THE STEP-BY-STEP DEVELOPMENT OF ANXIETY-HYPERACTIVITY
THREE KEY STUDIES
Years ago, as others stepped up their researches into the biochemical and genetic factors underpinning psychological problems, I turned my attention to discovering/deciphering corresponding social-family mechanisms.xiii The workings of a variety of dysfunctional family triangles were teased out. Two preliminary studies led up to my definitive research on SIH. Designed to examine coincidence of hyperactivity with the SF:RS-MSF mechanism, it took place piecemeal over a span of 30 broken-up years starting in the late 1960’s. At its inception I had no idea the study would last so long.xiv (Private office research is daunting. It took 26 active years to gather less than half as much data as earlier in just two years at the city clinic. I attempted to set up an ongoing matched and blind protocol, but over the long haul it was not feasible. There was no control group of hyper children not connected with some sort of community meeting.) It bears emphasis that during the active years of the study I maintained a general medical family practice to which I applied psychiatry. So the numbers are consistent with what a family doctor might expect to see—which, in turn, corresponds with general incidence-prevalence.
Data: On average, between 4 and 10 hyperactive children were seen each year for a total of 150 over a 30-year, partly broken up, time span. In that entire period only six were diagnosed with genuine neuro-ADHD—all of which were responsive to Ritalin ® (or generic methylphenidate). One child had squirmy rheumatic restlessness. All the other hyperactive children, 143, were found to be relayers in split field families. About two thirds of this group, 90, were also at the nexus of multiple split field triangles involving school, court, child welfare, etc. (Twirling little autistic children were excluded from the study as were head-banging, pacing, mentally retarded children. Unfortunately discounted, referred children wrongly on Ritalin were mostly SIH cases. One notable small girl had very profound hyperactivity secondary to cerebral complications of rheumatic fever.)
Differential outcomes: Symptoms were alleviated in 95% of instances that used two modalities of intervention—family Rx and conferencing. Where a community conference was not possible (rarely), but incisive family therapy with a focus on MSFs was, the success rate dropped to between 75-85%. Thus the significance of SIH was verified.
A BIT OF SOCIAL EPIDEMIOLOGY
According to the Internet Pediatric Database, the prevalence (all existing cases) of ADHD (defined loosely) is 2.5% of children, with an incidence (new strategies case occurrence) of 1-6% of school age children.The truth is shown in the above graph: neuro-ADHD (grey) accounts for less than 5% of all hyperactivity. Stated another way, there are 25 SIH cases for one of organic neuro-ADHD. The latter is grossly over-diagnosed. In SIH boys and girls are affected equally; in true neuro-ADHD the gender ratio is 3-4 boys for 1 girl. There is afoot an upsurge of this newly discovered type of hyperactivity. Formal epidemiological studies of SIH remain to be done. Coincidentally, the incidence of each, SIH and divorce, has been rising step by step in parallel – a true epidemic of both. I am less concerned with statistics than getting across observations and associated ideas. These are related to fundamental principles underlying social complexity and form, cybernetic feedback loops within a communication model, at three system-levels: the individual child, its family, and all appropriate wider social systems. Statistical evidence is tied into effecting family and social changes that correct hyperactivity. In science discovery and description should move toward search, research and measurement. This study admittedly has its numerical shortcomings, but it has heuristic value.
THE CRUX OF THE MATTER
There is an upsurge of this newly-discovered type of hyperactivity, SIH, afoot in Canada and the USA. What deeper trends could be behind it? To reach an answer we’ll meld together my own ideas about SIH with a seminal statement by the great Canadian philosopher, Marshal McLuhan, and the astute analysis of an American child psychiatrist, William Glasser. McLuhan, of ‘medium is the message’ fame, observed a radical reversal of two important personal priorities beginning around mid-twentieth century. He encapsulated this change in these seminal words: ROLE now precedes GOAL.
There always have been goals, selfless or selfish, related to survival and there always have been personal, self-enhancing roles. Only rich and powerful people could afford to equally indulge the latter. The helpless could but hope. The striking statement, goal now precedes role, means that a traditional emphasis on responsible planning and directing of one’s actions outwardly, with concurrent concern for others, now takes second place to an inward preoccupation with recognition by others of one’s own uniquely personal worth. Role now preceeds goal. And this means for just about everbody!
