. Burke backing up the rabbi. At school you didn’t have to question if you were bad or good. It didn’t matter. The rules were clear so you knew how to stay out of trouble. But a sermon? You might walk in feeling fine but in those days a skillful rabbi could make you rethink just what kind of person you really are. He could make you wonder about all the ways that you didn’t live up to your ideals. Or he could create new ideals that you hadn’t even thought of before. He could lure you into promising yourself, and more importantly, God, that you will try harder to be better. That’s a dangerous combination. It asks the ultimate question, whether deep down you are really good.
For the first 13 years of my life I believed that at every moment I was watched by God. And not just what I did; he knew my every thought. Telling my children about this, we all agree it was almost surrealistic. An omniscient, omnipotent, omnipresent Being monitoring me (and everyone else). It now seems absolutely wild. Back then it was absolutely true. You never really questioned it. God’s presence was a fact of life. With God as judge you perpetually prepared for your trial. So being good was the only way to go, and when not good, sincere remorse was necessary. Very necessary.
On and on the rabbi’s voice continued. It was like being stuck in a car, crowded together for a long trip. Remember this was fifty years ago, before there were SUVs, everyone comfortable in his own captain’s chair. Before Sony Walkmans or Gameboys, before car air-conditioners, back then going on a trip could be more of a trap than a trip. It would go on forever. “Mom are we there yet?” When was the rabbi going to realize enough was enough?
I wasn’t the only one in this predicament. All the children at synagogue had been ordered to sit still. Mark’s mother had him sitting on his hands hoping that would stop them from flapping around. Or making spit balls. Allen’s hands were held tightly together, out in front of him, where his mother could see them. Mark tried to stare straight ahead. He tried his best to listen. But his eyes were like mine. They darted here and there in search of action, hoping to catch someone else’s eyes also darting around, and the two of you could share a brief moment of rebellion. Which we did. But it was just that split second…
The rest of the time it was prison. Prison is a bleak place. It means you’ve finally lost. Total capitulation, the fight’s over. They get to call all the shots, unless you want to escalate it from being behind bars to being put in shackles. Anything to break the monotony, any stimulation at all might have done the trick. It might restore the balance more to my liking–a joke whispered to my sister, a noogie in the arm of my brother, getting up and walking around, tapping my feet, making a funny face at Mark… Anything!
Now it seems like it would have been easy to regain some form of control. Then I gave no serious thought to mounting a protest. The icy stares of my mother could put a quick end to even a peep, to any and all shenanigans, not to mention the fear that God himself might be offended and then I’d be in real trouble.
We are taught to be good
The ability to sit still and quietly apply oneself for extended times to unwelcome tasks does not come naturally to human beings, especially children. It is a virtue and despite claims to the contrary, virtues do not blossom without careful care. For although there may or may not be excesses of worthiness in us, planted there by our genes, by nature, by the goodness in all living things, long lasting virtues only flourish when they are cultivated.
Our parents get the first crack at building our character, at teaching us what is expected. Who can forget Pinnochio’s long nose as punishment for his lying, or his father’s broken heart when he cut out of school and went to the pleasure palace? The three little pigs and the wolf who blew their house down– what a fine hero the diligent pig was, the one who stopped playing all the time and planned for the future. His neat little brick home saved the day, which was fully acknowledged by the other two lazy piggies. And my friend the choo-choo train that kept saying “I think I can” “I think I can” and just kept climbing and climbing until over the hill he cried out “I thought I could. I thought I could”—I can still hear the happy rhythm of my mother’s voice as she proclaimed the choo-choo’s victory.
But other methods are needed. In the 40’s and 50’s and even the early 60’s parents did not think of themselves as their children’s friends. That awaited adulthood, and maybe even then, a parent was still a parent, the voice of the right way to do things. This was an era before psychobabble. No one cared about making children feel guilty. It was a parent’s job to do exactly that. They had to prepare their little ones for the future. Like an untrained pet dog, children could easily become obnoxious. Innocent play could become annoyingly noisy, and there was the grabbing, and squabbling about who was entitled to what, and whose turn it was, and who hit whom first.
This era was well distanced from Jean Dubuffet, and Jackson Pollack and later the aptly named counter-culture and all those who extolled the natural, the child, letting go, creativity, Zen, spontaneity, as a superior state of consciousness. On the contrary, in Queens, where I grew up, letting go wasn’t a real choice. No one doubted that parents were in charge, or that they had things basically right. They had a mission. They had to civilize us. We were like wild broncos. Our parents had to calm us down, jump on our backs and hold on ‘til we became comfortably ready to follow their directions. Little by little parents tried to teach their wunderkind how to not act like a child, how to forego pleasure and pay attention to what was expected. Preparing their children for “life” was how parents showed their real love, not with loads of candy and gifts and hugs, but by doing what was needed to keep their children on task. Parents did not give a second thought about whether they were cool. They knew they were party poopers. They knew nothing of quality time. The essence of parental identity consisted of doing whatever had to be done, bribing, cajoling, threatening, whatever it took to remind their charges to not stray too far from the true and only path.
Yes, hugs and kisses, fun, and parties, were part of the mix. That mix varied from home to home. But special occasions were just that, occasions. Christmas (Hanukah for us) and your birthday added up to two occasions a year. Reward was never a given, never assumed. Even on Christmas there was no free lunch. Consider these lyrics:
“You better watch out, you better not cryyou better not pout, I’m telling you why.Santa Claus is coming to town…
He’s making a list and checking it twice.He’s gonna find out who’s naughty or nice.Santa Claus is coming to town…He knows if you’ve been bad or good, so be good for goodness sake.”
I don’t know if any child in the entire history of the world actually received coal for Christmas, but it was important for each to believe in this possibility. Unconditional love would have been considered a goofball notion in the 50’s. Instilling virtue was at the very core of child rearing. And education. It was not considered an easy goal to accomplish. Otherwise the lessons would not have been so incessant. No opportunities were wasted at school. Spelling, penmanship, grammar lessons took every opportunity to educate the child “The early bird gets the worm,” “a stitch in time saves nine,”– over and over, encapsulated wisdom was hammered home, until these truths became reflex, until they were on an entirely different plane than a good idea, or a word to the wise, until they became eternal truth. And we had it easy. In the generation before mine, when misbehavior occurred, a student might have to write one of these sayings a hundred times on the blackboard as punishment for his misdeed.
And it did not let up at home, especially dinnertime. Ah, the hearth and home, the family bonding together, communicating, recuperating from their daily stress with mom’s loving meals. Not where I lived. Phrases such as “children should be seen and not heard” were not considered unjust but rather assumed to be necessary weapons to resist anarchy. No curse words, not even “Shut-up.” “Respect,” that was mentioned a lot. I got that lecture whenever there was an edge to my voice. “Please” and “thank-you,” and “may I?” were golden words. Our dinnertimes could get tense, especially with my forever-bad manners. But this was not an occasion to question the basic model of good and evil. Just who is good, and who bad was obvious. Policemen, chaperones, teachers, camp counselors, authorities of any and all varieties- rule makers represented the good. Comportment, demeanor, posture, proper attire, waiting your turn, forming a line, sportsmanship, all were part of the same package, all part of a sensibility that valued discipline as the road to success.
During the 40’s, in my parents’ social set, having your child toilet trained as early as possible was something to brag about. Similarly, scheduled feeding as opposed to demand feeding of infants was the fashion. You didn’t run to comfort an infant every time it cried. Once again character building, a fear of spoiling the child, dominated thinking. By today’s standards it must sound like the Gestapo occupied my home. During the 60’s when I was a wild-eyed rebel in my 20’s, living in Berkeley, I was sure of it. But the truth is, when I was a kid, I never doubted for a moment that my parents wanted anything other than the best for me. And frankly, my home was fairly typical. I played ball, or did whatever I wanted most of the time. There simply were certain times, when I had to obey those in charge, in school, around my parents, and in synagogue. It was assumed that I would do my homework, but that was basically it. The rest of the time I was free to be me.
Of course this was before the revolution, before the 60’s when everything in America got turned upside down. That we could swing in a diametrically opposite direction does not really contradict the original importance of the older stance, for all along there was another way to look at things, a countercurrent opposing declared virtuous intentions. God fearing Christians identified it as the devil, there since the beginning of time whispering temptation in our ear. That was the whole point of the sermons, the whole point of discipline. Christians understood that the war against Satan had to be waged perpetually. Jews were less specific about where evil came from but right and wrong was no less clear. Right was obeying the rules. Wrong was doing whatever you felt like doing even if it meant breaking the rules. Rules were not up for discussion.
Perhaps, our parents only had to let us have it once, clearly demonstrate that when it came to punishment they weren’t fooling around. After that a raised eyebrow was warning enough. Or they had to repeat their message again and again, escalating the consequences until the meaning became clear. Different strokes for different folks. Soap in the mouth, standing in the corner, and, if necessary, the belt; the war to keep children on the righteous path was waged one child at a time. The aim was fear, a fear of the consequences of misbehavior. That is why God gave us religion; to show us the right way. And then remind us as often as needed. The trick was to transform fear, hopefully ennoble it so that it is comfortably experienced as respect.
Freud agreed with this description of character building as war but as an atheist he gave it a different spin. Children’s natural inclinations and parents’ intentions for them are on a collision course. The price paid for locking up the pleasure seeking self isn’t trivial. Casualties are inevitable. He argued that the basic cause of neurotic misery, of all kinds of crippling inhibitions has to do with the things that animals do freely and openly but that human beings must control. Although we rise above our animal bodily drives, our bodily imperatives, our oral, anal, and genital urges have to be regularly satisfied. He thought the drives utilizing these parts of the body were of great importance in stirring up conflicts. He derived their energy from sexuality. I don’t think he was correct about this, but the basic point remains. Animals screw and eat and defecate openly. Society demands that we be civilized, that we learn the right way to satisfy ourselves. Animals know nothing of euphemisms. They do not have to hide their sexual secrets and longings. They do not have to try to be better. They sleep when they want to and without difficulty. They are unaware of anything being asked of them. Like a counter culture mantra, they simply are. They know how to be. In Queens the worst thing in the world was to be like an animal.
My parents, particularly my mother, used the tried and true as her main weapon to keep us focused. Her willingness to sacrifice, her distilled virtue never seemed put on. Centuries of practice had perfected her identity, her embrace, her hold on us. It was hopeless to resist. She inspired us. She reached a deep place that clarified our direction. She was part of an army of millions, subtle and not so subtle Jewish American Sarah Bernhardts, her theatre arguably most effective when she believed in it, when we became her dream. It was done quietly, no nagging, nothng other than praise, but when you did her proud she was enthralled. Disappointing her dreams for my future would be like sticking a dagger in her heart.
The Jewish guilt schtick soon enough became good for a laugh on Broadway, and many a psychoanalytic session was spent trying to rid the soul of the cloying imprisonment of maternal martyrdom and expectations from us that would make it all worthwhile. However, there are many variations. Catholics of my generation told me about the nuns at school smacking their fingers with rulers when they stepped out of line. That kind of crime and punishment created different complications. And there were many other ways of getting the message across. But whatever the particulars of child rearing that each culture used, and there were many, each knew that character building was a never-ending struggle against children’s natural tendencies. Victory against temptation could never be assumed. Learning how to subdue and transform the natural, the beast, our heart of darkness, finding a way to ignore Satan, required effort. To return to Freud’s perspective- murder, stealing, lying, unallowable sexuality, sins of every variety make up the stuff of our entertainment in films, books, theatre, and newspapers. When he was on, Mick Jagger orgiastically celebrated his sympathy for the devil. His fans wanted to go there with him. But, even those who have committed their souls to a staid existence, deep in the night visit this wildness in their dreams. Freud understood the reason. Side by side with virtues our psyche demands a steady supply of vice.
We define particular behaviors as vices and guard against them, precisely because inside each of us we want to act on them. They are a basic part of our makeup. Ninety plus percent of our genes are shared with rats. The neocortex is evolutionarily placed on top of the older ancient parts of the brain. Both parts of the brain function. The psyche will forever be divided, will forever be in conflict with itself. The animal, the natural, the cave man in us, temptation of all kinds of variety, is opposed by our conscience. Each is determined to be victorious. One demands yes, the other elaborates on no. We are asked to be good, to say no. Sometimes we are not good. We prefer freedom, passion rather than virtue. Sometimes it is the only way to feel alive. When that occurs trouble is sure to follow.
There are extreme religious groups like the Amish who allow very little entertainment, whose whole bearing communicates that they distrust any and all loss of control. Raucous laughter, noisiness- they don’t like any kind of kidding around. In modern America most people do not feel that way. They see no difficulty with fun-everything in its time and place. But the Amish are probably closer to my grandparents’, or great grandparents’ point of view. A few generations back, our predecessors did not consider entertainment a regular part of the daily fare. There was too much work to get done. There were no nightly TV or radio shows, no movies. To be sure children were allowed to play, but out of necessity they were also expected to help their parents. Entertainment was a treat for adults as well. There might be pleasures stolen here and there, but generally it was reserved for a weekend night when nothing would be expected the next day. Take a look at old family photographs. There were no grins. Not even on the children’s faces. Take a look at a photograph of Billy the Kid. Even he wanted to be seen as serious. That was once considered cool. Grinning was for idiots.
Unlike today, in this very different world, back then, people with the capacity to entertain were not considered special in the larger scheme. Indeed the pied piper was feared not welcomed for their children. In the old country, proper people considered people in show business little better than prostitutes or n’er do wells. In America parents worried that their son in college might come home with a show girl. Thomas Mann in Confessions of Felix Krull compared artists to con men. Certainly imagination, exaggeration, fiction, possibly a comfort with outright lies may be necessary tools for the aspiring story teller. Wandering minstrels were sweet in the Mikado, barkers at traveling carnivals were champions of the pitch, charmers of ungodly talent. But they were not welcome in the home. All wanderers were suspect. It wasn’t just rich society people. It was how the average person thought. Values were perceived as permanent endowments, rooted by years and years of belonging to a community. Our modern hallowed qualities, originality, creativity, individualism, self expression were the very opposite of desirable. Too much freedom was the surest way to a fool’s paradise, to mind games in the service of chicanery. Tolerance was a desirable virtue. But a relativistic moral perspective was no perspective at all. Everyone in the community knew the rules.
In the old country you knew where a person came from. You knew his parents, his aunts and uncles and grandparents. Any one of them had the right, the duty to protect the family’s name. You were part of a greater whole. Individuals’ behavior reflected not only on themselves but on the rest of their family, perhaps for generations to come. A person’s word was more valuable than nice sounding talk. Art? Artists? Artifice? A person too in love with fiction was not of the real world. He was a dreamer. The ability to have fun was not held against you. It was probably a plus. The ability to bring pleasure to others was certainly a good thing. A lovely singing voice, a capacity to find humor in ordinary happenings could lighten everyone’s load. But a person who wanted too much fun was going to get in trouble. He was the kind of person who would hang out on street corners or at the local pool hall. Parents worried that their children could turn into someone like that. In Freudian language the Pleasure Principle had to mature into the Reality Principle. Yes had to be met with a lot of no’s. Ulysses, James Joyce’s or any other variety was not a hero. He was a lost soul away from his family. “Yes yes yes yes” meant adventures had gotten out of control.
Most of psychiatrists’ work used to consist of making sense of the tangled inhibitions that result from the war between desire and the forbidden. Freud felt neurosis was a terrible price to pay for civilization. He also thought it was a necessary price. There was no choice. Not everything that a fully free man might choose to do is good. Freud’s earliest reputation was earned by his revelations about father-daughter incest. Following the carnage of World War I he wrote Beyond the Pleasure Principle speculating that man may have, not only the stupidity to kill, but an animal instinct to kill. We share it with our biological predecessors. It will never go away.
Times change. It may take a village to raise a child but there are no longer villages. Our jets and jeeps bring us to far off places where the soil under the feet is sacred, where families have remained in that exact place for hundreds, perhaps thousands of years. It is not our soil. Nothing is. Even in our own land we are wanderers. The average American moves twelve times in a lifetime. The kids sent to psychiatrists today are less likely to be tangled up by inhibitions. It’s more often the opposite. A lot of children are sent to psychiatrists because of their lack of inhibitions. They have problems controlling their impulses. It is not unusual for such children, when they get into trouble, to be devoid of fear (as in “Uh-oh wait ‘til my parents find out.”). Nor do they necessarily lose their bluster when a trip to the principal’s office is threatened. Many are not rattled at all. ADHD kids are known for their bravura. Some say they do this to make up for their poor self image. Some say this bravura is exactly the problem. They haven’t learned that in certain situations being reined in is the only way to get where you have to be. Sometimes, if the principal has spoken too harshly to a child, or physically grabbed him to bring him under control, parents are ready to sue.
Following the successful inculcation of 60’s (all you need is love, nature is good) beliefs, generating fear became an unacceptable motivator in the modern educational lexicon. Children were recast as basically good, as lovers of learning when properly inspired. This meant no more Mr. Burkes teaching with their countenance “obey or you will be in deep doo-doo.” Using fear threatens a child’s self esteem. I assume that deep inside, some of the kids now brought to a principal’s office know they are screwing up, and their “self-esteem” isn’t the greatest. But then self-esteem is very different from what it once was. During my childhood (henceforth to be known as “those good old days”) feeling good about yourself was connected to staying out of trouble. And this was connected to the larger picture. Ultimately, you would be endowed with self esteem by being obedient to God’s rules, kind of stick with what you are supposed to do and you’ll be okay. You will be protected by God. You will go to heaven. He will be on your side because he knows you are good, something like that. Your self-esteem rested on faith that God existed and the belief that being on good terms with him guaranteed eventual justice. Or else, after many, many years of effort, many years of staying on the long but true path you will have proven to your parents, or the community that you are a good person. But mostly it was proving it to God. Self esteem was not related to how close you could get to a vision you had of yourself perfected, or, to being cool, or to putting on a great public performance (perhaps emulating a wild rock star who trashes all that is held sacred, or casually ignores it). It was being on the same page as the rules. God was the perfect one. Not us. We lived under the cloud of original sin, guilty until our virtue might prove us innocent.
But man cannot live by bread alone. Something is missing. Buddhist believe the opposite. Nothing is missing. Nirvana awaits those who discover we are complete. The secret is to stop all striving, accept ourselves as we are. But we are not Buddhists. We feel incomplete. I described the faithful in my synagogue during the Shmonah Esrai, their ability to reach beyond the daily nonsense of life. We need inspiration that lifts us out of the ordinary, that brings us beyond rules. We crave transcendence, ideals, hope perhaps, that some day we will become the person we always knew we could be. We will at last be the real us. Yet nonbelievers are also correct. It doesn’t have to be in heaven that this will happen. It doesn’t have to involve God.
