THE STEP-BY-STEP DEVELOPMENT OF ANXIETY-HYPERACTIVITY
All front line professionals dealing with children should
1) keep a sharp eye out for hyperactivity caused by improper administration of a stimulant drug and
2) be able to distinguish between true-organic, ie., neuro-ADHD and SIH.x
neuro-ADHD SIH
DEFINED: ADHD is a structured syndrome disorder—a medical-psychological mix with educational and social consequences. There is a familial pattern, probably inherited. SF:RS hyperactivity is a sign of family distress often extending to the school and other social environment giving rise to MSFs. A child plays the signal relayer role. One IP per family.
INCIDENCE: Much lower than commonly thought. 1/25 cases. More boys than girls (ratio of 3-4 to 1). Strictly by the odds an SF:RS source will win out: the ratio of SIH to neuro-ADHD is 25/1. Girl-boy 1:1.
SYMPTOMS: Commonly listed for diagnosis are short attention span, distractibility, hyperactivity,and impulsiveness. Emotional lability is mentioned in the literature, but anxiety is not common. Learning disability can accompany the disorder. True ADHD is distinguished by its continuous and relentless nature. That is, the badly afflicted child, except when asleep, is restlessly overactive, twitching and jiggling constantly, and the degree of inattention is very hard to overcome.
Note: Distractibility primes the hyperactivity. SIH children may variably display the triad of short attention span, distractibility, and hyperactivity. Symptoms come and go: definitely ‘on’ when in proximity to a split field. They are overactive and inattentive only some of the time. There is no realattention deficit, often the reverse—hyper-vigilance. If the above triad is intense, concentration diminishes and learning in school may be affected. Anxiety, visible or not, underlies hyperactivity.
Hyperactivity primes the distractibility.
CAUSE: It is hypothesized that in ADHD the brainstem reticular system is not working up to par. A definite organic, neurological flavor with soft, non-localizing signs and a diffusely abnormal EEG is common. No organic clinical flavor. In the family, blocked communication between the parents sets up a relayer system (SF:RS). At a higher social level there may be multiple split fields (MSFs) involving outsiders.
Rx: Stimulant drugs work favorably in just a day or two. A whole month’s trial, as recommended in the pharmaceutical sales-blurbs, is not at all necessary. If a stimulant is tried it usually makes SF:RS-MSF children worse, revs them up! Sedatives just make them dopey. Family Rx, community conference.
Key point: Some clinicians make their diagnosis on the basis of a differential response to drug treatment, that is, a short trial of Ritalin—which is only partly okay. Before doing such a ‘trial of treatment’ try the ‘finger twitch’ test. And always see parents and child together at least once.
SPECIFIC RATIONAL TREATMENT OF SIH
Psychologists usually recommend a combination of drugs and behavioral modification for ‘ADHD.’xi No one can deny the seemingly good sense of such—hitting the problem with both barrels. But such a shotgun approach, it must be admitted, is pretty nonspecific. The essential difference I emphasize is: Management strategiesof hyperactivity should not be blind; its diagnosis should be accurately focused and its treatment tailored, i.e., varied according to specific cause.
ONE SPLIT FIELD: Dealing with a family SF:RS is simple and direct. The problem and its resolution can be seen first hand. It doesn’t require tedious and long drawn out individual therapy sessions. It can be as incisive as a surgical operation. And it cannot be overemphasized that it is worth trying before committing any child to any ‘trial’ time on any drug, let alone years on Ritalin. General steps, once an SF:RS is discerned, are:
1. Dissolution of split fields: First and foremost, get the parents talking together! Facilitate talk between parents and teachers. When communication across a split field is opened up—if secret, emotionally important disagreement is pointedly externalized—a relayer is no longer necessary: the position becomes redundant. If the relayer is very young or the SF:RS of recent onset, anxiety-hyperactivity level subsides, often abruptly.
2. Carrot and stick: If the relayer is older and compulsive (like the school nurse), controls need to be invoked lest s/he set up new strategies triangles or reactivate old ones. When controls are successful, not only does the relayer’s anxiety-hyperactivity level drop but intrigues cease.