Glasser, author of The Identity Society, tied McLuhan’s reversal of personal priorities, beginning after two world wars and the great depression, into two long-emerging social trends and an epochal technical revolution: 1) rising levels of affluence and buying power, 2) progress in human rights (and hopes) for women and children as well as minorities; and 3) television, which portrays an overflowing fantasy-land of wonderful things and beautiful people.xvi
TV advertising displays the likes of a shapely, sparsely dressed girl sitting on the hood of a car. The image says, “Buy me (this car) and you’ll be somebody!" Or, in school, get a pat on the back first, then study. From a 2011 viewpoint, television still promises instant role gratification ... without real social effort. Social-technological trends have moved ahead apace to include personal computers and the endless internet. Results still can be dramatically translated into before and after scenarios in which the old goal of relatively selfless but sheer survival continues to give way to a self-centered, me-first role, in a materialistic world. Now, how does all of this clever theorizing tie into the immediate clinical problem of hyperactivity? In five ways:
1. There is a burgeoning of divorce. In the old survival-security and goal-oriented society people got married and stayed married. It was safer. It was a goal in life. In our modern identity society, confirmation as a valuable person, as ‘someone,’ is an almost insatiable craving. If a partner feels unappreciated, or poorly stroked (as described by Eric Berne), even merely unhappy, it is seen as okay to keep an eye out for someone new strategies who might combine all the marital talents of a small village, and depart for greener fields. Impossible! but believable. Thus, people easily split up and divorce rates spiral ever up. And as we earlier saw, separated parents are a perfect setup for split social fields and SF:RS hyperactivity. Compounding it even more, many children are farmed out to multiple recreated families – with new strategies fathers, new strategies mothers, new strategies siblings. These families of divorce are ideal opportunities for the emergence and maintenance of yet more split social fields. It is my strong impression that the incidence rate of each, divorce and child hyperactivity, has been rising step by step in parallel – a true epidemic of both.
2. Nowadays, intact nuclear families are probably much more democratically laissez-faire than were their counterparts of half a century and more ago. Children are often allowed and feel free to cross the generational barrier with relative impunity. In times past, families were less child-centered and it would hardly be conceivable to allow, let alone enable, any child to mix into parental affairs, and be relayers. Also, children themselves ‘knew strategies their own place’ and were less likely to get in the middle. Certainly some did, and SF:RS’s must have existed in small numbers. Also before, most people chose a partner from the same social-cultural background. There were few child rearing differences between them to argue or simmer about – or to exploit. Parents certainly had their silent differences, probably much more hidden than now, but, for the most part, they wouldn’t enjoin a child to convey their complaints to the other. Now, as we know, many do. Taken together, we can tentatively conclude that in intact families there has been an overall, absolute (but likely moderate) increase in SF:RS hyperactivity.
3. Single parent families are on the upswing, either by initial choice or through separation and divorce. At least for the latter, separation and divorce, everything said in the first point above applies. Even in the former, where a mother (or father) wants no committed part of the opposite sex, there may be an alienated boy/girl friend lurking in the wings, so the same applies. In short, single parent families are not immune to SF:RS’s. They are just harder to get at and treat.
4. In our present day entitlement type of world respect for many societal institutions has gone way down. Professionals too are less highly regarded. So, if there is a difference, say, between a parent and a teacher it is easier for the child to become a relayer of hostile messages. Back when I was in grade-school most parents were solid allies of teachers. If I got into mischief at school the chances were about 100% that I’d catch the dickens even more back home. The long and short of it: there was little chance for the sprouting of a noxious split field between parents and teacher with a child swept up in it. Now it happens all the time over many issues. Another point: Before, performance took precedence in school; reward for effort was considered a fillip. Just like for dad, it was a ‘day’s pay for a day’s work’. Few kids expected a pat on the back first. Children were expected to study hard and pass. Otherwise, no easy ‘A’ for effort. Things have changed. Another point yet: While respect for institutions has diminished, unhappy involuntary involvement has increased. I think there are more children from more families being ‘helped’ by more agencies now than ever before. The sheer numbers increase the chances of more split fields – multiple split fields – and induced MSF hyperactivity.