For some people it is imagined that a state of perfection, total confidence will be achieved when a perfect partner in love is found. For others, fame or fortune will allow a person to become the person they always wanted to be. There were Marxists who once believed that the problem was societal; capitalism is the devil. The Revolution would bring heaven, bring equality, the peace and contentment that is missing on earth. Some Marxists were willing to die for it. They were willing to kill. There were once young students in the 1930’s whose most trusting loving side, their finest ideals, had to be maintained through faith, through blind loyalty to Stalin long after the slaughter of tens of millions of innocents had become indisputable. There are today Muslims willing to be martyrs.
The need for idealization is especially strong in the young. As they leave the absoluteness of their embedded connection to their family, as they begin to test their freedom, and soon feel lost and alienated by the real world, they search for a replacement for the role that their parents once played. They can’t go home again. They must move forward. Their identity forms (and reforms) around feeling connected to an idealized image. They are very impressed (blown away) by the extraordinary, by moments when they feel they have transcended their ordinariness.
The entertainment industry understands this need to be transported. Love stories used to be an American specialty. Hollywood romances made American movie stars famous all over the world. The story was repeated over and over- lost, unhappy, challenged until true love is found. Then the movie can end as story books promise. They live happily ever after. But that has changed. David Denby recently noted that our movies now seek sensation more than emotion. Apparently rock stars with light shows, flashing plenty of kazam accomplish this level of fulfillment. They create amazement- tens of thousands of people, all rocking to the same beat, holding their Bic lighters high, feeling the oneness, magically connected to everyone else, the sound, the commotion, all merging into an awe inspiring, perhaps drug induced epiphany.
The grandeur of the high mountains, the wizards and flying creatures in Lord of the Rings, the sizzle of fast machines in Star Wars (”may the force be with you”)- we are good at it, good at creating pop deities, good at enrapturing the young. Before 9/11, measured in dollars, America’s biggest export was not cars, or farm products or high tech software and gadgetry. It was entertainment. Michael Jordan and Nikey’s-the French understood just how glamorous we can be. Until Iraq our movie stars were constantly on the covers of French magazines. Their young went to Hollywood not French movies. American TV programs, American jeans, gossip about Madonna, or Brittany or Tom Cruise, Coca Cola and McDonalds were replacing wine and cheese; so much so that their ministers objected to our cultural imperialism. The Ayatollahs also understood just how hypnotic our razzmatazz spell makers, our dream makers could be. And so do we know it. Our kids are buzzing all the time. Dancing to the music. Sometimes with the help of ecstasy. The Ayatollahs felt their children were in danger. Women’s rights, gay rights, sex before and outside of marriage, children turning to drugs to enhance their pleasure. Political freedom is a tempting idea, but for what. Look where it leads. We were the agent of Satan.
The West is actually not that far away in time from the Muslims. Four, five generations ago our image of the extraordinary, our embodiment of perfection, was the same as theirs. It was also spelled G-O-D. Back then people died young, as they still do in the undeveloped world. Ashes to ashes? Rich or poor, nobility or commoner, with death as a regular visitor to the family, when every child had a brother or sister or cousin who died as a child, and they might be next, when adults did not expect to live very long, Christianity and Judaism provided a compelling antidote. It engaged the religious in a story they could relate to. Everyone was invited to participate! It was their very own story, beating death by going to heaven. With that as a motivator, doing the right thing or the wrong thing was a daily challenge, a new chapter to be written in the book. You could save yourself, keep your soul on its pathway to reward.
Or go to hell.
Compared to that drama a story on a movie screen was not all that important. For centuries, the truly great art of the West was religious, cathedrals that breathtakingly seemed to contain the sky within its structure and then point beyond to the heavens, paintings, sculpture, requiems, poetry, psalms, stories that celebrated the magnificence of miracles. Winter was defined by Christmas. Easter announced the spring- the seasons were sanctified through the holiday celebrated. All of the most important events in our lives were met with religious rituals. Birth. Death. Marriage. Rites of passage into adulthood. All were demarcated, defined, given tangible form by religious ceremony. It was how we held on, how we marked progress, how we understood everything that happened.
It was where we found divine guidance. Knowing what was right, knowing what had to be done, the rules were intertwined with the majesty of God. It worked well for reasons I can explain as a psychiatrist. The psychology of discipline, determinedly sticking to an assigned role, is best accomplished when it grows out of the disciple’s belief that he is part of a higher order, when the rules themselves are idealized because the authority making them represents the good or true, the perfect. Then the willingness to obey is not capitulation but confirmation of allegiance to this higher good. And this allegiance provides a feeling of protection. It brings belonging. It delivers strength.
Operating within a context where His will must be done used to give parents backbone. It made nuanced strategies superfluous. Whether to guide children to the right path through “time-outs” or “you’re grounded” or by “showing you mean business” might or might not be effective for a given child, but overall it was less important than the socially agreed upon absoluteness of the moral order. There was no need for child rearing “experts” in magazines, on TV, in newspaper columns, in best selling books to educate parents about the latest and ever changing certainties of “scientific” child rearing (with the implied threat that anything else was child abuse). In the old system what parents did with their children was a natural outgrowth of the larger purpose. Moral purpose shaped and encompassed all behavior. It wasn’t reserved for children.
I clearly remember from my childhood visits of aunts and uncles and discussions that lasted deep into the night. High court was called into session in our living room. Being judgmental was not a negative quality. On the contrary it was the evening’s entertainment. They would sit in judgment of cousins, aunts and uncles, retelling old stories, sometimes going back generations, recounting and debating their sins, sometimes with great eloquence, or brilliance, or compassion that brought a hush to the room as they elaborated the reasons for a misdeed, and whether or not the individual in question could be forgiven. And sometimes, when they disagreed, the arguments would become passionate. It was the breeding ground for future Allen Dershowitzes. This jurisprudence was practiced before 60 Minutes, and 24 Hours and a whole slew of TV shows made exposes of celebrities and high officials into a satisfying catharsis. It was before the latest angle on shame, reality TV offered the humiliation of ordinary folks for the delectation of tens of millions of Americans. The new hunger to connect to real people on TV wasn’t necessary. TV had not taken over quite yet. Real people were regularly part of life and put on trial in living rooms across the land.
I do not want to be deceptive. The moral system enforced during my childhood was not particularly terrific. It, for instance, took me well into adulthood before I was able to figure out why I was so self critical even though I was rarely, if ever, criticized by my parents. I didn’t notice what an outsider might have seen immediately. They got across what they wanted to by criticizing others for qualities they saw in me that were unacceptable. Had my parents directly accused me of these faults I might have argued with them, or made excuses, or felt attacked by them, and maybe thought they weren’t very nice and loving. But I got praise and more praise. By disapproving of behavior done by others they could lay it on thick, leaving me to reflect on it, draw my own conclusions, and claim ownership. Mission accomplished. I would try to eradicate the bad sides of myself. And there were other cute little devices. I was often praised for qualities far beyond my abilities. When I would object it fell on deaf ears. Eventually it became clear that I was to try to reach beyond myself and make their praise a reality. I don’t know if they were aware of their methods, whether they were consciously and cleverly devious, or whether they blindly repeated child-rearing techniques used by their parents and perfected over the centuries. But it worked.
Actually it was amazing. With God vaguely in the background of moral sentiments, even self criticism could take on a quality of nobility. It was somehow gratifying to hold oneself to the highest standards, a pride taken in suffering that an outsider might call kvetching, but which we, in our strange Jewish masochistic way, got moral points for taking on our shoulders. The more suffering, the purer the soul. It wasn’t exactly noblesse oblige. We were after all aspiring middle class, not aristocrats but…
My family was not alone in our complicated ways of teaching values. Jewish guilt was so complicated for most Jews to figure out, placing us in a labyrinth so confusing for those with a bad case of it, that getting rid of irrational guilt was made a high priority for psychiatrists trying to return composure to their Jewish patients. In so far as Jewish intellectuals and psychiatrists influenced more general ideas in America, they may have placed guilt and “being judgmental” in an overly pejorative light among liberal child rearing and educational thinkers. I’m not sure of this but I wouldn’t rule it out. Century after century the driving energy for Judaic practice was obedience to God’s laws. Century after century the most brilliant Jewish minds were devoted to elaborating on the fine points of the Torah, correcting, arguing over earlier interpretations and misinterpretations of God’s will, forever refining moral expectations. The brightest young student might be matched up with the daughter of the wealthiest man so that he might devote his life to learning and arguing Torah. To be free to cultivate the wisdom of Solomon was considered the most blessed existence. This outpouring of intellectual energy at the top of society was proportionate to the central role of morality in every Jew’s life. Being a sinner meant being an outcast. It was the most serious state of unhappiness and alienation. Clearing the conscience was essential to feeling properly connected to your life. Catholics went to confession to unburden themselves. On Yom Kippur Jews fasted and made promises that they would do better.
For those no longer involved with a living God, one who listened and watched, and judged, renewal could no longer come from being more observant. Modern thinkers went for the jugular. Seeking to be free of guilt they attacked most guilt as “neurotic.” The intricate web of family relationships, the silent and complicated, the implicit sticky emotions that cause so much angst and misery were described as symbiotic, enmeshed, judgmental.
Maybe I am making all of this too complicated. Because it seemed simple during my childhood, when God ruled. He was there, everywhere. I don’t mean that the people I knew were religious fanatics, who keep saying things like “God willing”, “with God’s permission”, stuff like that. We were not orthodox Jews, wearing yarmulkes and growing paises. We were pretty typical Americans. We thought about and talked about baseball far more than religion. We were “conservative” Jews somewhere in between the very religious and the even more assimilated “reform” Jews. I thought about God maybe once a month if that much. It was more the spirit of God that was everywhere. My uncles, in saying their prayers at the synagogue were most certainly not hung up on God. They too liked to demonstrate how fast they could doven. I don’t think they thought about the words they were supposedly saying to God. They were flying through the prayers too fast for that. But when they dovened their chests swelled with pride, like they were on the dance floor at a Bar Mitzvah. The joy they felt had something to do with being back in their old days swinging it out with their old gang. And being very good at it. Or maybe they could feel my grandfather, looking down on them from heaven and proud as hell of his boys. They could doven with the best of them. They swayed, they glowed. Well maybe that is God. Which is my point. God was in the very marrow of existence. Not with every breath, not with every single bit of good luck or bad luck, but there. Alive.
Every time I get carried away with God talk I have to emphasize even more strongly that we were far from perfect in our devotion to holy purpose. Superstitions, vanity, hypocrisy, rigidity, all kinds of very common foibles were a regular part of our lofty language. My grandmother would have us children open the refrigerator for her on the Sabbath because turning on the refrigerator light (through a wild stream of logic) was considered work and work is forbidden on the day of rest. My memories of preparations for the High Holy Days also seemed to have little to do with a holy purpose. It had a lot to do with getting a new wardrobe. My mother’s new hat seemed to have special importance. You dressed up not down in God’s house. Making a good showing, making a fashion statement often seemed to be the essence of the High Holy Days. And while I was taught repeatedly that “beauty is only skin deep” I knew my mother counted not only on our perfect behavior at shul, but her handsome husband and great looking children to start the year off right. Not only that, my dad was Ivy League in style, oxford cottons, not shiny shirts like the others at shul. Her father had been in the sweater business. People with a garment center background placed special emphasis on looking smart.
Great energies were directed at keeping our dishes kosher even though after Nanny, my mother’s mother died, our family ate non- kosher foods outside of the house. This was not unusual in my parents’ generation. Dishes themselves became sacred artifacts, strictly, absolutely, 1000% kosher at the very same time no one in the house any longer followed the dietary laws. At 86 my mom sometimes says she no longer believes in God. But if I were today to put a ham on one of her dairy plates she would literally die at that very moment. To a young logical 13 year old like me none of this made sense. But pointing this out could make you quickly unpopular. It was flirting with blasphemy. Except among bohemian intellectuals religion is a very serious subject. It is not something that you are supposed to discuss with a wise guy attitude. People have been willing to die for the flag. And they have been willing, and, among Muslims, still are willing, to die in honor of God. Only among true believers can the passion behind religion be fully appreciated.
Phillip Roth in his collection of stories, Goodbye Columbus describes a young boy standing on the roof of his synagogue threatening to jump after he was threatened by his Hebrew school teacher for asking too many questions. His Hebrew teacher had little patience for a little pip squeak in his class. The 50’s were the happy time of Ike, Coca Cola and Chevy convertibles. But it was not a great time for free thinkers. The 50’s began with Joe McCarthy. It was not a good time to pose challenging questions to anyone with authority. People were afraid. First the depression, than Hitler and World War II and then the communists. There are no atheists in a foxhole, and there weren’t many in the 1950’s. I will not retreat from my argument that the best kind of morale and morality is achieved when authority can be idealized and the individual feels aligned, included, protected by his obedience to the rules and spirit of a transcendent authority, but it must be clearly stated that this is also an accurate description of Hitler’s Youth Movement.
Roth said his final goodbyes to Columbus with Portnoy’s Complaint, the hilarious detailing of his masturbatory rituals. Turning this dirty secret into comedy seemed to break a kind of spell. Amazingly it soon accelerated. I stepped out of this world of my fathers long ago. But so did my parents. Judging from what I can observe, so have most Americans. “Is God Dead?” Time magazine asked in a 1966 cover story. Most Americans would say no, but he certainly changed to a kinder friendlier kind of God-also one less in the center of life. Most American find the Muslims daily preoccupation with God completely foreign. I do (Although not completely. There are fascinating details about the 9/11 terrorists- how they covered pictures of women in swimming suits in their hotel room. But some also used their charge cards to visit pornographic sites. I remember those days when I was religious, at 13 or 14 years old masturbating yet again, then promising God, swearing to God that this would be the last time. Then doing it again. I did not, however, blame the infidels for my temptation.)
I recall those years now as I write this, but as recently as a month or two ago my former life ruled by God would have seemed to have happened so long before, that it is almost as if it were centuries rather than decades ago. It is almost as if it weren’t me but another person who lived within God’s domain. I suppose that means that as much as I might like to sentimentalize my Jewish heritage in bagels and lox and black and white cookies, if I met my grandparents for the first time they would seem peculiar to me. (Although even they did not pray three times a day as prescribed by Jewish law.) I suppose it also means that the Muslims’ view of us as infidels would not seem strange to my grandparents. They would agree that our popular culture has become bizarre, especially the prominence of sexuality, but also the completely looser, less strictly defined ideas of proper religious practice. Indeed I can’t imagine the mind set behind a story my father-in-law, now 84, told me about his bar mitzvah.
This was the big day, the beginning of his identity as an adult, specifically the beginning of a life where he would become morally responsible for his acts, the crucial difference between an adult and a child. It was a time of great pride for his family. He was reading from the Torah, the book supposedly given by God to the Jewish people. For thousands of years Jews have thanked God for this gift. As I noted they have argued over its meaning in the most serious way. What is it that God meant by this passage? What did he mean by that? What does God want us to do? Loving prayers are sung as the ark is opened and the Torah, dressed like a king in satin and silk, is brought before the congregation. Reverent prayers are sung by the congregation to God as the Torah is once again dressed and returned to its holy spot at the center of the altar. As children we were told that every vowel, every syllable, of this very long scroll must be written by hand. One mistake and the inscriber must restart from the beginning. We were told that dropping the Torah meant years of repentance. This was my father-in-law’s big day standing before the Torah.
Instead of kissing his tallis and then touching the Torah with it, my father-in-law bent over, put his lips on the Torah, and gave it a smacker. Without a moments hesitation the rabbi slapped him on his head. It wasn’t a tap either. He can still feel that blow. Did getting hit by the Rabbi in front of everyone on his Bar Mitzvah day ruin his life? Did it poison his disposition? I don’t think so. You should see him work the crowd at his country club. To this day his nickname remains Sunny. But the story is even more amazing when it is contrasted to the synagogue I attended in the 80’s in Connecticut (after many years away). Kids, dressed in jeans were running up and down the aisles as if they were at a playground. And no one minded. Since then a new rabbi has been appointed. He is less of a hippy. In fact he is straight as an arrow. But his greatest virtue seems to be his incredible ability to make the kids feel at home. He is a terrific hockey player.
It isn’t just our rabbi. I have been to community meetings in Connecticut where ministers were dressed in shorts. They too were regular guys.
I like to think of myself not as a sinner but as a good person. For a while, as I moved out of my youth, defining myself politically was enormously important. But then political correctness became a joke. And as all of that has faded I see how those abstract concepts, substituted for the old system. The high moral discussions of my parents’ evenings (or if you prefer gossip about cousins) were replaced by debates about women’s rights, or gay rights, the environment, or political solutions to the problems of African Americans. So much effort was expended to refine our beliefs, prove we were pure of heart. I have to admit these ideals were also a way to prove that we were better, that people with the wrong political beliefs were bad people. It wasn’t just the victory of good over evil that I sought, or the political debates that I wanted to win with my brainy arguments. Somehow abstract high end ideals filled in the blanks of the demands elaborated by my conscience. Looking back at those years I have come to appreciate how much passionate ideals can become a cheap and easy way to feel superior to the rules, a way to get away with misbehavior, a way my generation used to get out of an awful lot of do’s and don’ts.
When I am very hard on myself, I have to admit my idea of a good life ultimately has been reduced to having an enjoyable life. Perhaps I am being too harsh. I want to feel superior to our “have a nice day” culture and, in truth I have taught my kids that there is more to life than pleasure. But still, often times I have to admit that “meaning” in my godless life can be reduced to a “you only live once” mentality. I greatly value a fine meal and a terrific vacation with my family, a house with a view, a good movie or show or book, or music or art. I like pursuing pleasure. And I am not displeased that America has become more like France and less like England. We now treasure and indulge our senses. Not just sex. We like great food, dance, music. But then England has become more like France and less like England. I don’t know if, like the French, the English now sneak into lines, rather than remain masters of the queue, or value deviousness while mouthing excitingly high sounding philosophy. I just know that while I have always admired the English I am intoxicated by the possibilities of Paris. For most of my life, if I had to be stranded on a desert island, I would prefer a French chick to a sensible English young lady.
