ADHD, Laziness, or Neither?

Child and adolescent psychiatry, like much of life in general, has its seasonal variations. Around September, I tend to get a cluster of new patients (usually kindergartners and first graders) whose parents or teachers are concerned that they cannot seem to sit still or keep on task during school. The winter months bring in more people with depression and anxiety as the stress of work/school, decreased hours of sunlight, and more time spent indoors take their toll.

In the past month, as the school year ended, I've seen multiple new patient evaluations for another reason: high schoolers or college students who have made it through the academic year, but just barely. Most of them have gotten good grades in the past, but have had gradually declining academic performance over the past few years. Now their parents—and it's almost always the parents who make them come in—want to know if they have ADHD, or if it's "just laziness."

I'm fairly confident whether I can diagnose ADHD, but I'm not even sure how to answer the second part of that question. How does one determine whether someone is lazy? Is being lazy equivalent to "procrastinating" or "avoiding hard work?" It definitely feels more pejorative, like a character flaw that will never go away. Fortunately, I've been able to avoid the issue somewhat, since it seems there is always something else going on besides laziness.

In general, I do not readily diagnose older adolescents with ADHD if they had been able to focus on schoolwork previously. ADHD generally manifests long before high school, though it's still possible that an older teen may have previously undiagnosed ADHD. Often, these teens have a fairly high IQ and never had to study much prior to high school, but they eventually get overwhelmed by academic demands. However, multiple other causes of poor school performance are much more likely. Below are some of the ones that I've come across lately.

Depression: An obvious contributor to lower grades, but it surprises me how often parents (and even the patients themselves) miss this. Perhaps it's because they have difficulty telling depression apart from the normal moodiness of adolescence, or perhaps depression often manifests in adolescence as anger, irritability, and mood swings. However, a teen doesn't have to be clinically depressed to be unhappy, and I believe that unhappiness can also lead to academic decline. One example I saw recently is a patient who moved across the country right before 11th grade, and her grades went from A's to C's. Not having any friends at her new school and being somewhat shy, she spent most of her evening time trying to stay connected with old friends via texts and social media. Studying made her feel less happy, so she did much less of it.

Anxiety: I often see teens who are perfectionists, afraid of making a mistake, and stay up late at night unable to sleep because they can't stop worrying about an upcoming test or assignment. The anxiety can also contribute to procrastination, because thinking about the work brings up unpleasant feelings that dissipate when the teen does something else, like checking Facebook. Of course, actually starting the assignment can decrease the anxiety as focus shifts and a sense of self-efficacy builds, but Facebook is often easier and more fun.

Sleep: Teens often go to bed late and have to wake up early. However, in recent years this has been greatly exacerbated with the proliferation of bright back-lit devices that teens have access to their bedrooms, combined with a dearth of parental monitoring/control. It's amazing to me how much coffee or energy drinks teens are consuming these days to avoid falling asleep at school.

Substance use: Yes, drinking and smoking weed (and/or hanging out with those who often do) can make it harder to focus on doing schoolwork.

Family conflict: Family dynamics are complex, but needless to say, many different types of stress within the family can contribute to a teen not doing well in school. For example, I saw one teenager whose drop in grades seemed to have no rational explanation, until I found out that his parents were alcoholics who had recently both taken up drinking again, leading to a big decrease in the time the family spent together doing other things. Even though this patient insisted that his parents' drinking did not bother him, it seems that when he started to fail in school, his parents ended up engaging with him more, even though they continued to drink. In another case, I had a patient whose parents divorced and her mother almost immediately found a boyfriend, who moved in a few months later. The patient denied feeling upset by this, but her grades tanked when she "just couldn't motivate myself to do homework" after school. This caused considerable distress for her mother, who valued academic success.

Habitual avoidance: This is certainly not a DSM diagnosis, but I do believe avoiding work in favor of fun can become a habit that is difficult to change. I'm not calling it laziness, which implies a flawed character. Rather, I think this has a lot to do with the interaction of culture, parenting style, and a child's temperament. Most of us would rather not do hard or tedious work if we didn't have to. Society tells adolescents that they should have fun and enjoy themselves while they're still young, while parents often tell their children to work hard for some benefit that will accrue years down the road. Unfortunately, some parents want to avoid conflict themselves, so they may not impose the necessary consequences or structure to back their words. Furthermore, adolescents can avoid the tedium of work by multitasking like mad: simultaneously listening to music, texting friends, checking social media, all while trying to study with the TV on in the background. Thus, many teens never develop good study skills (to say nothing of the capacity for deep, focused thought); it's amazing to me that more aren't failing school.