5. Today, there is more recognition – ‘case-finding' – of what is thought to be ADHD. But it is most likely spurious. When I was a child (in the 1930’s) there were three great gangling, twitching, 14 year old boys held back in my grade 4 class. One of these, in retrospect, was definitely hyperkinetic – with unrecognized, probably true ADHD. But the problem then was virtually unheard of. In the 1960’s a whole school might have had only one true ADHD child, if that. (ADHD then was termed ‘minimal brain damage.’) There might have been just one or so SF:RS-MSF child in a classroom, generally unrecognized as such. Now, SIH which is wrongly diagnosed as ADHD seems rampant. I doubt – I know! – that the absolute incidence of pure neurological ADHD has increased all that much if at all over the intervening years. SF:RS-MSF hyperactivity (SIH) has.
SUMMARY
Problems: Increased case-finding by teachers understandably fails to separate out distinct varieties of distracted, hyperactive children who may arrive at the sometimes poorly informed doctor’s office – indiscriminately lumped together. Current treatment is driven by drug manufacturers capitalizing upon the misconceptions of parents, teachers and doctors – all. Thus, true neurological ADHD is over-diagnosed and non-organic hyperactivity (SIH) incorrectly treated with drugs.
A Discovery: In light of a new strategies causative source, the biphasic SF:RS-MSF mechanism that constitutes SIH, the burgeoning concerns posed by hyperactivity and distractedness can be reevaluated. Not coincidentally, the rising incidence of SIH parallels a rising divorce rate in our modern laissez-faire society. Not all divorces are bad, but some badly affect children. SIH, much more prevalent than neuro-ADHD, accounts for most child hyperactivity. It does not need medication. In fact, stimulant Rx is contraindicated. Haphazard treatment stems from an absence of theoretical perspective and proper diagnostic tools to differentiate types of hyperactivity.
The Remedy: When teachers and doctors learn to recognize SIH – its phased, 2-step SF:RS-MSF mechanism is easy to see; it’s right before our eyes – then the unhappy scenario of children wrongly on drugs may change. Distinction is possible between bona fide neuro-ADHD, which is properly treated medically, and SIH, which is not. Thus, the vast majority of child hyperactivity (and concurrent school issues) can be handled without resort to drugs. That is, secondary prevention of school failure and bad conduct associated with SIH is effected through effective social management strategiesand almost surgically incisive family Rx.
WFH April 2011
iHogg, William. The Split Field Relayer System as a Factor in the Etiology of Anxiety (A matched study of 48 cases), Psychiatry (Journal for the Study of Interpersonal Processes), Vol. 35, No. 2 (1972).
iiIn the wordy disciplines of psychology and sociology succinct mechanism-diagrams not only are a visual bridge between verbal and mathematical-scientific descriptions but also are sophisticated process explanations in and of themselves. In psycho-social clinical work, as we’ll see, concrete problems almost inevitably give way to even more abstract etiologies that involve dilemmas and/or disputes.
iiiHogg, W.F. & J. E. Northman Ph.D. The Resonating Parental Bind (RPB) in Delinquency, Family Therapy (1979).
ivAnthony, E. J. Psychiatric Disorders of Childhood, in Freedman and Kaplan, Comprehensive Textbook of Psychiatry. Williams & Wilkins (1967). Note: My references are mostly ‘ancient’ as the modern literature is understandably devoid of the SIH concept.
vJenkins, R. L. Classification of Behavior Problems of Children. Amer. Psychiat. Jr. (1969).
viIt is useful to bear in mind that easily distracted children with short attention span may be surmised as having a learning disorder (eg., dyslexia) and unnecessarily subjected to an expensive battery of psychological tests. In the end the correct diagnosis may turn out to be SF:RS anxiety with minimal hyperactivity.