3. Innovations: In dire emergencies separation of the principle parties (eg., Timmy from mother, as we’ll later see) may be a necessary short-term expedient. In special instances tricks that skirt covert conflict with outsiders may be initially advisable (as in Michelle’s case).
 |
THE STEP-BY-STEP DEVELOPMENT OF ANXIETY-HYPERACTIVITY |
Right after a diagnosis of SIH is established, it’s best to get the child out of the room and temporarily deal with parents only. This has symbolic as well as practical value. It conveys a message that the child is not ‘the sick one’. Carefully explain the SF:RS. Show them what is happening; draw a diagram. Then get the blocked parents talking with each other about taboo child-related topics. Teach them to agree to disagree! Firmly instruct them not to get sucked into sending pejorative messages about each other through their child anymore. Insist upon it! A child may be unable to extricate itself from a humming split field, but even half-intelligent adults can do so—once they are informed. Don’t let them wiggle out of it. They must make a decision to end and exit this noxious triangle.
Once the parental split field is opened up, and that is the instant they start to talk again, once a child realizes there are no more hostile messages to relay, it all stops. Parents will report their child’s cure with awe. Some very long-standing, older relayers may try to reinstate the familiar system, but little kids welcome their rescue from it. “Someone has finally got me out of this mess with mom and dad.” A very occasional refresher course to follow-up on parents and reinforce their good intentions is enough. The fact that the child needs no medicine is a most happy verification of success in itself.
MANAGING MULTIPLE SPLIT FIELDS:
Handling MSFs that involve the extended family can be hectic and complicated. It's wise to pass the problem on to a knowledgeable specialist. But the informed family doctor can give it a first, front-line try by advising ‘converted’ parents to be firm with interfering relatives, and if necessary, cut them out of the circuit, unless they stop mixing in and messing up. So, help parents set conditions and limits.
Expanding circles of people potentially harboring MSFs must be considered. Some fervent workers would go so far as to include everyone in the hotbed of intimate therapy. At the other extreme some doctors hand out scripts without ever seeing both parents together with their child. Much better: approach them all through a well-organized conference. Conferences, however, pose added issues of coordination and confidentiality. The latter can be knotty indeed. Institutions that dole out money to the poor have an inherent conflict of interest. Nevertheless, responsible child welfare agencies, correctional services, schools, etc., should insist upon a community conference of all persons constructively involved with a particular child. Parents must be included! Doctors usually cannot find the time to attend, but some will, so they should always be invited. Simply getting key people together may be enough to start the healing process. The climate will be relaxed, friendly and informal, with refreshments.
1. There will be an exchange of information that airs differing approaches. You’d better believe that agencies, schools, courts have them! The chairperson should highlight and praise areas of agreement and success. Never be critical. Insist upon total confidentiality.
2. There should be an attempt to develop a short agreed-upon operational plan with overall reachable goals. This plan must include parental input. It cannot be arbitrarily ‘laid-on’ with much success.
3. Finally, it is even better if the conference can agree to select or elect a case coordinatorfrom its midst—not a supervisor—to henceforth actively follow all aspects of the case, later calling periodic sub-conferences as indicated.
From a practical standpoint it is worth bearing in mind that the ‘virus’ affecting split field relayer families often spreads far afield. If you can correct the family itself, complicated dealings with multiple agencies might be forestalled. Primary prevention of socially induced hyperactivity is not yet practical. But some degree of secondary prevention is; dealing head-on with SIH reduces secondary learning and conduct debilities.
DRUGS: As SIH does not require medication, it behooves us to know a bit about medicines, where they work and when they do harm. An intact brainstem ‘reticular formation’ (RF) screens out irrelevant incoming stimuli (see next illustration). It is surmised that in neuro-ADHD the RF is not working up to par, so that the rest of the brain, flooded with massive input, becomes overburdened. The result is that the afflicted child is distracted, cannot concentrate very well or easily sit still. Correct treatment, seemingly paradoxical, is a stimulant drug to perk up the lazy underfunctioning brainstem and thereby tone down the hyperactive child. However, other kinds of hyperactivity, as well as SIH, are worsened by stimulants!
Years ago Ritalin ® (methylphenidate) for children was highly controversial. Only child psychiatrists, not even pediatricians, were allowed to prescribe it in the mid-1970's! Protest groups faught it. But their voices died out. With the advent of new strategies related drugs, caution flew out the window. Now, the CPS (Compendium of Pharmaceutical Specialities) and the Internet carry page after page dedicated to anti-ADHD drugs.xii Stimulants are widely accepted, promoted, overused. Stories paint nightmarish pictures of children at school lining up in droves to get their ADHD drug-hit! Detail-reps aggressively promote anti-hyper drugs in doctors’ offices. One wonders if the remedy is driving the diagnosis. Obviously the big pharmaceutical companies are cashing in. But it is not entirely as underhanded as that. Certainly, the populace wants a pill for every ill. As an MD I’m all for medication, but I am dead against its excessive and incorrect use, especially in children. Unfortunately, many family doctors and teachers seemingly find it convenient. Is it their placebo? Ritalin is a stimulant drug. It works on the brainstem's Reticular Formation (RF) and the cerebral cortex (shown at left). If it is going to calm down children with true ADHD, a favourable response can be expected within a couple of days, not the entire month that the pharmaceutical brochures recommend. Several methylphenidate homologues of Ritalin are now on the market: Concerta, released in 2000, and Metadate in 2001 are two examples. Another CNS stimulant now being promoted, Cylert (pemoline), is more powerful than Ritalin and can cause liver damage! Also (amazingly) promoted is the amphetamine, Dexidrine, used by German flyers in WW2 and lazy students before examinations. Obviously a poor practice! Strattera (azomexetine), a norepinephrine antagonist, is claimed as the “first non-stimulant for ADHD.”