I am confessing this because I don’t want my explanations for ADHD (eventually the goal of this piece) to be dismissed as self-righteousness. Perhaps at 60, I have become a fuddy-duddy- the kind of old fashioned, out-of-it kind of person that in my 20’s I swore I would never become. Perhaps, as my libido has quieted, I would prefer an English lady. Perhaps not. Be that as it may, I will argue that much of ADHD can be explained by the historically unprecedented ability of so many members of our society to gear their lives towards the fulfillment of pleasure, by a deterioration in our moral fiber, by a pervasive need for immediate gratification, immediate sensation, less talk more action, bam, bam, bam MTV. Our editors despise words formulated in the passive tense, despise characters who yield their will power, who settle into routines in which they are absorbed into a conventional sensibility. Unlike the religious people of my youth who, above all, valued convention, who knew that the way to nirvana was dissolving “me” in the larger permanence of the group’s rituals, in contemporary culture, rituals represent ossification. They “say” nothing. Forever is de facto not a good thing. It is not American. It is against progress. We want characters that stand out, that want change and bring change, that make a statement, that are unique. America insists on verbs, insists that we keep things moving. Our news is delivered in sound bites. Our reporters went wild when it briefly appeared that the Iraq war might last more than a few weeks. We don’t like talking heads at the movies. Parisians look down their nose at yesterday’s fashions. We discard old ideas as old fashioned. We need to get on with it quickly, smartly zip along our charged up path ahead. That said, despite my belief that ADHD has very much to do with these issues, the evidence, not my thesis, must determine what ADHD is and how it should be treated. So let us get to work.
Sin and ADHD
First a few interesting statistics about adults diagnosed with Attention Defict Hyperactivtiy Disorder(ADHD) and their sense of moral responsibility. They have many more lifetime sexual partners (18.6 vs 6.5) than the average person, and tend to stay with each partner for less time than other adults do. They are less likely to employ contraception and have a far greater risk of teen pregnancy (38% vs 4%). Fifty-four percent of adults with ADHD do not have custody of their offspring. Adults with ADHD are also at a higher risk of contracting sexually transmitted diseases (16% vs 4%).
There are striking differences between those with ADHD and the general population with regard to driving an automobile. Adults with ADHD were reported as using fewer safe driving habits, being more likely to drive before licensing, and having more accidents (and more faults) than other drivers (2 to 3 for ADHD adults vs 0 to 2 in the control group). There is a far higher percentage of ADHD adults with 2 or more crashes than in a control group (40% vs 6%). The same is true for 3 or more crashes (26% vs 9%). They also had more citations for speeding (4 to 5 vs 1 to 2), worse accidents ($4200 to $5000 in damage vs $1600 to $2200), and a greater percentage of crashes with injuries (60% vs 17%). Drivers with ADHD had more suspensions/revocations (mean 2.2 vs 0.7) and license suspensions (22% to 24% vs 4% to 5%).
A Utah survey done by a Dr. Paul Wender found approximately 24 % of male prison inmates to have ADD/ADHD with classical clinical findings. Other studies and his own experience led Dr. T. Dwaine McCallon, M.D. Asst. Chief Medical Officer, Colorado Dept. of Corrections to believe that “upwards of 40% of the residents in a medium security prison have the findings along the Tourette/ADD spectrum. According to him, “if you separate out the nonviolent, impulsive criminals (whom I term my basic, charming and even lovable car thieves and traffic offenders), the percentage is much greater…”
The medical view of kids with ADHD is that it is a biological illness unrelated to child rearing. ADHD kids are born with it. Parents haven’t done anything wrong. They are innocent of all charges that would have been leveled against them in the past for raising wild kids. By law we have banned religion in our schools. And we have marginalized religious preoccupations in our understanding of behavior. It has become improper for professionals to classify what is going on with a kid in moral terms. When a kid is in trouble, teachers do not think of contacting the family’s clergyman. They think doctor.
I appreciate the esteem granted to my profession. The ideal doctor is trained to be dispassionate, to use a scientific point of view to get at the truth. The rules of science, the discipline of science, allow us to arrive at cold hard facts whatever the implications. In our modern liberal concept of reality we will settle for nothing less. Doctors and all professionals must leave moral spin out of formulations about cause and effect. We pay good money to reap the benefit of this way of looking at things.
But while religion has no place in classifying an illness what if we are not talking about an illness? That is the core of the argument. We get so used to approaching issues in a modern way that it never occurs to us to step back and question the assumptions behind our viewpoints. Let us start with this. Who made doctors experts on child rearing? It is a relatively new concept. Doctors were once assigned the role of treating illnesses not provide a perspective about misbehaving children. When did we make them all knowing about child rearing? Was Dr. Spock’s book that good? Okay Freud talked about the importance of childhood experiences but few people accept Freud today. I suppose the issue to be settled is just how far we have come with our scientific knowledge about how the brain works. If we can scientifically explain ADHD than the discussion is over and doctors should replace moral pedagogues as the best way to approach wild kids. But if we don’t have the scientific knowledge, then what?
Let me say it again. I am not an anti science, anti technology person who wants “holistic” or alternative care for patients because science is inherently anti human. Quite the opposite, I would be thrilled if the treatment of psychiatric patients could be reduced to the application of well researched and confirmed scientific findings, which in turn would lead to logical and well thought out treatment. I would relish writing prescriptions that are as effective, as say, antibiotics are for strept throat. When scientific methods lead to the understanding of a phenomenon there is nothing like it in getting the job done. Antibiotics, which we take so for granted, are truly miraculous, as is the polio vaccine, cholesterol reducing agents, and many other life saving medicines. We rightly appreciate firemen as heroes because they put their own life on the line. But if we want to talk about heroes who have literally saved ten, perhaps hundreds of millions of lives, we cannot ignore scientists as our true miracle workers. Indeed all reported miracles performed on earth by Jehovah or Jesus pale when compared to what our scientists have been able to accomplish. Never mind walking on water. They have allowed human beings to fly from here to Texas. They have flied some of us to the moon. I don’t want to go too far with the obvious, but as the religious some times say as they view a mountain, or a rainbow, or the oceans “this is God’s work,” we should take a look at the miracles performed by human beings. Before the 20th century there were no refrigerators, no cherries in the winter, no steel and glass skyscrapers, no computers, no paved roads and cars, (and critics would counter traffic jams.) I’ll end it right here. Good or bad, science is clearly the most effective way to understand reality and effect change.
But making decisions about child rearing on the basis of “science” is not the same thing as scientific investigation. Preference for science in our approach to our children is a value decision, particularly when, as we will see, the prestige of scientific methods is often used to justify attitudes that stretch far beyond what is scientifically known. What is known and not known will surprise the reader. He or she may rightly question the way I will organize my material about ADHD in the second part of this article. Fair enough; I have a definite point to make. But the facts are the facts.
First let us turn our attention to the decisions made by recognized authorities in the field of ADHD, those who have defined this illness in DSM IV, the American Psychiatric Association’s diagnostic manual. Attention Deficit/Hyperactivity Disorder is listed in the same category as Conduct Disorder, Oppositional-Defiant Disorder, and Disruptive Behavior Disorder. It isn’t just the APA. The validity of considering ADHD an illness, its scientific credentials as an illness is supported by every major medical organization, not to mention the National Institute of Mental Health, the Center for Disease Control, the National Center on Birth Defects and Developmental Disabilities, US Department of Health and Human Services, Agency for Health Care Policy and Research and I can name a dozen other organizations.
Let it also be stated at the outset one point of agreement. Many kids demonstrate the qualities that earn them an ADHD label. The question at issue is what perspective is most useful in understanding what is wrong with them. What follows, word for word, is the universally agreed upon basis for making the diagnosis. Carefully reading through the details of this classification will probably clarify, more than any arguments I could make, just how much ADHD is, or is not, an “illness”.
Attention Deficit/Hyperactivity Disorder
A. Either 1 or 2:
1. Six or more of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:
- Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
- Often has difficulty sustaining attention in tasks or play activities
- Often does not seem to listen when spoken to directly
- 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) (although Dr. Adrian Sandler from the University of North Carolina claims the “comorbidity” with oppositional defiant disorder or conduct disorder can be as high as 72%)
- Often has difficulty organizing tasks and activities
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as homework)
- Often loses things necessary for tasks or activities (toys, school assignments, pencils, books, or tools)
- Is often easily distracted by extraneous stimuli
- Is often forgetful in daily activities
2. Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:
- Hyperactivity
- Often fidgets with hands or feet or squirms in seat
- Often leaves seat in classroom or in other situations in which remaining seated is expected
- 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)
- Often has difficulty playing or engaging in leisure activities quietly
- Is often “on the go” or often acts as if “driven by a motor”
- Often talks excessively
- Impulsivity
- Often blurts out answers before questions have been completed
- Often has difficulty awaiting turn
- Often interrupts or intrudes on others (such as butting into conversations or games)
B. Some hyperactive, impulsive, or inattentive symptoms that caused impairment were present before age 7 years
C. Some impairment from the symptoms is present in two or more settings (such as in school or work and at home)
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning
E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or another psychotic disorder and are not better accounted for by another mental disorder (such as a mood, anxiety, dissociative, or personality disorder)
ADHD, predominantly inattentive type Meets inattention criteria (section Al) for the past 6 months
ADHD, predominantly hyperactive-impulsive typeMeets hyperactive-impulsive criteria (section A2) for the past 6 months
ADHD, combined typeMeets criteria for section Al and section A2 for the past 6 months
I hope it is clear simply from reading the DSM IV defining characteristics of ADHD that it doesn’t resemble a description that you would expect to find if it were the result of scientific understanding. The defining characteristics read more like a committee had debated and finally agreed upon what would qualify as ADHD and what would not. There is a reason for this. We do not know what causes ADHD and how the various symptoms come into being. This is not unusual. All of the criteria for every DSM IV disorder were arrived at by committees who debated how a given “disorder” should be defined, not by an understanding of the causes of the disorders. Nor is it the work of clinicians who have a feel for the condition and trust that to guide them part of the way. Pointedly, that is not what was wanted. The makers of DSM IV had the mindset of lawyers. Carefully chosen words and carefully constructed categories were the goal.
This approach to mental illnesses is not ridiculous. There are legitimate reasons for it. Before DSM III psychiatric diagnoses were loosely defined. Except for extremely serious diseases like schizophrenia or manic depression diagnosis per se was not considered very important. DSM II fit the needs of psychotherapy, then the preferred treatment of most psychiatrists. Most therapists believed that forces operating underneath the surface of consciousness were far more important than particular symptoms that might be showing up at a given moment. Anxiety, overwhelming sadness, irrational repetitive patterns of behavior were usually the result of underlying psychodynamics. Emotional conflicts tied an individual in knots. Secret desires, still boiling hatreds, painful experiences in the past, in the present, and feared in the future, were the source of disturbance.
Our consciousness is where we live all the time. Nothing is more familiar to us. But when psychiatric problems emerge that changes. We experience emotions and thoughts that are foreign and frightening. Part of the reason is that we routinely defend ourselves against emotional pain by getting rid of it as quickly as possible. These defenses are often effective. But when our defenses don’t succeed the very methods used to erase the pain also make the underlying problems invisible to the sufferer. So we may be left with symptoms or emotions without an inkling of what is behind them.
The mission of most psychotherapies has been to get at what is really going on. Many psychotherapists agreed with, or took off from Freud’s basic idea that an individual’s story, where a person has been, where he is, where he is going, is far more important than a label that might be attached to his symptoms. Psychiatrists were no different than other doctors in their approach. Figuring out how someone developed their problems was the best way to attack getting rid of them. Until DSM III most psychiatrists didn’t think focusing on symptoms per se would especially get you there.
Not that there weren’t problems with looking at people in terms of their underlying issues. It wasn’t always easy to fix problems that needed to be fixed. You could be absolutely right on about why an individual was suffering and still might not be able to fix it. More to the point, understanding could only come one individual at a time, and even then, case studies depended less on hard proof than persuasive arguments. And some of the premises of psychoanalysis and other theories stressing childhood origins for adult problems were very challengeable. While it is clear that the child is the father of the man in very important ways, there are many aspects of behavior that are not necessarily best appreciated in a childhood context. It is a very useful tool, but in many cases it will only get you so far. Other perspectives are needed.
Besides the times were changing. The counter culture toppled the authority of everyone once held in high esteem-not just cops, soldiers, college presidents, but two consecutive presidents of the United States, Lyndon Johnson and Richard Nixon. If during this period Time magazine could ask on its cover “Is God dead?” you can imagine what critics thought of Sigmund Freud. He had somehow evolved from an iconoclast taking on the beliefs of his day, to a not to be questioned establishment figure, the worst position to be in. Freud was especially vulnerable because of a few politically incorrect quotes from his work regarding female psychology which at the time, and perhaps still today, would get him dismissed to nowhere land in a heartbeat. But even before it was decided that his ideas about women were ridiculous, he had never been acceptable to academic psychologists who insisted on statistically generated analysis to make up their minds about what constituted an explanation. Freud’s leaps of logic, his grand generalizations, his brilliant and radical conclusions were a completely different way of knowing things. A researcher might accept that difference and see no contradiction working with laboratory rats at his job and undergoing psychoanalysis to discover secrets about his own psychology. But when it came to science he expected knowledge to be measurable, small packets of discovery firmly based on the facts. Scientists like problems that can be reduced to hard data, where the significance of a finding can be objectively measured. Scientific knowledge is gained one step at a time. From this perspective Freud was not a scientist.
There was another factor. During the 60’s and 70’s psychotherapy had gained a new foothold in popular culture. Many more people were seeing psychotherapists. And there were more therapists than ever before, some with excellent training, but others with little training beyond catchy slogans for change. Much of the rhetoric of the new practitioners had nothing to do with Freud. Some of them tended to use touchy feely psychobabble.
It got to be an embarrassment. The prestige of psychiatry, never high to begin with in academic circles, especially in Gentile cultures, was given its coup de grace. A new generation of psychiatrists wanted to bury the corpse. They were determined that the new psychiatry would use the tools, language, and techniques of science. DSM III and then DSN IV were the outgrowth of that effort.
The earlier diagnostic system might have had a certain logic given the goals of therapists but it was practically useless for researchers who wanted to approach treatment with more precision. When they wrote articles on diseases like depression, mania, anxiety disorders and reported their treatment results, others who tried to replicate their findings (an essential requirement of science) were very often not able to do so. With definitions of diseases not carefully worked out, one researcher’s idea of depression and another researcher’s idea of depression might lead to different patient populations. Inter-rater reliability was the mantra, the impetus for the committees. It was their job to create “operational definitions” of what constituted each illness. This meant they were not going to make a statement about what a given illness “really” is or is not. They would simply agree to call an agreed upon list of symptoms by a specific name. That way, at the very least, everyone knew they were talking about the same thing. The term disorder rather than disease was intentionally used because describing the various clusters of symptoms as diseases would imply more knowledge about these symptoms than we actually had.
But it wasn’t long until these distinctions were totally lost. Psychiatrists and even therapists began to believe that they could best understand what they were treating if they could say the problem with a given patient is he/she is “really” depressed, or has ADHD, or bipolar disorder, or whatever. Even though the causes of a particular diagnosis were no better known than before, somehow making a diagnosis “explained” the problem. It goes even further. Today most psychiatrists treat most DSM IV disorders as if they are dealing with a disease that is basically no different than (I’ll use my example from earlier) strept throat. A specific germ causes strept throat and treatment consists of killing the streptococcus. Yes, people differ in their immunity, in their ability to fight streptococcus, but usually you don’t bother with these things. If streptococcus is found in the throat culture, antibiotics will take care of it. Similarly, in this way of thinking, depression is a discrete illness. The defined characteristics, the agreed upon symptoms described in DSM IV that constitute a particular variety of depression are most, if not all, of what has to be known. Once you have made the diagnosis you can proceed to the treatment. The factors leading to a depression are merely precipitants. It doesn’t matter what the patient perceives to be the cause of their unhappiness. The treatment is the same. Here is a problem with this viewpoint.
I treated a depressed patient who was miserable in her marriage. She didn’t understand why this was so. Her husband was a nice enough guy. She had two wonderful children, no financial problems, and everyone was healthy. But she couldn’t control her outbursts. She often provoked fights with her husband. He said he loved her but she invariably found evidence that he didn’t. She was sad most of the time. Sometimes, in despair, she thought about suicide. During many months of therapy she cried bitterly again and again. She told me about her dead father. He had always seemed tuned out. He was so quiet, almost invisible, a ghost while he was alive. She never believed he cared about her. He had never said he loved her. Other than occasional irritation he didn’t show many emotions. He was like a neighbor rather than part of the family. He sat in his chair with his remote control watching TV and changed channels a lot. But then a memory… Fighting back her tears, she described how on cold, bone chilling wintry mornings, five minutes before she was to leave for her classes, her father went into the street and started her car, so that it would be warm when she got there. Sometimes, when she arrived his teeth were chattering. He said little. She didn’t either. She mumbled a perfunctory thank you and drove off to school. Recalling these moments her eyes watered, then the tears started to run down her cheeks. Then she sobbed, totally bereft of comfort. Then she stared off into space. And then she was finished. Later she would say that she had brought her father back from the dead, felt connected to him for the first time, perhaps more connected than she had ever felt when he was alive. It changed everything. Over the ensuing weeks she reported little things that her husband did for her and that she had never noticed before. More tears. But her depression went away. The memory cured her.
This case is not remarkable. Every therapist has many similar cases. But in the new scientific psychiatry this kind of case report is not relevant. In the treatment for a specific disease model the only way to treat patients is with “evidence based” treatments, those tabulated to be more effective than placebo for the specific DSM IV disorder that is diagnosed. Evidence based treatment sounds like the kind of treatment most of us would want. Researchers take a group of people with the operationally defined diagnosis and compare how many people get better with a particular treatment compared to those getting placebo. It makes a lot of sense. It is a reasonable way to treat a disease. Go with what is proven to work. But the downside of this is that other ways of approaching treatment are dismissed. Doing what was done with this patient, digging deep for memories and experiences that might point to what is wrong, this memory leading to changes in her feeling for her father and her perception of what he felt for her, and that in turn leading to differences in how she perceives her husband’s emotions towards her, this time honored way of doing therapy is now considered an “unproven” treatment. In the new psychiatry the story of how a given person got to be depressed, the reason it developed when it did, things like that are not relevant to a treating physician. The illness is the DSM IV defined form of depression not this woman’s memories of her father. The diagnosis describes every thing that has to be known and the cures are whatever has been shown to work for the diagnosis in question. This case might have been treated successfully but the success is dismissed as “anecdotal”- a putdown in the world of scientific knowledge. As an undocumented treatment insight therapy is in the same league as chiropractors using megavitamins, or herbalists putting together a concoction of Chinese herbs.