viiToolan long ago described acting-out as a ‘behavioral equivalent’ of depression. The reader may ask: Do SF:RS-MSF triangles produce just anxiety-hyperactivity? Why not aggressive rage? Well, triangles are malleable during their early, open phase and may display indicators of more than one basic emotion—fear, anger, happiness, sadness, disgust. If paradoxical metamessages are present a triangle becomes fixed and specific in its emotional-behavioral outcome: primary fear turns into anxious hyperactivity whereas anger in teens may escalate to acting-out.
viiiBakwin & Bakwin. Behavior Disorders in Children, Saunders.
ixHaley, Jay. Problem Solving Therapy, Harper and Row, New York (1978).
xThe astute physician, in addition to SIH and neurological ADHD, will consider such esoteric possibilities as anemia, rickets and scurvy, intestinal pin worms, rheumatic fever, diffuse brain trauma, post-encephalitic effects of influenzal meningitis… Brain-inflammation simply cannot be missed and treated as ‘ADHD’ with potentially lethal stimulants! Rheumatic fever is successfully cured with RAP: rest, aspirin, penicillin—not Ritalin. One child’s life saved is the best argument for a properly executed differential diagnosis.
xiJohnson, L. A. et al. What is the most effective treatment for ADHD in Children? Jr. Fam. Pract. Feb. 2005. Note: This paper was picked randomly off an Internet site devoted to posting quality ‘ADHD’ research. It surveys primary care professionals, concluding, “Stimulant drugs have a therapeutic edge over (vague) behavioral and family approaches.” In this biased article no criteria for the consistent diagnosis of ‘ADHD’ are cited.
xiiInternet searches done by high school senior, Patrick Hogg, 17.
xiiiThe Next Fifty Years (Science in the first half of the 21st Century), Edited by John Brockman, Random House, NY (2002). Note: This misguided book is cited as an example of retrospective 20-20 vision projected into a very Utopian future. The wild assumption is made that all genetic knowledge underlying child development, psychopathology, and social behaviour is or will soon be complete, and no future research (of any kind) in these fields will be valid without a prior genetic screen. If only such were so! In a fanciful spasm and burp of reductionist hubris, biology and genetics checkmates psychology and social studies. If only such were so simple. In short, social-psychological research, especially with a view to elucidating mechanisms, must continue apace.
xivThe original research, lasting two years in the mid-60’s, was done at the Children’s Service, Public Health Dept., Hamilton. The facility served all schools, agencies, hospitals, etc. There were 391 disturbed children overall and 48 matched anxiety cases. 70% of all children assessed as anxious were found to be relayers in families with split social fields. Dissolution of the split field quickly alleviated anxiety in 76.6% of the study group. (This rate climbed toward 85% as skills improved.) Controls had a predictable success rate of 66.6%. The hyperactive aspect of some of the SF:RS-triangle was a serendipitous finding which rested fallow over the years except for three update presentations: 1) Relevance of the Family in Medicine, a tape by Communications in Learning, Inc.; 2) a symposium on The Family in Health, Disease and Disorder, Roswell Park Cancer Institute, Buffalo (1978); and 3) a talking-paper, same year, at the American Association for the Advancement of Science annual meeting in Washington. The 2nd study came out of a community conferencing project in the mid-60’s designed to determine if information exchanges and coordination of effort between ‘divisive’ agencies would reduce police incidents with delinquents. Lt. Jim Paterson head of the police juvenile division and Mr. Sid Blum of the Social Planning/Research Council were critical to this phase of discovering SIH. 50 carefully matched, multi-problem families participated. All services dealing with these families met weekly at my clinic. Study group children had a significantly reduced incidence of police occurrences. I noted, then, 25 hyperactive children from the study families dramatically improved following their family’s conference. This seemed a curiosity only, at the time not published. But it set my brain to turning on the beneficial effect of community conferencing on MSFs and (later) SIH.
xvInternet Paediatric Database: ‘ADHD’ incidence stats as of Dec. 2003; last update 5/28/94!
xviGlasser, William. Reality Therapy in Child and Marital Counselling, 1973 (seminal) audiotape from the Audio-Digest Foundation, Vol. 2, No. 17. Los Angeles, CA.