More often than not, the reason for an adolescent's falling grades is a combination of the above factors. I used to be a big believer in laziness, in the sense that I was quite sure it existed as a trait. However, after being asked to evaluate for laziness many times and finding more plausible explanations, now I'm not so sure.

What to Do if Your Kids Are Obsessed with Technology

I clicked on author Steve Almond's piece in yesterday's New York Times Magazine fully expecting to roll my eyes at yet another alarmist screed about how electronic devices are destroying childhood. However, after reading (and re-reading) it, I came away mostly impressed. I think he made many salient points about the challenges of parenting in the touch-screen era, which I would like to explore some more.

Look in the Mirror

One of the most important influences on how children interact with technology is the example set by their parents. Many parents take the approach of "do as I say, not as I do," which almost never works. Here, Almond does a good job of self-examination:

[...] But even without a TV or smartphones, our household can feel dominated by computers, especially because I and my wife (also a writer) work at home. We stare into our screens for hours at a stretch, working and just as often distracting ourselves from work.

Our children not only pick up on this fraught dynamic; they re-enact it.

He also recognizes when he is using technology as an easy pacifier:

After all, we park the kiddos in front of SpongeBob because it’s convenient for us, not good for them. (“Quiet time,” we call it. Let’s please not dwell on how sad and perverse this phrase is.) We make this bargain every day, even though our kids are often restless and irritable afterward.

That he views this strategy as one of his "failings as a parent" is a bit harsh. Almost all parents do this at least some of the time. Unfortunately, what he does not discuss in detail is just what his relationship is like with his children. That is the critical piece. If he is having meaningful conversations or one-on-one play time with his children, or if he is helping to get them involved in a variety of activities, then he is probably not failing as a parent.

Set Limits, Maintain Balance

The American Academy of Pediatrics recommends the following: "Children and teens should engage with entertainment media for no more than one or two hours per day, and that should be high-quality content. It is important for kids to spend time on outdoor play, reading, hobbies, and using their imaginations in free play." The AAP also recommends that children under age 2 not be exposed at all to television and other entertainment media. It's best to start implementing rules around technology use early on; waiting until a child becomes a teenager is way too late. Almond tries to set some appropriate limits for his children:

[...] We ostensibly limit Josie (age 6) and Judah (age 4) to 45 minutes of screen time per day. But they find ways to get more: hunkering down with the videos Josie takes on her camera, sweet-talking the grandparents and so on. The temptations have only multiplied as they move out into a world saturated by technology.

Consider an incident that has come to be known in my household as the Leapster Imbroglio. For those unfamiliar with the Leapster, it is a “learning game system” aimed at 4-to-9-year-olds. Josie has wanted one for more than a year. “My two best friends have a Leapster and I don’t,” she sobbed to her mother recently. “I feel like a loser!”

He is certainly right about just how much various devices have become a seemingly vital part of children's lives; it is unrealistic to think that any child can be immune from their allure. In my mind, an important task for parents is to help their children learn how to use technology without being consumed by it. Setting appropriate limits and having a plethora of other activities for the child to engage in helps this learning process. It sounds from this anecdote that despite his daughter's heart-wrenching words, she did not end up getting a Leapster. Perhaps she was able to learn a small lesson here, that her life will go on even if she does not have the same shiny thing as everyone else.

Be Aware of Family-of-Origin Issues

When it comes to parents' attitudes about raising their children, it's always interesting to see how some parents recreate a similar dynamic with their children as the one they had with their own parents. Others go to the opposite extreme: if their own parents were too harsh, then they might be too permissive with their own children. Thus, one of the most interesting paragraphs hints at the author's own relationship with his parents:

My brothers and I were so devoted to television as kids that we created an entire lexicon around it. The brother who turned on the TV, and thus controlled the channel being watched, was said to “emanate.” I didn’t even know what “emanate” meant. It just sounded like the right verb.

This was back in the ’70s. We were latchkey kids living on the brink of a brave new world. In a few short years, we’d hurtled from the miraculous calculator (turn it over to spell out “boobs”!) to arcades filled with strobing amusements. I was one of those guys who spent every spare quarter mastering Asteroids and Defender, who found in video games a reliable short-term cure for the loneliness and competitive anxiety that plagued me. [...]

Later, when Almond talks about seeing his children drawn to electronic games and cartoons, he wrote: "I’m really seeing myself as a kid — anxious, needy for love but willing to settle for electronic distraction to soothe my nerves or hold tedium at bay." I can't help but wonder how the approach his parents took to child-rearing might have influenced his anxiety and loneliness. I did find it curious that he wrote his daughter's "job is to make the same sometimes-impulsive decisions I made as a kid (and teenager and young adult). And my job is to let her learn her own lessons rather than imposing mine on her." However, his actions seem to indicate otherwise: he is much more active than his own parents were in setting appropriate limits around his children's technology use. There is nothing wrong with parents imparting lessons learned in their 20's to their own children, if those lessons are about not letting technology rule one's life.