There are only three scientifically documented cures for depression, the antidepressants proven effective by the FDA’s evidence based standards, and two very specific types of psychotherapy, also based on the proven reduction of DSM IV defined symptoms. Cognitive behavioral and “interpersonal” therapy have been able to reduce DSM IV symptoms in a statistically significant way. Cognitive behavioral techniques are derived in the spirit of Jack Webb’s one liner in Dragnet, “The facts m’am just the facts.” Cognitive behavioral therapists proudly see themselves as heirs to behaviorists in academic psychology, true scientists. The subjective wasteland of thoughts, feelings, shadings of attitudes and reactions that make up a person’s consciousness are gobbledygook to them, meaningless noise. The particulars have nothing to do with the disorder. What is relevant in depression is the patient’s negative thought patterns. They are considered by cognitive behavioral therapists to result from bad habits. Like Henry Higgins the therapists have boundless faith in the power of an ever rational self improving mind. “The rain in Spain falls mainly in the plain”; again and again patients practice until they get it right. They do homework, catch themselves every time they have a negative thought and replace it with a positive thought.
In this system my patient would have had to stop herself from thinking negatively about her husband. She would have had to do the same for her father. Of course, in the case history I described above that is exactly what happened, negative feelings, negative memories of her father got replaced by positive ones. But this happened because of the recovery of a meaningful memory. The question is whether she could have adequately gotten rid of her negativity more simply and efficiently by willing it and practicing it from the get go. My job would have been to convince her that being positive is sensible, also convince her that her depression was the product of bad habits of thought, and teach her how to change that in the same way as a dentist teaches his patients how to floss.
Perhaps I am taking my sarcasm too far. There is nothing wrong with positive thinking. I was raised on it. “Whistle a happy tune.” “Every cloud has a silver lining” “Put on a happy face” “The sun will come out to tomorrow.” Little Orphan Annie was a favorite of my parents’ generation, coming as they did out of the depression. Think positive was fed to me every time I got a sour puss. And I don’t doubt that it will often work with patients. If a doctor is a true believer in this approach, and a good salesman, if the patient is not too far gone, practicing positive thinking has been shown to work more often than doing nothing. Somewhere between 67 to 80% of depressed people are helped compared to 48 % still on a waiting list and not treated. I don’t disagree with the proponents of this approach that CBT, as it is called, is a lot quicker and more efficient than trying to make sense of the events in your life in the course, of what very well may be, long term therapy. And it is true, that in the past some people who went to psychotherapy for years didn’t make sense of anything, or if they did, they still couldn’t put on a happy face. Freud himself (undoubtedly during a down moment) described the purpose of psychoanalysis as helping patients change “neurotic suffering into ordinary human misery.” Many people were helped quite a lot by a deeper understanding of themselves and their situation, but some people don’t benefit from self-understanding. If a quick cure will work for certain people why not?
I have no problem with quick easy answers. Whatever can do the job is worth a try. There are stories of people who have had repeated depressions who then found Christ and never had a depression again. There are people who have been lost, feeling useless, who couldn’t find a reason for living, but then find Mr. Right, (and if they have been lucky) that does it, no more depressions. There are all kinds of events, and attitudes, and treatments that can overcome depression. My only problem with cognitive behavior and other “evidence based” therapy is that they are spoken about as if they are the only legitimate kind of therapy.
What if only certain types of people were amenable to insight or long term therapy, people who are psychologically minded, people with a certain amount of education, people who are curious, honest, reasonably flexible, whatever? Let us say that only 30% of depressed people have characteristics that will make insight therapy effective and of those 80% can be helped. That makes for a 24% success rate in the overall group of depressed patients, far lower than placebo if the treatment success rate is measure by diagnosis alone. Or is it legitimate to point to the 80% rate for those who can be helped by self understanding?
There is a bigger problem with focusing exclusively on diagnosis and sticking to evidence based solutions for the defined symptoms. It causes clinicians to wear blinders. Attending only to the reduction of DSM IV symptoms is fine and good if you are researcher, but an actual patient may need something different. This perspective can lead to completely wrong headed approaches to treatment. I once saw a sixteen years old teenager for medication whose mother had died two years before and whose father had severe emphysema and didn’t look like he was too long for this world either. The boy was sent for treatment because he was depressed. He kept talking about death. His dark moods didn’t make him very popular with the other students at school, which made him even more depressed. On the basis of his depression diagnosis, cognitive behavioral therapy was being pursued by his therapist. The patient was taught to replace his negative thoughts with positive thoughts through homework exercises. Although I am a non-believer I would have had no problem if he was being comforted by religion, if he was given a positive way to think about death, something like his mother was in heaven, and he would one day see her there. I can understand that. But being told to practice not thinking about death, replacing it with more positive thoughts, doing homework to accomplish that strikes me as shallow, as furthering his alienation from his experience. Fine, given his situation and personality he wasn’t going to be the life of the party in high school. He would probably not be invited to a party. But he might be able to learn to love the blues, or find friends who like to visit sad territory. He might be helped by a therapist who wants to visit him in his own experience, who might legitimize his negative feelings, bring dignity to his suffering, rather then offer a Henry Higgins conversion to a chipper chap as the normal way to be. (for further discussion of this issue see my “On the Banality of Positive Thinking”)
http://www.psychiatrictimes.com/p010701c.html
I saw a woman for medication who was left by her husband after 35 years of marriage. It came as a devastating surprise, the complete negation of all of her years with him, all of her efforts, basically her adult life as she had known it and lived it. After six months she still was very down. Her therapist indignantly told me that her constant sad thoughts were “obsessive.” She wouldn’t stop them, almost as if on purpose. She was trying to get others to feel sorry for her.
Probably true, but as suggested by her therapist the patient tried to do positive things like play tennis. However, when she missed a shot she got down on herself all over again and then got down on herself even more for getting down on herself. I told her she might “be negative” for months more, maybe even years, but at some point she would begin to feel okay about herself again, like she wasn’t such a loser. In the meantime I would try to medicate her out of her misery.
In both cases the diagnosis was depression and evidence based treatment protocols said depression is helped by cognitive behavioral treatment. Only nothing could be less helpful to these patients than treating them by diagnosis rather than as individuals with a story, as part of a life they had lived and would continue to live. We used to proudly proclaim that what we do is part art, part science. There was nothing wrong with that. It was simply stating the facts. It was what we had to do and, often times, we did it well. It was considered clinical judgment. In the new scientific psychiatry this is unacceptable. DSM IV defines illness and appropriate treatment. The rest is merely “problems in living” not the concern of scientific psychiatry.
But we are barking up the wrong tree if we argue that “scientific” psychiatry ascended to its current dominant position with the public because of findings derived from cognitive behavior therapy. Much of its prestige has come from the miracle of Prozac. Prozac and the other SSRIs (Paxil, Lexapro, Celexa, Effexor, Luvox, Zoloft) work great for a lot of disorders. Give a hundred depressed people any one of them. Give a hundred a sugar pill without telling them or the doctors which one they are getting. A statistically significant percentage of people taking Prozac will feel measurably better.
It is even better than that. Some of them will feel the best they have ever felt, what Peter Kramer called “better than well”. Not a small number of people decide, once they are on Prozac, that they had been depressed all their life, but had never given it a name. Their problems in living are gone as well, all this from a pill, from a chemical. The amazing effectiveness of Prozac created a widespread impression that the science behind treating illnesses such as depression, obsessive compulsive disorder, ADHD and a great variety of DSM IV illnesses had been worked out.
A catchy phrase was put forward, “chemical imbalances.” The various disorders in DSM IV were compared to diabetes where there is insufficient insulin. If a drug can correct this imbalance, everything will be OK. The media bought into this, brochures in doctors’ offices say this. Many family doctors believe that is true and so do many psychiatrists. More sophisticated academicians may point to more complex issues, but they don’t question the basic model. Making an accurate careful diagnosis constitutes a crucial first step, and correcting the chemical imbalance is usually considered the core of the treatment. This model is an article of faith, the reigning paradigm, just as 30 years ago child rearing was assumed to cause everything.
The reader may therefore be surprised to learn that not a single disorder described in DSM IV has been proven to be caused by a chemical imbalance. Not one. Does that mean that ADHD and all the various DSM IV “disorders” are not real or are not brought on by physical predispositions and causes? Are patients not being categorized accurately? It is not as simple as that. Patients can be definitively and accurately classified by DSM IV. And once categorized the reaction of a group of people with a particular disorder to a particular treatment can be accurately measured. No argument. Evidence based treatment is irrefutably logical and factual in this way.
Moreover, there are certain conditions that are clearly linked to physical factors. We know that hypothyroidism and other physical problems can lead to depression. It is likely that some people are genetically predisposed to get very depressed when others, in the same circumstances, might only get sad. Scientists have found a gene that allows certain people with good genes (2 long 5-HTT genes) to get depressed 17% of the time when hit with a series of misfortunes. Those with 2 short 5-HTT genes get depressed 43% percent of the time. (70% of the population have one long and one short gene.) And, to return to ADHD, there is no question that many brain damaged kids cannot sit still for very long, and we know that many retarded kids are easily distracted and need a lot of help to stay on task. But I have been implying that something like ADHD is the natural condition of all children, and it takes enormous effort on the part of adults and authorities to move children into a civilized mode of interaction. Some brain damaged kids physically lack the ability to achieve this behavioral integration.
I’ll go further than that. I would not be surprised if part of what is believed today about biological causality turns out to be approximately on the money. Real evidence may eventually substantiate that at least some children who fit the ADHD criteria, have something subtly wrong with their brain, something neurological, that corresponds to the original concept of a ‘minimal brain dysfunction.” And it is very possible that some kids diagnosed with ADHD have biological differences that are not quite on the level where a neurologist’s discoveries will be relevant, but who have been born with brain wiring or chemicals that predispose them to be unfocused and chaotic to a greater or lesser degree than the next person. This isn’t just true of ADHD. Some portion of every person’s mental attributes is unquestionably determined by heredity, and some proportion of the factors that lead to actual mental disorders is contributed by our genetics.
But we don’t know as much about this last category as layman think we do or as propagandists for the disease would like you to believe. Evidence linking the vast majority of kids with ADHD to a physical problem is simply not there. The often touted connection of ADHD to a chemical imbalance is not based on science. It is totally and completely speculative. We don’t know what chemicals in the brain cause the syndrome and where in the brain to look even if we could get inside the skull to take our sample. People have guessed that since drugs which increase dopamine seem to help the disorder, there might not be enough available dopamine in certain parts of the brain that control attention. It is an interesting thought but that is it. Despite the confidence implied by those who intuitively believe this will eventually be born out by research in the future, it is wishful thinking to believe that it will necessarily turn out to be the case. It is downright deceptive when presented as a logical conclusion based on where the evidence is pointing. It is simply too soon to know these things. The ground work from which to take a really good leap is simply not in place yet.
When I was in medical school a long retired professor was given the podium every year to share his salty observations with us. In one lecture he told us about the controversies that once surrounded syphilis when it was the scourge of the Western world. Whole walls of books described the causes and treatments for syphilis. Theory after theory, rebuttals, discoveries, clues. Then they found out what causes it. A single sentence trumped everything that had been written before. Syphilis is caused by the bacteria treponema pallidum. Later when a cure was found one more sentence said it all. Penicillin will get rid of it. With ADHD we are at the stage of books and books on shelf after shelf, walls and walls of shelves all completely unable to cover our ignorance. Here is a paragraph from a May 2003 John Hopkins University publication Advanced Studies in Medicine regarding risks for developing ADHD.
“Environmental risk factors may interweave to create a complex and compounded risk profile. Lead and fumes, carbon monoxide, a variety of heavy metals, and cadmium have all been implicated in ADHD. These findings suggest that a mother in the inner city who feeds her child cow’s milk early rather than breast milk because she has to return to work embodies both socioeconomic and nutritional risk factors. Those risks are compounded by others: the child received inadequate amounts of iron because it is not as absorbable from cows milk, which in the presence of an environment laden with lead results in an even higher overall risk. A similar interplay of environmental risks has been observed in studies of cadmium, which suggest that high cadmium levels are related to hyperactivity and learning disabilities, but only in those subjects who do not eat whole-wheat bread; zinc in the kernel of the whole wheat is protective against the absorption of cadmium. Such complexities typify not only the origins of the disorder, but also its manifestations.”
Not all of the advocates for the biological basis of ADHD are at the level of health food store babble. There have been a number of experiments which are often cited. At the National Institute of Mental Health (NIMH) adult subjects were asked to learn a list of words. As they did so, scientists used a PET (positron emission tomography) scanner to observe the brain at work. This technique measures the level of glucose consumed by the areas of the brain that are used in this kind of thinking, in this case the parts of the brain that inhibit impulses and control attention. Glucose is the brain’s main fuel, so measuring how much is used in a particular part of the brain at a particular time is a good indicator of that part of the brain’s activity level. In people with ADHD, the brain areas that control attention used less glucose than normal people when given a task requiring attention.
Here is another picture using another brain imaging method.
Pretty impressive isn’t it? There is no reason to believe those results were fudged. Nevertheless, there are several problems with this research. For one thing, although cited over and over as proof that ADHD is a biological condition the PET scan studies, done in 1991, have not been consistently replicated. But leaving this criticism aside, there is an even more fundamental flaw in interpreting what this finding means. It tells us what we already know. The parts of the brain used by others to focus and concentrate are not being used by people who have ADHD. Did the researchers expect to find that this part of the brain is being used when the subjects aren’t paying attention?
When a person lifts his right foot a specific part of the brain sends the signal. If the left hand is raised another part of the brain is used. When we listen to music still other parts of the brain are being used. Yes it is true. The parts of the brain used to think things over, to focus on a task, (in the research cited above, learning a list of words) are not being used by people with ADHD and they are by others. We already knew that.
PET scans are really neat stuff. People who can use these gadgets take great pride in having mastered the sophisticated technology. Finding a possible use for them in research about an important issue is close to nirvana. My hat is off to them as it is to computer geeks and all other masters of technology. But my hat goes back on when it comes to admiration for the conclusions reached by the researchers. The assumption that, if the part of the brain that is supposed to light up when the subject is doing a task isn’t lighting up, it must mean that something is physically wrong with that part of the brain, is not supported by the findings. The evidence for this important step in their logic is completely absent. There are many reasons why a person might not be paying attention to a task put before them, other than that part of the brain is physically broken. I have elaborated on how much effort, cultural coherence (or however we label it) might be behind the willingness of a given person to go along with a task that they might not want to do at that moment. I have put forward my ideas of the cultural and family issues behind ADHD. Their speculation that it is a physically incapable brain that is causing the problem is a possibility but, and this is the important point, their conclusions are no more scientific than mine.
They have used scientific instruments, and done careful statistical analysis which is wonderful. But the most important tool in science, logical deductions on the basis of the evidence must receive a resounding F. This is not evidence for a biological basis for deficits in paying attention when a task is being presented. If I am right, it is simply a picture of the brain when a task isn’t being attended to. My suspicion is that the people with ADHD, in contrast to others who more routinely want to stay on the same page as those directing them, didn’t care a damn about learning that list of words, didn’t concentrate for more than a moment. Okay the scientists at the National Institute of Mental Heath didn’t think that was going on. Maybe they are correct, maybe I am. But it is their duty to at least mention this possibility in their discussion of their findings. And then set about devising an experiment to eliminate this possibility. They didn’t. They didn’t mention that it was a possibility. Nor has anybody else discussed this possibility in the vast literature of those who cite this kind of research as confirmation for the biological nature of ADHD. Given the arguments I have presented I find that astounding, as astounding as the lack of criticism, the lack of discussion of this issue in established journals. But most of all I object to these pictures being shown over and over and over in article after article making it seem that the difference in these brains is absolutely clear, that it has been absolutely established that the problem in ADHD is physical. A picture may say a thousand words but it can also be used with smoke and mirrors. The thousand words are needed to see more clearly
A similar false proof of biological origin is found in patients with “panic disorder”. There may or may not be a biological predisposition to panic in people with this problem but the same kind of evidence is used here. The PET scan of the brain of a person with panic disorder during a panic attack will light up very differently than someone who does not have panic disorder when each is given lactic acid. Typically lactic acid sets off panic attacks in patients with the disorder. But a very strong case can be made that the reason for this is that people with panic disorder are exquisitely sensitive to anything that feels strange in their body and they panic. (One of my patients reported to me that she had an attack when she thought she was losing her vision. Only later did she realize that her impaired vision was due to dirty eye glasses.) So once again the significance of pictures can be deceptive. You do this science thing, give lactic acid to patients with and without panic disorder, take PET scans, and find a fantastic difference in the pictures of the brain of these two groups of people and it all seems so clear, objective and scientific. But it proves nothing when alternative explanations are not presented or refuted. You are simply taking a picture of the brain when a person panics, and that definitely will look different than a person who is not panicking.
The only way a scientist could not know about the tendency of panic disorder patients to freak when they experience something strange would be if the scientist had rarely talked at length to someone with panic attacks.
That happens to be the case.
They don’t have a lot of time put in talking to patients with panic disorder. They don’t know very much about the psychological side of things. Part of the reason is they don’t think it is very important, but part is they don’t have the time. I used to arrange lectures at my hospital by many of the authorities that regularly opined about the proper treatment of various disorders. I could almost never reach them. Invariably they seemed to be out of town giving lectures. Research assistants often see their patients or when the scientists meet with patients it is for a short visit focused on research defined symptoms.
But even if we grant that they may be too busy to spend the same amount of time giving patient care and observing patients as the average clinician, so that they don’t have an opportunity to learn first hand about this tendency to panic when these patients feel something funny in their bodies, this tendency is well described in the literature. Once again I simply do not get it. Why isn’t this possibility mentioned in citations of this kind of research? There is another fact that is never brought up. If you successfully cause people without panic disorder to panic, their brain lights up similarly to someone with the disorder. I do not understand why this research is almost never mentioned. It didn’t take long for me to find it with a search engine. This research isn’t refuted or denounced, simply ignored.
And so it goes. When examined as a group, three structures in the affected circuit on the right side of the brain, the prefrontal cortex, caudate nucleus and globus pallidus have been found to be smaller than normal in boys with ADHD. The prefrontal cortex, located in the frontal lobe just behind the forehead, is believed to serve as the brain’s command center. NIMH researchers also found that the entire right cerebral hemispheres in boys with ADHD were, on average, 5.2% smaller than those of controls. The right side of the brain is normally larger than the left. Hence, the ADHD children, as a group, had abnormally symmetrical brains. Since ADHD is thought to be rooted in an inability to inhibit thoughts, finding smaller right hemisphere brain structures responsible for such “executive” functions strengthens support for a biological basis for the disorder.