Use of sedating anxiolytics – such as Valium (diazepam) and Buspar (azapirone) – is irresponsible. They impair memory and are habituating if not addictive. Barbiturates (mind-dulling depressants) sedate from cortex on down and may compromise an already under-functioning reticular substance, aggravating neuro-ADHD. If a doctor puts an SIH-child on a sedative or anxiolytic drug it should be a clear medical choice. In my opinion it’s a poor choice; there are just too many unnecessarily doped-up children around.
The Internet list of drugs for ‘ADHD’ goes on: Powerful anti-hypertensives such as Tenex (guanfacine) and Catapres (clonidine) have entered the race. The old-fashioned tricyclic antidepressants Tofranil and Desipramine have been resurrected! Prozac (fluoxetine), a serotonin re-uptake inhibitor, is also pushed. SRI variants, may work in SIH, but it seems excessive. Reports of suicide in young people support my long held doubts about their willy-nilly use.
TREATMENT QUANDARIES: Strategically placed people—teachers in particular—actively find and, in one way or another, refer hyperactive children to compliant family doctors who simply—prescibe. A cautionary vignette:
C6: I once saw a wildly hyperkinetic boy who was spiraling up and up. His doctor had started Ritalin and, egged on by the child’s teacher, stubbornly kept increasing the dose. It turned out that this was a pure SIH-child. By stopping the medicine and dealing incisively with both parents the boy literally wound down overnight. The teacher needed no extra convincing.
DOUBLE DIAGNOSIS—‘ADHD’ and SIH acting together—is not uncommon. Genuine neuro-ADHD may be complicated by the concurrent presence of single or several split fields. Consequent wildly exaggerated hyperkinesis poses a true treatment dilemma. Increasing the stimulant drug will aggravate the SIH component; decreasing it may exacerbate the organic ADHD. So, if hyperactivity breaks through in a child previously under good medical control, don’t automatically increase a once effective dosage to high levels simply hoping for the best. Do not start switching medications around. Do not add a sedative for the SIH on top of the ADHD stimulant. These children are best kept on a level dose of a proven stimulant while the newly active split social fields are sought out. The split fields are dissolved as described earlier, or the child, if in danger, is extracted from the noxious situation—hospitalized or taken into temporary protective care. The following life-and-death emergency makes it clear that mixed SIH-ADHD is nothing to trifle with:
C7: Timmy, 10, was hospitalized in a drunken stupor. Vomiting 20 times/hour, he weighed a cachectic 15.4 Kg. The pediatricians (attending and resident) had investigated everything and tried almost anything—tube-feedings, IVs, antinauseants, sedatives—to no avail. The boy on the verge of dying, ‘last resort’ psychiatric consultation was saught. Timmy was frantic: hyper, dilated pupils, hair pulled out in tufts, tied to the bed. He had been diagnosed ADHD—now off Ritalin.
Multi-level assessment brought out that a vicious family SF:RS was central to MSFs involving ward staff, nurses and doctors. The mother was found to be subversively orchestrating the mess. She was primarily at odds with the head nurse and caught ‘pleasantly’ tickling Timmy’s ear-canal with a Q-tip while suggesting he throw up. The original clinical diagram of years ago shows three quite distinct split fields (T = Timmy, P1&2 = pediatricians, N = nurse, M&F = mother/father).
The mother’s visits were diplomatically ended; she was seen in my office, ostensibly to keep her informed of the boy’s progress. Children’s Aid was discretely notified as back-up in case she try to pull Timmy out of hospital. All meds and heroics were stopped. Staff meetings to air differences and coordinate treatment activities were started. This simple approach turned things around. In a few weeks a calmed-down Timmy, back on Ritalin, his weight doubled, was smiling ear to ear.