Statistical update
Statistics update (MedScape pediatrics July 30, 2008): Miranda Hitti in WebMD Health (July 24, 2008) writes, "The CDC today reported that about 5% of US children ... have been diagnosed with ADHD according to their parents." The 5% figure derives from telephone interviews (04-06, reported in Sept. 2007) at Cincinnatti Children's Hospital by University of Cincinnatti College of Medicine in which parents of almost 23,000 children (aged 6-17) were asked if an MD or other health professional had diagnosed their child with ADHD or ADD. (The CDC didn't check children's medical records to confirm parents' reported diagnosis.) The CDC also reports a 3% average annual increase in childhood ADHD from 1997-2006, that children with ADHD were more likely than other kids to have chronic health conditions and that the true number of all ADHD-children may be much higher than 5%. The CDC acknowledges that social-economic strategies factors and access to health care affect chances of an 'official' ADHD diagnosis.
Notes
I think the concept of SIH is interesting. Its practical reality, however, is seminally important, for far too many children are wrongly receiving powerful medicines for what might be called pseudo-ADHD (i.e., until SIH is more widely known). Some time ago I thought my research work should get out to professionals dealing with children: family doctors and pediatricians, public health nurses, social welfare workers, and above all, teachers. So, ten or so years back, I submitted the article to a major pediatric journal. It was turned down out of hand "because you discourage the use of drug Rx ... and pharmaceutical advertisements sponsor/support our publication ... we must rely on them." (This article of course does not discourage medicines used correctly!) Subsequently, two general medical journals essentially said the same thing. Then I tried a major educational journal and was delighted to be accepted. But, a couple of months later was told that "we only publish pedagogic principles." The editor of a top psychology journal declared that their journal was for PhDs not MDs. A social work journal was equally parochial. But I never give up on what I think is a good thing, so when Google came out with Knol, I jumped at the chance to at long last have this work read. Maybe some people will apply it. Maybe others will formally try to verify or reject it. And, maybe, a few parents will eventually get the message too, on behalf of their non-neurological ADHD children. /wfh
________________________________________
[1] In the wordy disciplines of psychology and sociology succinct mechanism-diagrams not only are a visual bridge between verbal and mathematical-scientific descriptions but also are sophisticated process explanations in and of themselves. In psycho-social clinical work concrete problems almost inevitably give way to even more abstract etiologies that involve dilemmas and/or disputes.
[2] Toolan long ago described acting-out as a ‘behavioral equivalent’ of depression. The reader may ask: Do SF:RS-MSF triangles produce just anxiety-hyperactivity? Why not aggressive rage? Or reactive depression? Well, all triangles are malleable during their early, incipient, open phase and may display indicators of more than one basic emotion—fear, anger, happiness, sadness, disgust. If paradoxical metamessages are present a triangle becomes fixed and specific in its emotional-behavioral outcome: primary fear turns into anxious hyperactivity whereas anger in teens may escalate to acting-out.
[3] Differential diagnosis: The astute physician, in addition to SIH and neurological ADHD, will consider such esoteric possibilities as anemia, rickets and scurvy, intestinal pin worms, rheumatic fever, diffuse brain trauma, post-encephalitic effects of influenzal meningitis… Brain-inflammation simply cannot be missed and treated as ‘ADHD’ with potentially lethal stimulants! As a crucial case in point, Rheumatic fever is successfully cured with what I call RAP: rest, aspirin, penicillin—not Ritalin. One child’s life saved is the best argument for a properly executed differential diagnosis.
[4] The original research, lasting two years in the mid-60’s, was done at the Children’s Service, Public Health Dept., Hamilton. The facility served all schools, agencies, hospitals, etc. There were 391 disturbed children overall and 48 matched anxiety cases. 70% of all children assessed as anxious were found to be relayers in families with split social fields. Dissolution of the split field quickly alleviated anxiety in 76.6% of the study group. (This rate climbed towards 85% as skills improved.) Controls had a predictable success rate of 66.6%. The hyperactive aspect of some of the SF:RS-triangle was a serendipitous finding which rested fallow over the years except for three update presentations: 1) Relevance of the Family in Medicine, a tape by Communications in Learning, Inc.; 2) a symposium on The Family in Health, Disease and Disorder, Roswell Park Cancer Institute, Buffalo (1978); and 3) a talking-paper, same year, at the American Association for the Advancement of Science annual meeting in Washington. The 2nd study came out of a community conferencing project in the mid-60’s designed to determine if information exchanges and coordination of effort between ‘divisive’ agencies would reduce police incidents with delinquents. Lt. Jim Paterson head of the police juvenile division and Mr. Sid Bloom of the Social Planning Council were critical to this phase of discovering SIH. 50 carefully matched, multi-problem families participated. All services dealing with these families met weekly at my clinic. Study group children had a significantly reduced incidence of police occurrences. I noted, then, 25 hyperactive children from the study families dramatically improved following their family’s conference. This seemed a curiosity only, at the time not published. But it set my brain to turning on the beneficial effect of community conferencing on MSFs and (later) SIH.