Once again leaving aside the inconclusive replication of these findings mentioned by critics, the more fundamental problem with this conclusion is that how often parts of the brain are used effects the size of those parts of the brain. So the differences in ADHD, even if they hold up, while interesting, do not necessarily prove anything. Learning Braille causes enlargement of the part of the motor cortex that controls finger movements. After they have passed their licensing exam, London taxi drivers have been found to have a significantly enlarged hippocampus (a part of the brain that stores memories (in this case spatial-visual memories))compared to non-taxi drivers. Patients abused during their childhood with post traumatic stress disorder will have a flattened out hippocampus. Professionals musicians have brains that are different than non-musicians. Buddhist monks who meditate show measurable differences in their prefrontal lobes. And so on.
The pictures of the brain that we are now able to take are truly amazing. There is a chance that one day they will be part of the solution to puzzles that now bewilder us about mental illness. However, we are many years from that goal. In the case of ADHD we are very early in the game. There is a lot we don’t understand. This isn’t just my point of view, pushing as I am for a non-biological explanation for most cases of ADHD. In November 1998, the National Institute of Health held a three and a half day conference of non-advocate, non-federal experts with the goal of establishing a professional consensus on a number of questions surrounding ADHD. Here is the next to last sentence of their consensus statement: “Finally, after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains largely speculative”.
More. Here is a concise and to the point segment from an interview on PBS’ Frontline with Xavier Castellanos M.D. , head of ADHD research at the National Institute of Mental Health (NIMH) (interviewed October 10, 2000). He, by the way, believes ADHD is a biological illness. His studies have been criticized by opponents as always managing to put any misgivings he has about the interpretations of his findings in very small print. But in this interview, under the public scrutiny of an investigative report, he is very circumspect about the state of our knowledge.
How does ADHD work on the brain? What do we know about it?
“We don’t yet know what’s going on in ADHD…”
[Or later]
“…When I get discouraged, I think about a map that I have in my house that came from an exhibit in the Smithsonian from 1500. It’s a map of the New World, and you can tell that they knew about Florida–there’s a peninsula. They have an idea about the East Coast, and even Texas, but you wouldn’t want to use that to drive from Tallahassee to Atlanta, because it’s just too crude. So we’re about at that level of getting an idea of where the major pieces are, and what their relationships may be. And it’s better than it used to be. But we’ve only been at it for about 10 or 12 years…”
He then speculates about several of the biological possibilities. Later he is asked about the rationale of using stimulants (like Ritalin and Adderal, a combination of amphetamines). His explanation is flimsy which leads to the following:
Are you uncomfortable with how little you know about this?
“Yes. But I’m also glad that I know more than I used to. It’s both half full and half empty. It’s not even half full. It’s about a tenth full.” [italics mine]
Following his discussion about all of the uncertainties regarding research findings the interviewer asks:
Give me one true fact about ADHD.
“The posterior inferior vermis of the cerebellum (a part of the brain used for motor coordination) is smaller in ADHD. I think that that is a true fact. It’s taken about five years to convince myself that that’s the case. That’s about as much as I know—that I’m confident about.”
What does that mean?
“I don’t know what it means, but it’s true, and it’s a fact.”
Perhaps it is a fact but there are many critics who complain that Dr. Castellanos has consistently used findings in which the kids with ADHD have already been treated with stimulants so it is impossible to say whether the results he and others invariably find are due to ADHD or the stimulants. Stimulants could very easily be brain “poisons” Most intoxicants are. The kids have been taking enough of these drugs daily to constantly feed their brains with it. Lately, at NYU Dr. Castellanos has been trying to prove his critics wrong but in any case, for Castellanos to admit that most of his findings are primitive is quite an admission since he is the one of the leading researchers doing this kind of research.
To reiterate, a lot of children and teen-agers fit the description for ADHD. That is not at issue. The issue is what is going on. I am arguing that there is not, as most doctors, and the average parent of a kid with ADHD believes, convincing evidence that the problem is biological. On the contrary, as I noted, most often the problem is with contemporary culture and child rearing. Looking over the criteria for the diagnosis it should be obvious that when I was in the synagogue suffering through the rabbi’s sermon, when I was bored and restless, and felt trapped, I was fidgety and little different than a child with ADHD. A PET scan done on my soon to be adolescent brain would have shown a very different pattern than the adults paying attention. School was a different thing. There was no problem with focus. My parents were successful. I totally bought into the system, into the story of my life as created by them and how I was to live it. And maybe I have overdone the emphasis on God. For in Queens in the 50’s that I knew, Horatio Alger ruled. Becoming a somebody, in this case “my son the doctor” was a convincing motivator. Besides, if you haven’t noticed I was a relentless competitor. Like a lot of young guys I turned everything into winning or losing. Coming from a culture where being smart and doing well in school was the Jewish version of macho, there wasn’t going to be a problem with doing my homework. My motivational chemicals were totally alive, my attention at high alert. However, not everyone is brought up in a culture where school work is so valued. Not everyone is a player in the classroom.
So is it that kids with ADHD feel bored, frustrated and restless in all kinds of situations where they are being asked to do what they don’t want to do and act accordingly? They have not bought into and participated in the “story” their parents expected from them. Do they feel like prisoners like I did, and my pals did, when we had to shut up, sit still and listen to the rabbi talk? If you ask them they will tell you how boring their teachers are. Does school and homework chores seem like a total drag and they just can’t relate to it? Does it give them a terrible frustrated feeling that they don’t, won’t, and possibly can’t learn how to handle. I believe this explains the vast majority of children who are labeled ADHD. The problem is not that they have problems with attention or focus per se. It is that they are not connected to what is expected of them. They can’t or won’t relate to things that present difficulties, that may be monotonous, that require effort and perseverance, that seem like work to them.
Chances are if you ask one of these children how they do with video games most will tell you they have no problem. Hour after hour they can sit totally attentive, totally focused, totally absorbed by these games. This should not be the case if there is a biological interference with concentration. Very often these kids are said to have eye-hand coordination problems (supporting the argument for a biological basis) as illustrated by their sloppy penmanship and also psychological testing shows this to be the case. But video games require an amazing amount of dexterity. Why is there no impairment here?
I treated a teen-ager who told me that he could not read without his medication. His eyes glazed over, he could go over a page a hundred times and nothing would be absorbed. During summer vacation he stopped his meds, except when he had to read something for school. I asked if he ever read anything else, something not required for school. He told me he didn’t but then remembered one exception. He loved mountain biking. Each month when his mountain biking magazine arrived he tore through it, reading every word, cover to cover. He did not require medication to do this.
Many of the children I have spoken to do okay in one school subject and not another. Sometimes they are simply gifted in this area, so that it comes very easily year after year. But many of them do well in one subject one year and another subject the next year. Almost without exception the explanation for doing well is that the teacher is charismatic. He makes learning fun. Some parents therefore blame the educational system for hiring bad teachers who turn learning into such work. Perhaps, but in the good old days, in Queens very few teachers were entertaining. It was assumed that school was supposed to be work. And the kids had to learn how to deal with that. I don’t want to brag about the accomplishments of the kids in my neighborhood, but we were on triple shifts at Forest Hills High School, with a minimum of forty kids in every classroom, with very little individual attention, and there was very little ADHD. Many, many graduates are doing very, very well in science, the arts, law, medicine, business, academia, in every field of endeavor (minus sports). Amazingly well. We were hungry at that school. We took off with the starting gun and didn’t look back. Not that there weren’t exceptions. I remember one boy who I grew up with who probably qualified as ADHD. He was sort of a bully. He never did his homework and was often in trouble. His parents got divorced after his father had an affair with a neighbor in an adjacent apartment. That wasn’t a common occurrence in those days. But before their affair his parents never went to shul. He had not been sent to Hebrew School.
It is noteworthy that many adolescents diagnosed with ADHD seem to “grow out of it” when they find a niche that they are good at or that they enjoy. I think we are getting somewhere here. Sometimes they have found a guiding person, someone they admire and want to please and he teaches them a livelihood. Some of these kids are good at mechanical things. They can’t sit still in school but they can tear an engine apart, or do plumbing, or throw a football or they can do great things with the other thugs in their baaad man band. Or they can dance, or draw, or paint. Sometimes, after they have found something that they want to do real bad, they devote themselves to it with a diligence that was absent when they were young. It may not altogether be inspiration. Some know they are running out of time. They can’t be a kid forever. They apply themselves when there are no excuses left, when they have come to a dead end. They learn how to work when it becomes clear to them that they have to work. There isn’t any other choice. About 50% of children with ADHD grow out of it by adulthood. Biological advocates for ADHD claim that in these cases the neurons themselves took longer to mature than someone without the disease. While that is possible there is not a hint of evidence for this perspective.
There have been many fads in the biological treatment of ADHD, for example one which claimed too much sugar was the culprit. It is interesting that whoever thought up this theory intuited that the problem was an addiction to pleasure seeking, and prescribed parental strictness, cutting out the candy. It didn’t work that well but sometimes it did. I am willing to wager it wasn’t the sugar. It probably had to do with the structure created by this discipline. Another common sense strategy also emphasizing food is advocated for parents-no more eating standing up near the microwave as the mood strikes you. Back to scheduled, as opposed to demand feeding; the family must gather together at an exact scheduled time for dinner, like they used to do in the 50’s. Structure, structure, structure.
Other treatment advocates, seizing on the belief that the problem is an inability to be on the same page as everyone else, have advocated non- classroom experiences that teach the children how to be team players. A typical strategy in “outward bound” programs is placing the child with other children somewhere in the wilderness. This combines roughing it, perhaps touching on an elemental battle for survival, a kind of macho that strokes the pride of young guys. They learn that only by being part of a team, only by appreciating that their effort and performance are crucial, both for them as individuals, and for the others in the group to make it to safety, only than do they begin to catch on to the basic idea of self control, following through on assigned tasks, and cooperation with a leader. It is hoped that this recognition, this lesson from life will be a step towards maturity, that it will be applied to other tasks.
Some treatments emphasize carefully defined boundaries, a well defined day, earning privileges through responsible rule obeying behavior. Some kids with ADHD (and other more severe conduct disturbances where impulses rule daily behavior) are sent to military schools or their equivalent. Discipline is stressed with a heavy emphasis on fear tactics, especially in the beginning. Deeply engrained liberals shudder at this. They are convinced that sadism is the only plausible motivation for this kind of school. Undoubtedly there are sadists who manage to get jobs as jail guards, enforcers of the rules at military boot camps, and junior high school principals such as my beloved Mr. Burke. But there are others whose motivation to enforce discipline is woven into an integrated cultural institution with traditions that can win over the kids. Parades, uniforms, standing up straight and proud, many kids only get their act together when they learn to admire the very people who force them to be obedient, the very people they can be if they learn how to obey. They eventually understand that paying your dues has a sort of logic to it, that the world owes me a living is a punky attitude certain to bring failure. Going along rather than opposing daddy’s tough rules is a winning psychology. It allows a feeling of entitlement, but only after you have earned it. At its best the system is not based on perpetual fear but hard won pride gained from coming through on the other side. This is your basic unadorned masculine, I suppose, Republican attitude. Looking back at their own lives, a lot of guys feel that something like military school is what finally knocked some sense into them. Marines stand so straight because they are proud to be Marines. Part of an elite. Super straight.
When the model works, it encompasses the best aspect of discipline. Similar to Alcoholic Anonymous, great emphasis is placed on a higher moral order. The journey forward is taken in steps. The end stage is a transformation from being a misbehaving initiate to a proud upholder of the ideals, one who eventually becomes a sponsor for others, a teacher by example, essentially moving psychologically from a naughty child position to a parental (esteemed authority) identification.
But sometimes treatment can be a lot simpler. I once cured a boy of alleged ADHD by treating his father with Prozac. The father was a caretaker for an estate who lived with his family on the property. He felt life had treated him unfairly, or more specifically this father’s parents had not encouraged him enough to do his school work and so he hadn’t gone to college. Hence his position in life. He had an Archie Bunker disposition, sweet, likable, and very explosive. He’d be working on a job and he’d suddenly scream for his wife to bring him a wrench (while he was lifting a 100 pound object with his other hand). And she’d come running out with a wrench and he’d grab the wrench and throw it down into the ground, loudly cursing at her idiocy for bringing the wrong wrench.
She reminded me of Edith Bunker. In a nervous squeaky voice she invariably went off the topic, which was one of the things he couldn’t stand about her. Teachers at school were asking for their son to be evaluated for ADHD. He wasn’t concentrating in the classroom. He was all over the place. I put the father on Prozac. Within a week or two he started to whistle while he worked. He’d run into unexpected obstacles in completing a task and instead of losing it he’d find the problem “interesting” and he would calmly set about finding a solution. Eventually, his wife lost her nervous way of talking. She was actually quite intelligent, and could be focused and on topic. And suddenly their boy was doing well in school. And sometimes, when his father was working on a project, the boy would call out “Can I help?” He liked being on the same page. His presumed ADHD had disappeared.
And there are many who insist only “tough love” will work and sometimes it helps when a parent has been ridiculously lenient, but there are an abundance of kids who come from homes where tough love is practiced, sometimes very tough love with a minimum of love. Sometimes there is a lot of talk about discipline. My Archie Bunker patient futilely lectured his son about discipline and sacrifice and having it easy. He did this a lot. And yes he told his son he walked five miles to school every day as a child. It fell on deaf ears.
I have argued religion was once far more commonly a guiding principle in organizing experience and certainly there are no shortage of religious approaches to solving the problems of ADHD. There is also no shortage of kids with ADHD who come from parents who are holy rollers. Big time. In these cases religion just isn’t getting the job done. In other cases it is probably as helpful as it was for me in making sense of the world, and keeping me on track. I don’t know if a dramatic discovery of God can totally transform a family. I’m sure sometimes this happens and it helps with the children’s ADHD, the father’s alcoholism and all the other components of cultural fragmentation that have disassembled the family, and interfered with the child’s ability to focus. I also know that sometimes the religion can be turned into an absolutely nutty response to reality that is as much problem as solution.
Recently I spent time in Kyoto. It is the old Japan. You can’t help but notice the beautifully dressed children, their manners at the table, their self reserve. At two and three years old they are eating nicely, sitting straight, using their chopsticks. I am sure there were no proud pictures on kitchen walls of children in their high chairs with food smeared all over their face. I am told the Japanese don’t “child proof” their homes as modern American parents do today. At 18 months the kids have already learned what they can touch and not touch. The Japanese have a soft place in their heart for sweet little things, touchy feely teddy bears, cartoon characters, little innocent boys and girls. Like us they want to keep them like that. Lovable. From an early age the children are taught how that can be accomplished. They learn manners, self control, waiting their turn, the virtues of a modest presence. They do not learn that the squeaky wheel gets the grease. If you have to try that hard the results aren’t worth it. Their saying is “the nail which sticks out will get hammered.” Learning how to behave yourself, how to do what is expected, how to be respectful of other people’s space, how to behave in a group of people so that you all can get along- the Japanese do not take these matters lightly. It is everything to them.
In the realm of attention and focus you can’t help but admire their culture and other similar Asian cultures. Asian high performance cultures are disproportionately represented in the student bodies of the Ivy League. Indeed most school admissions policies discriminate against them because there are so many hard working talented Asian applicants. If admissions boards didn’t discriminate a majority of the students at the best schools would be Asian. And many of the great violinists, today’s child prodigies, all the breath taking visible accomplishments that used to be associated in my mind with the push of us Jews to get to the top, or do what we are doing well, that unforgiving quest to prove we are the best, at this point it is more likely to be seen in kids coming from an Asian culture.
So should the Japanese be our model of child rearing? Most people would not be happy with this. They don’t dance as well as we do. They don’t think as well out of the box. And their respect for rituals, for enshrining behaviors until they achieve permanence, permeates their culture a thousand times more than it ever did among the doveners in my synagogue in Queens during my childhood. The Japanese are very disciplined like the Germans, perfectionists, great engineers, hard working people, but both displayed unusual viciousness during World War II. Is there a relationship between repressed impulses and a cruelty that emerges when given the chance? Perhaps, perhaps not. There are plenty of undisciplined cultures that are brutal without the discipline. More relevantly, the Japanese have a suicide rate that is twice our suicide rate. Their self containment, their shaming, their striving for excellence creates horrible tensions. But I am pretty confident that the incidence of ADHD is extremely low in Kyoto and those who do step out of line will probably get knocked down pretty hard. Moreover, it should be pointed out that in recent years suicide rates among teenagers in the United States have greatly increased. From 1980 to 1996, the rate of suicide among persons aged 15-19 years increased by 14% and among persons aged 10-14 years by 100%. The suicide rate for white males (15-24) has tripled since 1950, while for white females (15-24) it has more than doubled.
I have seen kids who are driving themselves too hard, who are terrified that they will not perform up to their parents’ expectations. This exists as it did before, and it is a real problem. But I have seen far more kids who have made a suicide attempt where the opposite is true. Not infrequently their life has no direction. They have no dreams. None. Never had them. No accomplishments either. Their attempt didn’t happen after a big let down, a failure, the squashing of a fantasy they had intended to live. They were not disappointing their parents’ hopes for them.. Their parents are divorced. They don’t like their stepfather or stepmother. Their mother is running on empty, working long hours and trying to be a super mom. She is feeling guilty about not being there enough for the kids so she gives in a lot. Their Dad doesn’t want to ruin Sunday visitations with chores. Both want “quality time.” Showing the kids a good time is more important than imposing expectations, or maybe more to the point, it is easier. They may try to entertain their children’s brattiness away, as if this will prove their love.
Many doctors feel they are being compassionate when they tell parents they have nothing to do with their child’s ADHD. The kids were born that way. Undoubtedly it is great to get off the hook. It would be wonderful for my wife and I to believe that our children’s problems growing up, and even now, have had absolutely nothing to do with our child rearing. But like it or not that isn’t true. The joy and heartbreak of being a parent is, unfortunately, all too often related to what we are doing right and what we are doing wrong. Some of our children’s qualities may also be a reflection, for better or worse, of who we are. Of course many problems have nothing to do with parental mistakes. There are high spirited kids who have greater difficulty than other kids when it comes to waiting their turn, sitting still, and completing tasks. Parents have to work considerably harder to keep them on task. Some of this may or may not be genetic. But children’s willingness to go along with their parents’ expectations, their effort to move ahead, or their refusal to cooperate has everything to do with the state of their alliance to their parents. That isn’t to deny that even in the best homes there are going to be bumps in the road. Many bumps! Getting a child, any child, to go where he is expected to go is not easy. Some of it is luck, bad or good, and a lot of it is effort. The results of our strategies cannot always be predicted. And certainly, many parents may bring their children to doctors precisely because they have tried everything they can think of to improve the situation and nothing has worked. I don’t want to be a big shot because my kids are basically okay at this moment, at least when I last checked on them. Being a good parent is one of life’s impossible jobs. There are no easy to follow rules, no roadmaps that lay it all out perfectly. We will all fail at certain things, and succeed at others. But that is my point. It is not easy. Blaming ADHD on a gene is too easy an answer.