Understanding the Purpose of Technology

Of course, not all uses of technology are equal. A child could be using an iPad to learn how to read, draw, or even program. Alternatively, a child could be playing mindless games nonstop. The distinction is crucial, so parents need to know how their children are spending their time on these devices. While Almond acknowledges that iPads may be good educational tools when used effectively by good educators, he raises the following concerns:

The reason people turn to screens hasn’t changed much over the years. They remain mirrors that reflect a species in retreat from the burdens of modern consciousness, from boredom and isolation and helplessness.

It’s natural for children to seek out a powerful tool to banish these feelings. But the only reliable antidote to such burdens, based on my own experience, is not immersion in brighter and mightier screens but the capacity to slow our minds and pay sustained attention to the world around us. This is how all of us — whether artists or scientists or kindergartners — find beauty and meaning in the unceasing rush of experience.

If a person mainly uses a screen device to banish unpleasant feelings, then that is indeed very unfortunate. I do agree with Almond's emphasis on the importance of children learning about the real physical world that surrounds them. I would add that it's important that they learn about their own inner world of thoughts and feelings as well, so that when they inevitably experience anxiety or sadness or boredom, they do not automatically seek to banish it with a screen of some sort.

I once tweeted:

I wonder if all these children raised on touch-screens will ever learn the art of being able to sit and do nothing? http://t.co/dEk2BBpzLe
— Psycritic (@psycrit) March 22, 2013

If I could have a do-over, instead of "do nothing" I would say: "I wonder if all these children raised on touch-screens can keep themselves occupied without one?" Almond ends the essay by writing about how his daughter is able to sit for five minutes while waiting for a cardinal to visit their family's compost bin and his hope that she does not forget the wonders of the real world. I think there's reason to be optimistic, despite the very pessimistic title of the article: "My Kids Are Obsessed With Technology, and It’s All My Fault." I'd like to say to Mr. Almond, it's not your fault. Most kids are obsessed with technology. If they were obsessed and you allowed them to spend all their time in front of a screen, then it's your fault.

The Treatment of Early Age Mania Study Revisited

The Treatment of Early Age Mania (TEAM) study is not news, and more diligent and timely bloggers have already written about it. However, it is one of the more infuriating outcomes of the whole pediatric bipolar disorder phenomenon; in the last few years, few publications have irked me as much as the ones from this study. Thus, I'd like to chime in as well. 1 Boring Old Man had a lengthy blog post (the sound and the fury...) summarizing the main findings [I added the links]:

The first report shows that these children respond better to Risperdal® than either Lithium or Depakote®. That’s no surprise. They don’t respond to the traditional anti-manic treatments [that suggests to me that they don't have mania]. They do respond to Risperdal®. That’s something we knew before we ever heard of Risperdal® – you can control disruptive behavior with antipsychotic medications. It also showed that the metabolic side effects of Risperdal® were already apparent at only 8 weeks. Notice that there’s no placebo group in this study so we can’t really say that the Lithium or Depakote® responses were clinically significant.

The second report set out to define moderators of response. What it ended up showing was the extremely high overlap between ADHD and the presumed Bipolar Mania and the more ADHD, the greater the likelihood of a response. But there was another moderator of response – site. What in the hell does that mean? To me it suggests that there is bias in making this diagnosis or in measuring the response. I think that says something about the study and the diagnosis, not the afflicted. So in my reading, one thing it doesn’t mean is that Bipolar Disorder has some intrinsic regional difference.

1BOM used the study to illustrate how a fad diagnosis could become mainstream, to the detriment of children and their families, while benefitting pharmaceutical companies and the researchers (such as MGH's Joseph Biederman) they support. It's worth noting, though, that the TEAM study did not include the MGH group and was funded by the NIMH, not by pharma. The first author of the initial publication is Dr. Barbara Geller, and I've written about how her conception of childhood bipolar is different from Wozniak/Biederman's chronically irritable patients, with Dr. Geller trying taking into account more classical manic symptoms such as grandiosity. Thus, I've often wondered "what the hell happened?" when pondering this study.