[5] Private office research is daunting. It took 26 active years to gather less than half as much data as earlier in just two years at the city clinic. I attempted to set up an ongoing matched and blind protocol, but over the long haul it was not feasible. There was, sadly, no control group of hyper children not connected with some sort of community meeting.
[6] Twirling little autistic children were excluded from the study as were head-banging, pacing, mentally retarded children. Unfortunately discounted, referred children wrongly on Ritalin were mostly SIH cases. One notable small girl had very profound hyperactivity secondary to cerebral complications of rheumatic fever.
[7] I am less concerned with statistics than getting across observations and associated ideas. These are related to fundamental principles underlying social complexity and form—cybernetic feedback loops within a communication model—at three system-levels: the individual child, its family, and all appropriate wider social systems. Statistical evidence is tied into effecting family and social changes that correct hyperactivity. In science discovery and description should move toward search, research and measurement. This study admittedly has its numerical shortcomings, but it has heuristic value.
References
________________________________________
[i] Hogg, William. The Split Field Relayer System as a Factor in the Etiology of Anxiety (A matched study of 48 cases), Psychiatry (Jr. for Interpersonal Processes), Vol. 35, No. 2 (1972).
[ii] Hogg, W.F. & J. E. Northman Ph.D. The Resonating Parental Bind (RPB) in Delinquency, Family Therapy (1979).
[iii] Anthony, E. J. Psychiatric Disorders of Childhood, in Freedman and Kaplan, Comprehensive Textbook of Psychiatry. Williams & Wilkins (1967). Note: My references are mostly ‘ancient’ as the modern literature is devoid of the SIH concept.
[iv] Jenkins, R. L. Classification of Behavior Problems of Children. Amer. Psychiat. Jr. (1969).
[v] Bakwin & Bakwin. Behavior Disorders in Children, Saunders.
[vi] Haley, Jay. Problem Solving Therapy, Harper and Row, New York (1978).
[vii] Johnson, L. A. et al. What is the most effective treatment for ADHD in Children? Jr. Fam. Pract. Feb. 2005. Note: This paper was picked randomly off an Internet site devoted to posting quality ‘ADHD’ research. It surveys primary care professionals, concluding, “Stimulant drugs have a therapeutic edge over (vague) behavioral and family approaches.” In this biased article no criteria for the consistent diagnosis of ‘ADHD’ are cited.
[viii] Internet searches done by high school senior, Patrick Hogg, 17.
[ix] Ibid references 1 & 4 above.
[x] The Next Fifty Years (Science in the first half of the 21st Century), Edited by John Brockman, Random House, NY (2002). Note: This misguided book is cited as an example of retrospective 20-20 vision projected into a very utopian future. The wild assumption is made that all genetic knowledge underlying child development, psychopathology, and social behavior is or will soon be complete, and no future research (of any kind) in these fields will be valid without a prior genetic screen. If only such were so! In a fanciful spasm and burp of reductionist hubris, biology and genetics checkmates psychology and social studies. If only such were so simple. In short, social-psychological research, especially with a view to elucidating mechanisms, must continue apace.
[xi] Internet Pediatric Database: ‘ADHD’ incidence stats as of Dec. 2003; last update 5/28/94!
[xii] Glasser, William. Reality Therapy in Child and Marital Counseling, 1973 (seminal) audiotape from the Audio-Digest Foundation, Vol. 2, No. 17. Los Angeles, CA. 