Moreover it is not a blessing for a child to think of themselves as damaged goods, born with bad wiring in the brain, stuff like that. I can’t think of a worse thing to do to a child. I remember how often I told my pals that I didn’t study hard for this or that exam. It was my escape clause. My real fear was that a poor grade might reveal that I wasn’t that smart, that I was born with inferior intelligence. It isn’t just the self esteem of kids labeled with ADHD. It’s expectations based on these labels. So often along the way, when things aren’t going well people have doubts about whether they can or cannot do something. Children go through these crises of self-confidence all the time. Adults do too. They turn to their spouse or friends to pump them up, or they find resources within (including memories of the little engine that could). There are all kinds of studies that show expectation has a huge effect on outcome. And that includes teachers. Prophesies become self fulfilling. When teachers believe a child is limited, he will more often than not remain limited. If a teacher is told a child is gifted, performance on average will be at a superior level, even when the teacher has been lied to. Yes it would be cruel to ask a child with muscular dystrophy to toss away his wheel chair and play baseball like everyone else. But it is cruel to tell a child that he has been born defective with ADHD when he very well might not have been biologically cursed. More than one child has told me that he refused to take his Ritalin because it is for “retards”.
And while it is great for parents to believe that nothing is their fault, their child is born that way etc, biological explanations can have a malicious aspect as well. Ironically, when Freud argued hysteria was not an inherited trait, but was due to childhood experiences, patients felt just as liberated from society’s disapproval as those feeling freed from blame today because they have been told their kids behavior is due to inferior genes rather than poor parenting. In the Germanic environment of Freud’s day, having bad genes, being cursed with the family’s defective seed was not something to be proud of. Indeed genetic lineage was the basis of Hitler’s plans to rid the world of Jews, mental retards and other inferior genetic stock. It should be also noted that Dr. Frederick Goodwin was relieved of his position as head of the National Institute of Mental Health after he claimed that genetics played a large role in criminality. Many civil rights organizations rightly demanded his head.
Hopefully, the reader may be wondering why the perspective I have presented here about ADHD is not being seriously considered by most medical authorities. I have wondered about the same thing. I am not being disingenuous. I truly don’t get it. Other than extremists advocating natural foods, or people opposed to medication in any form whatsoever, there is remarkably little controversy within the psychiatric and medical community about the current way of viewing ADHD. Why aren’t others questioning these mainstream thoughts?
There are several explanations. First and foremost, in the 80’s there was a putsch in academia. The nature-nurture controversy has raged for as long as any one can remember. Sometimes biological psychiatrists have dominated, other times the nurture perspective has held sway. Ideally, it should be possible to synthesize both points of view, because in the end nature and nurture are important factors in understanding any psychological phenomenon. Indeed lip service is always given to this ideal by both sides. But in actuality neither side takes the other seriously. The nature/nurture debate is highly politicized, meaning it suffers from heated up points of view in the same way as abortion rights, global warming, or the Israeli-Arab conflict divide people. Ideas are so charged with loyalty to ideology that reason cannot prevail. You are either on one side or the other.
After decades of occupying the back offices in medical schools and universities the biological psychiatrists took charge of departments and got rid of most talking therapy academicians. Like the Trotskyites and Stalinists, members on each side of the nature-nurture controversy don’t talk to the other. In this environment your reputation is at stake if you stray too far from acceptable beliefs. It isn’t only ADHD where researchers almost exclusively focus on biological explanations for psychiatric difficulties. Almost every DSM IV disorder is viewed as a predominantly biological phenomenon. Quite a few academicians have told me privately that they agree with points that I have made in other articles along these lines but would not say so publicly. They said it takes courage to argue my point of view. Only it doesn’t. It does not take courage because I am no longer in academia. I can say whatever I want. In fairness I might add that when psychoanalysts controlled academia they were no more receptive to challenging ideas.
Not everyone is caught up in ideology. There are fine scientists working in psychiatric research who are diligently accumulating data, scrutinizing that data for clues, and designing experiments that may lead to answers. Not just Dr. Castellanos but most true scientists in the laboratory are very aware of how little we understand. Prozac was a home run. But those who discovered it were swinging half-blindly. And they have no problem stating that. The science behind it was not, and is still not clearly understood. Here is a statement accompanying the Discoverers Award given to Drs. Molloy, Fuller, and Wong, the discoverers of Prozac: “Human science still falls far short of fully understanding how the brain works. It is the most complex organ in the known universe, and though progress has been made in deciphering some of its secrets, much remains to be discovered.”
The story of Prozac is not the story of a step by step logical progression. Lilly came very close to canceling research on Prozac when it, at first, did not seem to do much. Most researchers did not believe serotonin was that important in depression. At the time their best guess was that there was a norepinephrine “imbalance”. The only basis for thinking serotonin might be linked to depression was a finding that serotonin derivatives were diminished in the spinal fluid of those who had committed suicide through violent means.
We still don’t know if serotonin is specifically important in depression. It definitely plays a role in some cases, particularly in the light of genetic differences in the 5-HTT gene (which is related to serotonin release) leading to different rates of developing depression under stress. But drugs that increase effective serotonin at the nerve juncture also help panic disorder, anorexia nervosa, obsessive-compulsive disorder, post traumatic stress disorder, fibromyalgia, social phobia, borderline personality, generalized anxiety disorder, premenstrual syndrome and dozens of other conditions. Although first introduced as anti-depressants SSRIs are not antidepressants per se. They are very effective treatment for depression but not because they specifically address an imbalance of serotonin found in depression. SSRIs effect serotonin in neuronal synapses whatever may, or may not, be ailing you. Since the effectiveness of Prozac and the SSRIs (Paxil, Zoloft, Celexa, Lexapro etc) are a key issue behind supporters of the biological orientation (and with apologies to readers who prefer a more linear presentation) let us visit the issue of what SSRIs do. It will give us a useful perspective to understand ADHD treatment issues as well as the treatment of other DSM IV conditions.
If you take normal guinea pig pups and remove them from their mothers, like pups of most species, they will frantically scream. If for a while you feed these normal pups SSRIs they will not react when they are removed from their mothers. (The ability to reduce “stress induced vocalizations” in guinea pig pups is a useful screening device used by researchers when they go through a myriad of chemicals hoping to find potential psychiatric meds.) I call SSRIs (drugs that increase effective serotonin) “well whatever” drugs. A “well whatever”, “no big deal”, “don’t sweat the small stuff”, “everything is all right” feeling allows normal (not chemically imbalanced) guinea pig pups to not be upset when they are separated from their mother. It similarly allows depressed people to no longer feel devastated and defeated by their circumstances. This same calm feeling allows patients with panic disorder who would ordinarily panic to remain okay when confronted with what would be a terrifying thought, situation, or body sensation. This same drug induced emotional state allows someone with anorexia nervosa to put on a pound or two without freaking out. The feeling of “well whatever” helps an obsessive compulsive patient, previously enslaved by required rituals, to realize they really do not have to perform their rituals. Everything is okay and will be okay. It allows shy people who have given up on social situations (DSM IV 300.23 Social Phobia) to find the courage to socialize more easily; same thing for people with fears of flying, crossing bridges, entering a supermarket, or whatever the particular phobia might be. People with body dysmorphic disorder, who might spend hours looking in the mirror trying to decide if they are going bald, can let it go with the help of these meds. And so on.
SSRIs are great drugs. I mean that. Many suffering people have had their lives dramatically improved by them. SSRIs will decrease a lot of DSM IV symptoms and that is wonderful. They have relatively few side effects and, as far as we know, are exceptionally safe when taken over a long period of time. There are suggestions that in a large population of people they may even decrease heart attacks and improve the immune system. But they are what they are, calming happy pills that will make most people feel better whatever it is that disturbs them. Increasing serotonin is not correcting a specific deficiency of serotonin that is missing in a specific DSM IV defined disorder. There may be a low level of serotonin in a particular person and it may even be genetically determined but serotonin is apparently one of the many neurotransmitters that effect our emotions. It is not specifically linked to any one disorder.
If you give enough alcohol to a schizophrenic, a person with panic attacks, a manic depressive, or a person with no diagnosis they will all get drunk through similar chemical mechanisms in the brain. People with differing diagnosis, or for that matter any two individuals might act differently when they are drunk but they will be drunk. If you give SSRIs to all sorts of people the drug will do its thing. A colleague of mine took an SSRI so that he could truly relax during a vacation. It worked. However, he found that when he returned he became alarmed when he noticed that when he was listening to patients talk about their problems he kept thinking “Who cares?”
There is a down side to a “who cares” attitude.
Dr. Jay Pomerantz, a lecturer at Harvard Medical School described a patient who was getting one speeding ticket after another while on SSRIs and didn’t seem to care until the dose was lowered. Here is a sampling of patients that illustrate a few of the good and bad consequences of these drugs.
Mrs. D a computer consultant with a terrible foster home past was successfully treated for depression. She had never felt she was as good a techie as her 5 male partners. She had a never ending need for reassurance, which was embarrassing to her. Every night on her drive home she tortured herself with the things she felt she had mishandled. On Prozac all of this changed. She acknowledged that she wasn’t as good a techie as her partners, but she wasn’t bad. More importantly, she realized she was indispensable to her team. She was the only one with sufficient social skills to handle their clients. Medicated, for the first time in her life she was able to ask questions at conferences without feeling stupid. No longer hungry for confirmation she was also able to stop a cycle of love affairs which had led nowhere. On the other hand her comments coming off the meds is noteworthy. “I feel like I’ve been drugged for two years. Now I want to take a look at my checkbook.” She also reported behavior that now, off the meds, seemed bizarre. She had bought a puppy that she kept in an unfinished basement. While medicated she had not cleaned up the poop, reacting with “well whatever”. Off the meds she was astonished by this behavior.
Mr. T. was a thirty-year-old man who was very unhappy in his marriage. He had always pictured a family life with two or three children. His wife, a beautiful woman, whom he had originally been smitten by, had never wanted kids. Mr. T had assumed she would change her mind. But now six years into the marriage, he had realized that there would be no change of heart. She was to be the project of the marriage, her vulnerabilities, her needs, the vicissitudes of her emotions. It had gotten old. Over the years, he had noticed his impatience with her grow into indifference and then sarcasm. He came for help when he had become depressed. He couldn’t sleep. He couldn’t eat. He couldn’t concentrate at work.
I’ll put the issue in a nutshell. What if the Prozac worked like a charm and completely rid him of his depression? What if Prozac returned bounce to his life and now he found he could, after all, live happily with the status quo? What if 25 years from now, Mr. T. were to wake up and suddenly realize he had wasted his life? He really had wanted children and a family all along. What if he wouldn’t allow a doubling of his Prozac dose at that point? A drug had deceived him, cheating him of what had been meant to be. Would Mr. T. have had major depression if he weren’t biologically predisposed? Possibly not. (Nor do we know with others.) But even if he would not have gotten as depressed without having a biological predisposition, it is wrong to dismiss his marital situation as merely a precipitant. In this case, the depression was an alarm signal. It told the patient that the life he was living would not do.
I had a patient who was having an affair with a married man who was on Prozac. Every time he came off his medications he couldn’t stand his marriage for a moment longer and he intended to marry my patient. As soon as he was back on meds his concern switched to his teen-age daughter who needed him to stay in the marriage. Which was the real him? I’ve had patients find the courage to ignore their fear of loneliness and leave an unsuitable marriage with the help of SSRIs, others find the courage on meds to have what proved to be an unwise affair.
I’ve seen a medicated patient quit his 9-5 job, use his inheritance and “go for it” as a singer. Was this realistic? I suppose it depended on his talent, connections, and luck. He had previously been cautious about his inheritance, recognizing that it was a one-time thing and was his only hope for financial security. Only after he also decided he was going to use this money to develop a solar car did I become concerned. He was not manic or hypomanic, but he was definitely feeling better than he had ever felt. When told he would have to stop the Prozac, so that he could review his choices unmedicated, he stopped therapy and went to a different doctor.
Continuing on the thought I developed earlier, the problem with viewing patients’ problems as DSM IV symptoms and measuring medications’ ability to reduce these symptoms is that other issues are not part of the discussion. In the cases outlined above (and many others that I could describe) these other issues are a crucial part of good treatment. They are almost never discussed in the journals, in training programs, anywhere for that matter. By keeping doctors focused on treatments that are evidence based, what is, and is not, in need of treatment is predetermined. It is very nice that researchers can have their target symptoms and disorders defined exactly and measure the effects of treatment on those targets. But why should DSM IV become not only the official but the only way to decide what is in need of treatment and what is not in a given patient? And to push this in a slightly different direction, why have most psychiatrist basically become medication doctors and that is it? If your only tool is a prescription pad it will change your thinking, or to quote the aphorism “If all you have is a hammer, everything looks like a nail”
Just as important as the lack of discussion among doctors, and doctors in training of these issues, patients are being misinformed about what the drug is purportedly doing. A patient told he is being given something that will drug him enough to dull his reaction to what has been upsetting him will approach that treatment very differently than a patient given a different spin, one told that his medication is treating the chemical imbalance that is causing his ailment. They will give drug treatment a second thought if warned that SSRI’s might affect their judgment. Or they will watch for it. Similarly, primary care physicians and psychiatrists will be far more enamored with the thought that an agent has been tested (and even better, FDA approved) for a specific DSM-IV disorder if the mindset is that the effectiveness is due to fixing faulty synapses, rather than that the patient is being drugged out of his suffering Primary care doctors and physician’s assistants are handing out SSRIs after spending five minutes with their patients. The patient complains a little and out comes their prescription pad. “Here try this.” They feel comfortable doing this partly because these drugs are powerfully effective and unusually safe. But also they use these drugs so easily because this approach appears logical, because it seems to offer a cure in which cause and effect are known. Cures based on science are beloved by anyone who wants to make rational decisions. If these illnesses truly were chemical imbalances that could simply be corrected with medication there would be nothing wrong with this approach, but this is not the case.
Let me say it again. I would love a truly scientific psychiatry and would support it without hesitation. However, that it is not what we have in the actual practice of psychiatry. We have people who like the language of science, the experiments, the technology. But mainly we have people who love the prestige of science and want to claim it for their speculations. They especially want the public to believe we have reached an age of scientific psychiatry where we have uncovered amazing information about brain mechanisms which guide us in our practice.
It may be decades. It may be centuries before we are there. But it isn’t just the public. It is what is told to busy doctors. Doctors are besieged by “experts”, people who make up protocols on how to treat a condition based on a polling of the “experts” in a field. It is not unlike the polls taken on TV. Three days into the war people were asked to vote on whether Saddam Hussein was alive or dead. I am not sure what it means to do a poll of experts, when the experts lack the knowledge to truly guide us scientifically. I don’t blame them for not having all the knowledge we need to give fully rational treatment. No one has it. I blame them for calling themselves experts. The fact that they use this term so frequently says a lot about their intellectual integrity. Many researchers are astonished by the pronouncements of experts. But the worst part is that experts have an agenda. Experts create protocols which try to force doctors to follow expert consensus treatments. The considerations I mentioned above are never (repeat) never, part of the deliberations of the experts.
So what is going on? How do the experts feel so comfortable calling themselves “experts”, why do experts try to give the impression that they know more than they do? And lastly, why are doctors so poorly informed about the state of our knowledge?
I recall my first or second day in medical school in a histology lab. We were all nervous. I was not accustomed to using a microscope. Nor were my classmates. This was during a time when professors used to greet entering freshman with the certainty that a number of us were not going to make the cut.
Our lab manual described what a fibroblast should look like. I couldn’t find it. I asked if anyone else was having the same trouble that I was. A student told me to look in his microscope. He said his pointer was on a fibroblast. I looked. I saw nothing. It wasn’t even close to the description in the manual. I told him this. He was annoyed. I asked to see what other people were calling a fibroblast- the same thing. I thought maybe something was wrong with me but for the best of me I could not find in their microscopes anything that even vaguely resembled the description.
I have always been that way. I can never accept very much on faith. As early as the second or third grade, if I were given a mathematical rule, one used for a thousand years, I couldn’t simply memorize it and use it. I had to come at it from several different angles to make sure it made sense to me. Then fine, I would use it without a second thought. But the first time around I had difficulty accepting anything on the basis of authority. My Aunt Anne used to cackle deliriously about this quality. It just cracked her up. She and my uncle took me to Raspberry Park (Asbury Park, NJ) when I was a young tyke of three or four. Only it wasn’t Raspberry Park. They thought they could fool me. I kept saying in the most serious way “This isn’t Raspberry Park. This isn’t Raspberry Park.” They laughed and laughed. Pisher, my aunt used to call me.
Perhaps the students showing me the fibroblast in the histology lab were wrong but others were successful. I asked others if I could look in their microscopes. I still saw nothing. The group consensus was clearly growing that I had some kind of learning problem. Eventually, the teacher came around. He put the pointer of my microscope on a fibroblast. Sure enough there it was, just as the manual described.
So how come the other students, none of whom had found a fibroblast, did not react as I did? They also didn’t have the slightest idea of what they were supposed to find, but they acted like “no problema”. I don’t know, perhaps they didn’t need to see things for themselves like I do. They were unfazed, seemingly confident that they knew what they knew. Only they didn’t.
Some people curse the darkness. Others prefer to shine a light. There are also those who remain in the darkness but claim to others, even themselves, that they are standing in the middle of the light. It isn’t just a case of “the emperor wears no clothes” which more than most laymen realize, is on the money in the practice of medicine (as well as most human activities). It is something else. Not only doctors, most people would rather warm their hands at the fire of communal belief than venture out alone in the night. It is understandable. It is safer, it is warmer by the fire. But the net result is that all these very bright Phi Beta Kappa’s in my lab, all from fine schools, future doctors, providers of care for you and me, were capable of being totally wrong not only in their knowledge but in knowing what they knew. They were without an inkling of how to distinguish when they knew something and when they didn’t. Most people’s way of knowing something is not whether it makes sense but whether what they believe is the same as what others believe, especially an authority. Maybe that is it. Maybe they have less problems with authority than I do. Yes, I keep extolling the virtues of authority and faith in this article, but that is because it does not come easily to me, and I have only late in life begun to appreciate its value, and my loss in not being more able to simply accept what I am supposed to accept. As much as I rail against the latest certainties, I am now, for the first time willing to accept that there is an argument to be made for consensually validated truth. Okay I will not argue out of both sides of my mouth, but for the first time I will grant that it is not totally catastrophic for a doctor to have a tendency towards self deception.
In the real world we make decisions all the time with only half knowledge. There isn’t any choice. If you have the time and inclination you might use a lot of energy gathering all known facts that would be relevant to a particular decision. But you still might be faced with large gaps in your understanding. The knowledge you gain might give you a 30% chance of success rather than a 25%. Okay let me be generous with psychiatry, a 65-70% chance of success rather than 50%. You still must go forward. You don’t have the luxury of a scientist who can isolate the question, eliminate all variables and hope to come out with data that will allow conclusions to be drawn about one specific question. If you have someone with ADHD you can’t keep thinking that you really only know 10% of what you need to know. Practicing psychiatry, practicing medicine, practicing social work, practicing business, doing whatever you do in the real world, involves many unknowns. Like it or not, you are forced to fly by the seat of your pants. If you didn’t make educated guesses quite a bit of the time you might as well close up shop and lock yourself in a laboratory. There is no choice.
Besides a doctor advertising that he does not know something might cause a lot of trouble for others. We are paid to know, paid very well to fix problems that patients come to us to treat. We can’t go around saying “I don’t know what to do.” It isn’t only image. Compassion dictates that you not tell people that. I see people who are suffering. Some feel they can’t go on. They have run out of options. Is it my job to tell them not to count on the state of psychiatric knowledge? For some of them their doctor is their best last hope. It helps to believe their fate is in the hands of a good protecting authority figure, like Robert Young in Marcus Welby, or like we wished our father could have been, like Robert Young in Father Knows Best. Faith heals. Any faith. Placebo works almost as well as medication. Even with panic disorder. It is effective 55% of the time. Medication works better than that, but not by much. For a doctor to throw away the healing power that a patient’s faith will give him is to needlessly diminish his effectiveness. The combination of placebo and a drug that works can be a very effective treatment. I have certain doctors who refer to me and I succeed probably in the range of 90% of the time with their patients. I have other patients from other doctors and I succeed 0% (if I am lucky). Evidently the doctors who I always fail with don’t think highly of me. I’m sure they don’t say to their patients this guy is a jerk but you should see him anyway. Nevertheless they manage to convey something very different than the doctors who have confidence in me. It makes an enormous difference. After Freud became famous, and officially a genius, he could cure people in a single consultation. He rightly distrusted this kind of cure as the magic it is, little different than the cures of circus evangelists and hypnotists. (After one person is hypnotized on stage, 500 people can be hypnotized in a jiffy) So Freud warned against “transference cures” but my guess is he was in no hurry to blow up his professional reputation in the name of honesty. It is a sign of maturity to act the part of Dostoevsky’s Grand Inquisitor. I am not doing it here, but I regularly try to be doctorly with my patients. So those future doctors in my histology lab, if some of them are psychiatrists today, may be getting reasonable results just because their ability to seem knowledgeable has been polished to a luster that inspires confidence.
I am not claiming that the practice of psychiatry is little different than the sweet talk of an Elmer Gantry. People who have gone to medical school and studied hard in school deserve more respect than habitually, knowingly, fraudulent con artists, who read a book or two, or take a weekend course at a prestigious sounding institute and hang the diploma on the wall or become experts at treating all of life’s ailments with herbs. Most doctors are trying to do things the right way. They have not taken shortcuts. They have had to absorb years and years of information from courses, from journals, from lectures, from chapter after chapter of subjects studied over and over. They have been tested and retested to make sure they know what they should know in their specialty. Most doctors, have learned the bulk of what there is to know about the proper treatment of the ailments they treat. Most desire to use the latest findings of science as they become available. Most believe that it is a good thing to follow guidelines prepared by scientists who are knowledgeable. Most doctors have done everything they were asked to do by society. I have respect for good doctors and good psychiatrists and there are plenty of them. I have respect for the character building that long years in school and playing by the rules engenders. But nevertheless, despite the many years other doctors and I spent studying, absorbing, integrating scientific methods of all sorts at fine universities, it is all relatively useless in the practice of medicating psychiatric disorders. I wish this weren’t true but it is. We simply do not “scientifically” understand the illnesses we are treating. It isn’t just ADHD. It is all of them.
We have little scraps of irrefutable knowledge, that such and such medicine will work X percent of the time for a given diagnosis. And if we continue the treatment X amount of weeks or months it will more often work better than if we stopped it earlier on. We read through heaps and heaps of information presented in scientific language. We have an abundance of speculations presented within a scientific context. We understand, in a scientific way, a couple of things here and there. To our credit, and this is no small point, unlike less trained people, we can sort out absolute nonsense when it is presented to us. On our own, we may have learned a number of tricks along the way. We may have discovered combinations of meds not in the books. We may know how to answer critical questions asked by our patients when they are desperate. From experience we have learned to anticipate certain difficulties and remain calm when we come across a crises we have faced before. I have my theories about drugs so that when I come across, for instance, a very sensitive person I might think SSRIs, or a tired sluggish depressed person might do better with Wellbutrin, or some one greatly in need of sleep might profit from Remeron. With certain patients I might make decisions almost unconsciously. On a gut level, they may remind me of someone else who did well on a particular drug so on that basis alone, unconsciously I might choose a medication. And when complications arise, I see how botched up mental health treatment can get when it is delivered by family practitioners, physician’s assistants, gynecologists, and others freely prescribing psychiatric medications. Especially when non-psychiatrists treat patients I understand that there is something to be said for specialized treatment by psychiatrists.
Nevertheless, when more than one medication is needed I am not that different than a cook who discerns whether more sugar or salt or cinnamon is needed. From a strictly scientific point of view all of those years of training in which we accumulated scientific knowledge and methods are practically useless when we take out our prescription pad. The majority of doctors and psychiatrists rely on the guidance of journals, on studies that tell them what to do and how. They will probably not have an understanding of exactly what a drug does and how it does it. Most of the time it isn’t known. Basically psychiatrists trust the journals or the books on what they should or should not do for a specific diagnosis. Sometimes they follow it like a cookbook.
And that is the problem. I have saved one argument for last. I don’t usually like conspiracy theories. But I can’t avoid making the charge. Some of the loyalty to biological explanations, and drug treatment is economically driven. Many drugs do terrific things for ailing patients and psychiatry is no exception. But drug companies push very hard for a biological perspective to be the dominant point of view among physicians. Every week physicians’ offices are inundated with dozens of journals all free, whose very existence depends on ads for medications. Many psychiatric journals specifically target primary care doctors. They contain sciencey articles by professors from all over the land. Many of the articles have a common theme. Fear not. You can do it. You can treat psychiatric disorders. No sweat.
Respectable academicians on drug companies’ payrolls deliver similar messages at the very best restaurants in town. The tab is paid by drug companies. They bring in an obstetrics professors to tell us “Relax. There is no problem giving these drugs to pregnant women.” I remember when Valium came on the market. It was going to put an end to the addiction problems with barbiturates. Sleeping pills, stay awake pills, you name it are presented as if the problems with the older drugs have been overcome. We have reached the promised land. The message is delivered in slides showing graphs, pictures of the brain, statistics, science, science, science, science. It gives the impression that we have come amazingly far in our knowledge base. Typically no one is going to be impolite and challenge their host speaker. The speakers are usually charming and articulate, smart enough but still regular guys. They are invited guests. Suitable decorum is expected. Similarly doctors are paid to stay on the telephone for “seminars”. The presumed goal is bringing the doctors up to speed on a new medication. Here too I have never heard anyone give the person making a pitch a hard time. Most doctors sound like cheer leaders for the main speaker. Even though their pitch is greatly in need of skepticism.
A December 4, 2002 article in the Wall Street Journal pointed out that 62%, of the $1.18 billion total spent for the continuing medical education of doctors is paid for by drug companies. In May of 2000, Marcia Angell – who was then the editor-in-chief of the New England Journal of Medicine – wrote a surprisingly candid editorial titled, “Is Academic Medicine for Sale?” Angell referred to the “Faustian bargain” that takes place when scientists accept pharmaceutical money. Dr. Joseph Biederman MD, (Professor of Psychiatry at Harvard Medical School. Chief, Clinical and Research in Pediatric Psychopharmacology Massachusetts General Hospital and McLean Hospital) is one of the most influential advocates for ADHD issues. I do not know what exact proportion of his annual salary comes from drug companies, but my guess is it must be substantial. My wife and I have been wined and dined at the finest restaurants in NY, taken to Broadway shows, and ski trips along with the other local psychiatrists. I have been given $300 to eat lunch with a drug salesman and answer questions about my response to his company’s advertisements. Dr. Biderman’s income from drug companies cannot be small. He has received research support from Shire, Lilly, Wyeth, Pfizer, Cephlon, Janssen, and Noven. He is on the speakers bureau for GlaxoSmithKline, Lilly, Pfizer, Wyeth, Shire, Alza, and Cephalon. He is also on the advisory board for Lilly, Celltech and Shire, Noven and Alza/McNeil. I do not believe he is simply lying to the public for monetary gain. (note added 6/8/2008 Although I am less sure now. He failed to report to Harvard that he had received 1.6 million dollars from drug companies. Researchers Fail to Reveal Full Drug Pay.) I assume he believes every word that he writes. But it is reasonable to wonder if we are on a level playing field when it comes to assessing the evidence, or more importantly having differing points of view represented in academia published in journals and funded by research dollars.
Are the professors duped by their bosses? I believe they are. Doesn’t every employee in every field of endeavor learn that part of the price of holding on to your job is learning what you can and can’t say? When I was chief of psychiatry at my local hospital I knew I could only go so far and then I had to zipper my mouth. For exactly that reason there was a time when academicians made a point of steering clear of the commercial world. When did that change? How did it happen at our richest and most prestigious universities? How can the Chief, Clinical and Research in Pediatric Psychopharmacology at Massachusetts General Hospital be paid by so many drug companies? What would happen to his living if he were to become a critic of the quality of research being done on ADHD?
The issue is even more compounded by what I alluded to earlier. Setting standards of care for my field are based not on scientific discoveries and logic but on the polling of “experts.” As I noted experts is a comical term when we don’t understand a fraction of what we need to know. It is worse than that. Expert consensus protocols are presented as “standard of care” for each designated illness. We are expected to follow these standards because if something goes wrong (which the law of averages promises every doctor) we will be in deep doo-doo during our day in court. So most doctors will be very influenced by experts. Very few of the experts dictating treatment standards are not on the payroll of drug companies.
This past year, right at this very minute, selling adult ADHD is evidently this season’s target market. That was one of the reasons I decided to write this article. It was bugging me- ADHD everywhere. Journals, one after another, have articles trumpeting the under diagnosis of ADHD, particularly adult ADHD. Was there a new important discovery? Has anything scientific changed? Not really. This campaign has clearly been inaugurated and orchestrated by drug companies. Why did they decide on this? I don’t know but obviously those whose job it is to look for market niches believe the time is right. Just like in any other business, their job is to catch on quickly to marketing trends. Americans are becoming a little looser, less afraid of the no, no drugs previously forbidden by the last generation. They will take drugs that would make their grandparents shudder. They believe their parents’ fear of drugs was exaggerated. Patients trust their doctors if they believe their doctor is giving them medicine for a “real” illness, for a chemical imbalance. And I shouldn’t leave this out. Many of them have seen a miraculous improvement in their parents now that it has become clear that all along their parents had been depressed. All those years of worry, all the unnecessary grouchiness- how different life might have been if they had been correctly diagnosed and taken a “well whatever” pill. The market is just about right to bring out the good stuff. The kids in college have known all along about these drugs. My son who just graduated from Yale, after reading an early draft of this article, told me an interesting story. He had been complaining to one of his classmates about all the work he had to get done and how he didn’t feel like doing it. Without a moments hesitation his classmate answered, “I got Ritalin. You want one?” I also showed this article to a friend’s daughter who just graduated from McGill. She had the identical report about what was going on there.
Here is a headline from the NY Times:
Latest Campus High: Illicit use of Prescription Medication, Experts and Students Say: NY Times Page B8 3/24/00
“Ritalin makes repetitive, boring tasks like cleaning your room seem fun” said Josh Koenig a 20 year old drama major from NYU.
“Katherinen Plyshevsky, 21, a junior from New Milford NJ majoring in marketing at NYU said she used Ritalin obtained from a friend with ADD to get through her midterms “It was actually fun to do the work,” she said.
The two most prescribed medications for ADHD, Ritalin and Adderall (a mixture of amphetamines) are in the stimulant class. They are pharmacologically similar to cocaine. They all work by giving a lift similar to “a shot of adrenaline” a much welcomed heightened state of energy. Unlike adrenaline their effect is mostly limited to the brain. Unlike they’re cousins, sold at natural food stores as herbs, the now famous ephedrine, these drugs are not sloppy. This is the good stuff. Compared to ephedrine, there is relatively little peripheral stimulation of the heart and blood vessels. These are drugs that make you feel good, confident, energetic, alert rather than beaten down, on top of things, acting rather than reacting. Given the opportunity to take them test animals will take them over and over. So will most people who need to feel up.
David Wells, the New York Yankee pitcher made a splash with his comments about professional athletes. The dirty little secret in sports is that performance enhancing drugs are very desirable. Wells estimates that over 40% of baseball players are on them (either steroids or stimulants). A moment’s thought makes it clear that athletes, like performing artists, need to feel “up”. When basketball players are in the zone, they can’t seem to miss a shot. Baseball players go into hitting streaks. When you talk to them about what makes the difference it will be something about confidence. The basketball player feels like he can’t miss and lo and behold he doesn’t-same for the hitter. They feel on the attack rather than back on their heels.
Observe the owner of a new restaurant. He will work ten, twelve, fifteen hours at a clip. He will polish the windows, try to improve the menu, rearrange the flowers, always with energy to spare. Unless he has a gift for management his low wage employees will be moving along at a snail’s pace, keeping one eye on the clock. They will go home more tired than the boss. These drugs help you feel like the boss. They make you feel in charge. They make you feel like reward will be assured. They make arduous tasks easy.
Doctors serving air force fliers have been accused of offering speed to keep pilots alert during their long boring flights. Truck drivers depend on them. Stephen King wrote most of his books with the help of cocaine. Lawrence Kudlow, one of President Reagan’s chief economic advisers, confessed that he used cocaine and speed. The list of others who found cocaine helpful is fascinating. Initially Freud hailed cocaine as a cure all. It should be emphasized that cocaine at that time was not forbidden by a narcotic agency. It was simply a product grown in South America believed to have medicinal value. Coca wine, a combination of cocaine and alcohol, introduced in 1863 by Angelo Mariani, rapidly became the world’s most popular prescription. Writers loved it. Anatole France, Henrik Ibsen, Jules Verne, Alexander Dumas, Sir Arthur Conan Doyle, and numerous other literary luminaries could be counted among its users. Vin Mariani was celebrated by royalty as well: by Queen Victoria; King George I of Greece; King Alphonse XIII of Spain; the Shah of Persia; and by William McKinley, President of the United States. Architect Frédérick-Auguste Bartholdi remarked that if only he had used Vin Mariani earlier in his life, then he would have engineered the Statue of Liberty a few hundred meters higher.
Devotion to Vin Mariani transcended petty differences of religious dogma. The Grand Rabbi of France, Zadoc Kahn, was moved to write: “My conversion is complete. Praise be to Mariani’s wine!” Pope Pius X was an enthusiast, as was Pope Leo XIII. He gave coca wine an official seal of approval by awarding Angelo Mariani a special gold medal.
According to the Sears, Roebuck and Co. Consumers’ Guide (1900), their extraordinary Peruvian Wine of Coca…”…sustains and refreshes both the body and brain….It may be taken at any time with perfect safety…it has been effectually proven that in the same space of time more than double the amount of work could be undergone when Peruvian Wine of Coca was used, and positively no fatigue experienced.”
Cocaine was once sold at Harrod’s in London. Prospective buyers were advised – in the words of pharmaceutical firm Parke-Davis – that cocaine “could make the coward brave, the silent eloquent, and render the sufferer insensitive to pain”.
Nothing has changed. Would the average person like the feeling Ritalin, cocaine or amphetamines gave them? Probably. Might they perform better? Very possibly. That is why they are illegal. Precisely because they are so pleasurable, so luring, (and eventually so destructive) they are restricted and governed by our narcotic laws. They are Class II controlled substances, in the category of the most carefully regulated medicines. They cannot be called in to a pharmacy by phone or automatically refilled. A new prescription, after a presumed careful assessment by a physician must be written every month.
Are Lawrence Kudlow and Stephen King, Freud and Pope Pius X evil? Obviously not. But my grandparents would consider them to have used poor judgment. After a car accident Stephen King eventually considered himself in great danger. Freud, after his initial enthusiasm, became very alarmed by the eventual fate of some of those who became preoccupied with the drug. Stephen King has said that the Kathy Bates character in Misery (the nurse holding James Caan captive) represented cocaine. The lesson of Robert Louis Stephenson is clear. Mr. Hyde eventually emerges from Dr. Jekyll. (Although Stephenson was reported to have written Dr. Jekyll and Mr. Hyde during a 6 day and night cocaine binge.)
So let us cut to the chase. What does Ritalin and amphetamines do for kids (and adults) with ADHD? It does the same thing it does for everyone else, people who do not have the diagnosis. It gives them a can-do-this-is-fun-feeling. Instead of feeling “yuk, who wants to do that? That is work. It is more than I can handle. It is unpleasant and frustrating and beyond me. I don’t want to even begin. I need to tune out, get out of this job, get out of here.” The drugs replace that feeling with a feeling associated with pleasure, power, and energy, thus allowing a person to do work without it seeming like work. When a person feels in charge, there is much less effort involved. It gives the feeling “I am on top of things, coasting, moving right along.” Back to Dr. Castellanos head of ADHD research at the NIMH:
“It used to be said that dopamine (the neurotransmitter released by cocaine and Ritalin) was the reward chemical–that if something was rewarding, then you would release dopamine. It turns out to be more complicated than that. It’s not just whether something’s going to feel good, or be rewarded; it’s more if there’s a possibility that something would feel good.
If an animal knows that they’re going to be rewarded when they correctly do a task, then dopamine is no longer involved. But when the animal thinks that maybe this is the way to solve the task, dopamine is leading the way, saying, “This, try this, try this.”
This works for work. Stephen King wrote a prodigious amount during his intoxications. But it was not because he was correcting a chemical imbalance. This is the conundrum about drugs. It would be very easy if they did nothing. But they are often very helpful. I don’t doubt for one second that the reported reduction in ADHD symptoms with the use of these drugs is a legitimate claim. The issue is the cost.
I am not opposed to Ritalin if it is used judiciously and without propaganda that it is a scientific solution to a chemical imbalance. I have no problem with considering it as part of the possible treatments for someone with ADHD. I have seen patients dramatically improve with it. I am strongly opposed if it is seen as the main treatment, if ADHD continues to be viewed as essentially a chemical illness, if, in the name of science, treatment approaches are mechanistic in concept and execution. I have gone out of my way to write about this subject as personally as possible, for it to have the scent of human frailty, for the reader to know, if he doesn’t already know from fortunate but also unfortunate experience, that doctors are human. They not only make mistakes, but like others they will not be too open about them. As humans we are all too willing to try to escape our imperfections and vulnerabilities. In psychiatry, hiding behind the cloak of objectivity, using the language of science gives both the doctor and his very willing patients an illusion of greater control than the state of our knowledge should allow. This is understandable. A surgeon covers his patient’s body and concentrates on the surgical field, on the task and methods he has mastered. As he cuts through flesh with his scalpel he rightfully should not be thinking I am stabbing a human being. I will state it for the last time. Nothing would give me greater pleasure than a true scientific understanding of the brain and how the various disorders in need of treatment can be logically handled. But we aren’t even close to being there yet. We may be centuries away
In the case of ADHD we are talking about raising children so that they feel motivated to work hard in the areas we and more importantly they consider worth the effort. We are talking about how this can be accomplished without squashing a child’s spirit, or for that matter an adult’s spirit. Intangible qualities, issues of individuality, freedom, discipline, learning how to apply oneself regardless of frustration are an important part of the equation. We will never have a perfectly worked out formula that tells us how to best raise our children. And an overall philosophical perspective, while helpful, still may not translate into the specific decisions needed here and now. It is easier to be a general than be stuck in the trenches fighting a real war. But I don’t want this to deteriorate into a relativistic what the hell, everyone is right. I am taking a stand against much nonsense. I am arguing against the pseudo solutions being offered by the medical profession. I am calling upon my profession to improve the quality of our work.
Summary
1. It has always been known that it’s difficult to get children do what you want them to do rather than what they want to do. When children are forced to sit quietly in situations that fail to engage them they become fidgety, disruptive, and not with the program.
2. Numerous methods have been tried to improve children’s ability and willingness to pay attention to chores being asked of them. The capacity of children to learn how to work may include the early development of good habits, fear of punishment, a desire to please parents and authority figures, keeping a cool head when a task is challenging, competitiveness about accomplishments, guilt, the example of parents and others’ willingness to do things they don’t feel like doing, encouragement, and many other strategies, tricks, and blatant forms of oppression learned over the ages. Religion played an especially large role in my life and the lives of many Americans. It was not a Disneyland world. Fear was an important element of respect. God was seen as the greatest, as awesome. But He wasn’t an easy going good guy. He ruled. He was a taskmaster. His rules, rules in general were holy.
3. Our culture has changed radically, from one in which moral concerns were at the center of experience, to a more pleasure oriented, stimulus bound existence. Being baaad was always exciting for young people. Not just adolescents. Everyone finds it exciting. Temptation is not new. But since the counter-culture smashed the rules, being bad has been particularly good. Related to this, entertainment and entertainers have assumed an especially huge role in our consciousness. When this sensibility predominates it is easy to get bored and distracted.
4. Like everyone else I swing back and forth on the issue of independence, pleasure and vice versus virtue. I stand accused of rooting for the sinners in movies like Chocolat and Footloose where religion is rightly seen as the enemy of pleasure and self-expression. Moreover, I am in awe of people like Michael Flatley the man with the “Feet of Flames” creator of River Dance, winner at 17 of the all Ireland flute championship, once a golden glove competitor, who growing up in Chicago was an ADHD diagnosed Irish charmer. He paid no attention in class and still is not willing to pay his dues to those with authority. I am in awe of many other diagnosed and undiagnosed people with ADHD who are talented and living free. I am not in awe of a lot of creepy annoying people who will make a total mess of their lives because they never learned how to comfortably do things that they don’t like doing. When they were children they behaved terribly. This article jumps back and forth arguing for and against discipline.
5. Psychiatry has its share of industrious, dedicated scientists who are slowly gaining information that may help us to understand children and adult behavior.
6. So far the information gained through scientific research is relatively trivial compared to the information that will eventually be needed. The public is being misinformed about the level of this knowledge.
7. ADHD as defined by DSM-IV accurately describes the behavior of many children.
8. Children with a variety of physical defects in their brain have trouble concentrating on tasks, learning the rules that are supposed to govern their behavior, and behaving in the way expected of children with a normal capacity to synthesize, integrate, and act with self-control when confronted by rules and tasks.
9. The vast majority of children labeled ADHD do not have a physical defect in their brain that can be demonstrated by any tests. There have been a variety of research tests done in laboratories implying that their brains are physically different but this work is questionable and the conclusions drawn from these studies highly speculative.
10. The vast majority of educators, physicians, and psychiatrists have not offered resistance to the view that there is a biological origin for ADHD. They also did not resist explanations given 40 years ago that the majority of children’s difficulties were due to poor child rearing practices, unhappy homes, and the full array of “nurture” hypothesis then in vogue. Most people will go along with whatever they are told by people in the know.
11. As much as we would like reality to be different, doctors do not have omniscience any more than other human beings. If they are intelligent, and have been, and continue to be, studious, if they are able to learn from their experience, they can do a better job than doctors who don’t possess these qualities. But most doctors are like most people. They accept a good deal of what they are told. There may be no choice. Doctors are faced with real patients throughout their working day. Unlike scientists in the lab, actual practitioners must make decisions all the time that are not based on fully adequate knowledge. They must go with people they trust, rely on knowledge fed to them by others.
12. In psychiatry (and other medical specialties) the source and reliability of the information fed to doctors is highly questionable. It is supplied by people who unabashedly call themselves “experts” which should be a tip off that their intellectual integrity is less than it should be. Despite inadequate knowledge about most psychiatric conditions many experts work diligently to standardize treatment, to develop protocols that clinicians are expected to follow. Most of these experts, at most of the most prestigious universities in the United States receive significant amounts of money from drug companies
13. Stimulants have a role to play in the treatment of ADHD if their mechanism of action is understood. They artificially supply a sensation of expected reward, a needed emotion if a student is going to willingly do unpleasant things expected by others. Another way of putting this comes from Mary Poppins. A spoonful of sugar makes the medicine go down. It turns work into pleasure. I do not contest that this, as well as many other drugs, effectively supply useful emotions for different conditions. Drugs have a constructive role to play in the treatment of suffering individuals. Perhaps they have a role to play for other purposes.
But the idea that doctors, through ever evolving scientific understanding, are correcting specific “chemical imbalances” found in a child’s brain or blood is pure fantasy. Doctors may talk about chemical imbalances but they do not test for chemical imbalances. There is no test. Equally imaginary is the idea that prescribed treatments for scientifically understood DSM IV defined ailments have been elegantly worked out in the august halls of science. We have not entered the Star Wars era, when presumably the brain’s pathological mechanisms will have been dissected and put back in shape with well understood treatment. This fantasy is ahead of reality by about 200 years. Or maybe it will never come to pass.
PCs are great and so is HDTV, but I’ll be damned if we are living in a world of coherent brain science now. Where are the robots? Where are the terminators? Where are functioning phone answering systems in corporations when we want to find the answer to simple questions? What I really want to know, given the fact that I am a psychiatrist, is where is the understanding of the brain everyone is being told we have. Are they hiding it from me?
I am itching for a debate in which doctors, patients and society might properly address not only the use of stimulants, but what their widespread use implies about increasingly common difficuties parents seem to be having raising children motivated and focuseed on work when it is required of them. It is a challenge for every parent. Always has been. The question is whether we are doing worse than we used to do. Or have we simply reached a point of affluence when pleasure seeking can be safely pursued without jeopardizing our children’s lives and livelihoods? Once again I would welcome the good news. Fun is far preferable to work, especially unnecessary work, as conceived by teachers we can all remember, who should be described as child abusers. On the other hand, as clever ass as I might be making fun of work which I remember hating, once you start asking too many questions like that you have stood closer to the slippery slope likely to give you ADHD children.
The debate is this. In the old days, everyone was clear about what the problem was if all a child wanted to do was play. If he or she was resisting the rules, or was oblivious to them it meant trouble. Parents understood that it is their job to successfully train their children out of their natural desire to dilly-dally, goof off, put off their homework and anything else that isn’t fun. They have always understood that such chidren can be noisy and disruptive to other children trying to do their work.
I don’t blame parents for wanting to protect and indulge their children, especially because lately love and sharing pleasure have become one and the same thing in Hallmark Card presentations of true parenting. Quality time dogma allows Disney like theme parks to charge ever increasing small fortunes to get into temples of quality time love. But I guess I also am saying get over it. Like Cher in Moonstruck, if you love your child tap your secret adult. Get mean if you have to. You are not Santa Claus. You’ll get your chance as a grandparent.
On the other side of the debate are those who claim the whole thing is caused by a chemical imbalance. I have tried to show that despite a wide spread impression that brain chemistry has been elegantly worked out in high tech laboratories and spread through out the world through scientific journals of complete objectivity, it just ain’t so. The editor of the New England Journal has questioned whether academia is for sale. She later wrote a book about the undue influence of pharmaceutical money. The editor of the British equivalent of the New England Journal, the Lancet, wrote a similar article in the New York Review.
If you have been misinformed get educated. Read critically what is being claimed. As I noted above, talking robots, terminators, rocket ships, and time machines do not come from the world of the real. The internet is magical and we are only at the beginning. Human intelligence, when we get going, is amazing. It may be legitimately argued that we don’t know what will be in the future. Maybe scientists will discover that it really is like propagandists claim today. They will discover that our self proclaimed “experts” really have figured it all out, figured out how to make our brains always function optimally, without pain and hardship and fear and with simply fantastic concentration. Wouldn’t that be fantastic for everyone? Fun and work combined, passion and focus, all in a pill. I can’t say they are wrong but I do know they can’t say they are right. It is too early in the game. It would be nice if the pill pushers would come clean about how much they do not know. ( I might add however, that, what I have in mind is not the hysteria the press and now congressmen are whipping up regarding SSRIs. We do not need the other extreme, a circus condemning useful medications. Perhaps I am asking for the impossible in public discourse, shades of grey rather than black and white)
But still, drug companies do need to be tamed, not by laws, but by information. Lately, there has been a push to get a lot of adults to also use stimulants, the same drugs that allow ADHD kids to enhance performance. They are being marketed as a cure for tiredness, a quick fix for depression, and as treatment for what is being claimed is widespread adult ADHD. People late for work, unable to keep to deadlines, impulsive to a fault, are claimed to have a physical ilness. If they have turned to street drugs they have simply been self medicating their legitmate DSM IV defined disorder. These drugs change tedious chores into interesting challenges. Such drugs have been banned in professional athletics at the same time as they are encouraged for classroom enhancement.
There is no doubt that many people feel terrific on these drugs and performance is often enhanced We are thus repeating a widespread practice of the 19th century, when a similar drug, cocaine, was the most used drug in the world. It would not have to be outlawed if it didn’t make people feel so fantastic.
14. Throughout the article I take a trip down memory lane. There are two reasons for this. At my age, 61, many people do the same thing. They try to make sense of their experience. I think it is a valid way to get perspective, not only on one’s own childhood, but also the problems kids face today. It is useful if you do it with enough honesty. When revisited in recollection our lives offer vast new opportunities for discovery. I know the modern perspective is that the past is not the present. It is not useful. What matters is now, now, now. I reject that. The past is the ground on which we stand, the foundation, the basis for what we do now and all the nows to come. Parents should regularly try to understand what went on in their own childhood. They should learn most of what they have to know from their own parents, sifting through, rejecting, accepting, maintaining the dialogue. It is a decent antidote to the points of view of experts, who wave their scientific “findings” indiscriminately and without a solid basis in fact.
15. Two additions to the original article since it was written.
a)It is noteworthy, that the most renowned “expert” in this field, Dr. Joseph Biederman of Harvard, failed to report to Harvard that he had received 1.6 million dollars from drug companies. Researchers Fail to Reveal Full Drug Pay
b) The following item concretely illustrates how drug companies influence opinion.
“It Was Like A Whitewash”
Enter Dr. William Pelham, director of the Center for Children and Families at State University of New York at Buffalo (SUNY). A leading ADHD researcher for 30 years, Pelham is a former member of the scientific advisory board for McNeil Pharmaceuticals, which produces Tylenol and markets Concerta, a popular stimulant medication trademarked by Alza Corp. of Mountain View, Calif. Over his career, Pelham has penned over 250 research papers on ADHD, many with industry grants. In 2002, he was given a lifetime achievement award by the world’s largest ADHD patient advocacy group, Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD).
In interviews with AlterNet, Pelham provided glimpses into the dubious methods drug maker McNeil-Alza uses to ensure that studies it funds produce favorable results for its ADHD medications. Between 1997 and 1999, he was paid by McNeil to conduct one of three studies used to get FDA approval. The company currently uses the three studies to claim that 96 percent of children taking Concerta experience no problems in appetite, growth, or sleep. But Pelham says the studies were flawed. The original intent of the studies was to measure both side effects and main effects of the drug. But two of the three studies, including Pelham’s, required that the subjects had to already be taking MPH and responding well to it in order to enter the study. In other words, by stacking the studies with patients already successfully taking stimulants, McNeil ensured the subjects would be unlikely to register side effects, Pelham says.
“It’s really misleading and I’m surprised the FDA is letting them use the studies to advertise no side effects,” he says. “They had no side effects because they took only people with only a positive history of medication. This is really pushing meds without telling the full picture.” There was also pressure from the company to tweak the findings, he says. Part of Pelham’s study involved “providing parent training to parents, having a simple behavioral program in place on Saturday lab days, and establishing simple behavioral programs in the children’s regular school classrooms.” When his paper was in the galley proof stage at the medical journal Pediatrics, Pelham says he joined a conference call with a number of senior people from the corporation who lobbied him to change what he had written in the paper. “The people at Alza clearly pushed me to delete a paragraph in the article where I was saying it was important to do combined treatments (medication and behavioral),” he says, adding that they also pushed him to water down or eliminate other sentences and words that did not dovetail into their interests. “It was intimidating to be one researcher and have all these people pushing me to change the text.” McNeil offered no direct response to the allegations.
“We cannot comment on unsubstantiated allegations,” says Gary Esterow, a spokesman for McNeil Consumer & Specialty Pharmaceuticals, in a written statement. “The protocols and full study reports for these clinical trials were reviewed by the FDA, and provided the basis for FDA approval. Prior to publication, there was ample opportunity for full discussion of the data among the investigators. Publication of the findings reflect the prevailing opinion of the authors and is further supported by the peer review process of the scientific journals in which these studies appear.” Pelham says McNeil didn’t stop there. The company commissioned a follow-up study on the conversion study mentioned above. This time McNeil did the data analysis and coordinated the paper writing. “I insisted on seeing the analyses and having major inputs into the manuscript and it was like pulling teeth to get wording and analyses changed,” he says. “It was like a whitewash, a praise to Concerta.” Pelham says the company submitted the paper twice to the Journal of the American Academy of Child and Adolescent Psychiatry. Drafts were sent to Pelham several times but he says he never returned anything with his signature. In the end, however, he says the paper was accepted without his knowledge and published with his name on it).
My assumption for the reason Pelham was pressured to remove the paragraqh emphasizing the importance of combined treatments (medication and behavioral) is that this would expose the limitations of pediatricians, who would be required to meet this standard of care. By far, the biggest presecribers of Concerta is pediatricians. Use would go radically down if the pediatricians could not believe that they were giving appropriate care based on reasoning that they were simply fixing the chemical imbalance.
References
Angell, M. (2000) Is Academic Medicine for Sale? New England Journal of Medicine 342: 1516-1518.
Angell, M. (2004) The Truth About Drug Companies. New York: Random House.
Barkely, R.A. (2005) Attention Deficit Hyperactivity Disorder, Overview: Handbook for Diagnosis and Treatment. New York: Guillford.
Hearn, K. (2004) Here kiddie, kiddie. available at http://alternet.org/drugreporter/20594/.
Horton, R. (2004) The Dawn of McScience. New York Review of Book 51, Vol4..Mental Health:
A Report of the Surgeon General Chapter3. available at http://www.surgeongeneral.gov/library/mentalhealth/chapter3/sec4.html
National Institutes of Health (1998) Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder National Institutes of Health Consensus Development Conference Statement November 16-18, 1998 Page7 Available at: http://www.consensus.nih.gov/1998/1998AttentionDeficitHyperactivityDisorder110PDF.
Schmidt, M. (2003) Clearing the Bases. New York: HarperCollins
Sobo, S. (2001) A Re-evaluation of the Relationship between Psychiatric Diagnosis and Chemical Imbalances. Available at http://www.geocities.com/ss06470/index.htm
Wells, D. and Kreski, C. (2003) Perfect I’m Not: Boomer on Beer, Brawls, Backaches, and Baseball. New York: William Morrow
Footnotes
[1] See “History and uses of the Coca leaf” http://www2.truman.edu/~marc/webpages/andean2k/cocaine/history.html
[2] The Life and Work of Sigmund Freud, Volume I (1856-1900) (New York: Basic Books, 1953), p. 82-83
[3] “Latest Campus High: Illicit use of Prescription Medication, Experts and Students Say:” NY Times Page B8 3/24/00.
[4] See Sobo, Simon “A Reevaluation of the Relationship between Psychiatric Diagnosis and Chemical Imbalances” http://www.geocities.com/ss06470/index.htm
5 See Adult ADHD: Recent Advances in Diagnosis and Treatment. Adler, L A , Cohen, J http://doctor.medscape.com/viewprogram/2054 (2002) Section 5
6 Ibid
7 McCallon, D “If He Outgrew It, What Is He Doing in My Prison?” ADD Consults (2000) http://www.addconsults.com/articles/full.php3?id=1103
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