Fortunately, Dr. Stuart Kaplan, child psychiatrist and author of Your Child Does Not Have Bipolar Disorder, has an excellent series of posts on his Psychology Today blog with additional insights into the TEAM study. In Dr. Kaplan's first post (The World Series of Child Bipolar Disorder), he describes a session from the 2011 AACAP meeting in which TEAM researchers talked about their study:

During the discussion, another nationally known presenter gave a wildly incorrect interpretation of defiance. The presenter claimed that defiant children are psychotic because they have a delusional belief that they can take on the far stronger adult world. Defiant children are not psychotic based on their defiance alone. They are mistaken in their belief that they can overpower the adult world, but this is a mistaken belief not a delusion. If the investigators believe that defiant children are delusional, this may explain how they found the high rates of psychosis in the children they studied (77%).

If defiance in children counts as psychosis, then my partner and I are both psychotic every time we argue, because we each have a false belief that we can convince the other with our arguments. Maybe some of the TEAM investigators would consider this folie à deux?

Dr. Kaplan's second post (Credulity Stretched) highlights the reasons why the children included in the study probably did not have bipolar 1 disorder, given the >90% comorbidity with ADHD, the 99.3% of patients with "daily rapid cycling" moods, and the fact that the average "manic" episode in the study lasted 4.9 years, which is about half the life of the average study participant (mean age 10.1 years). His third post in the series (Location, Location, Location) replicates the table from the second publication showing just how wildly variable the treatment response was at the various sites: "This was not a minor statistical artifact, but was the central finding of the study."

Besides highlighting the incredible (as in, not credible) aspects of the study that Dr. Kaplan already wrote about, I wanted to provide one additional anecdote: Several years ago, one of the renowned lead investigators of the TEAM study gave a talk at another institution. This mood disorder expert claimed that a 3-year-old who masturbates may be exhibiting the hyper-sexuality seen in mania. When audience members pointed out that a 3-year-old masturbating is actually normal behavior, the investigator appeared flabbergasted. Which makes me wonder if they thought 6-year-olds who were repeatedly touching themselves in defiance of parents telling them to stop were having manic episodes with psychosis.

One of the biggest problems in the field today is how biologically-oriented psychiatrists look at behavior in a vacuum without considering developmental, social, or familial factors. This study is one of the most egregious examples, not just of that problem, but also of how researchers at prestigious institutions, backed by NIMH funding, can get even the most ridiculous studies published. If I see a 16-year-old who is truly manic, I'm still going to seriously consider lithium over risperidone, "evidence-base" be damned.

A Chilling Encounter

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

Late one afternoon, I got a page from the emergency room about a 14-year-old male who was in for a suicide attempt, who was medically stable and ready to be interviewed by a psychiatrist. When I arrived at the tiny conference room adjacent to the ER, I was expecting the typical morose teenager, full of emotional turmoil. Instead, this young man looked at me calmly and nonchalantly, smiled, and said hello. He was thin and looked like he could be 12 or 13, dressed in a polo shirt and khaki shorts. He would not have seemed out of place in a Boy Scout uniform.

I started with the obvious. How did you end up in the ER today? He told me that he had tried to end his life earlier in the day by hanging himself, only to be discovered when his father got home early from work. Has there been anything stressful going on in your life? Yes, he said. Several weeks ago, a little boy had reported him for molesting him. When the police investigated, they eventually discovered several other young boys in the neighborhood with similar stories. Somehow, a judge had allowed the teen to remain in the custody of his parents while he awaited his sex offender psychological evaluation.

He seemed at peace, and neither the crowded space nor the noisy environment fazed him in the least. I tried my best to keep a poker face as I continued asking the standard questions. Have you been sad or depressed? No, he said. He'd been in a good mood all summer, even after the accusations surfaced. He has not lost any interest in enjoyable activities. How's your sleep? He slept very well, at least 8 hours a night. Appetite? Good. Any guilty feelings or negative thoughts? Nope. So how did you decide that today was the day to die? He had just finished the last book of a popular young adult series. "I finally got to see how that story ended, and it was very satisfying. Then I decided, I might as well kill myself so I don't have to go to jail."

I kept searching his face for any sign of tension, doubt, or guilt. There was none; he might as well have been chatting with a friend about his favorite video game. In the back of my mind, I wondered if he could detect that I was more uncomfortable than he was.

He told me that he had a normal childhood, that he got along with his parents, and that he was never mistreated or abused in any way. Do you have any friends your age? Instead of answering the question, he mentioned that he was on the golf team for his school and he got along fine with his peers. Are you attracted to males or females your age? "No, I only go for the younger ones." Any reason you targeted those particular children? He looked straight at me and said, "I take whatever I can get," sending shivers down my spine.

Later, I interviewed his mother and father, who seemed like nice, normal suburban parents. They both appeared stunned, uncomprehending. I felt sad for them, yet I was also glad that their son was caught when he was 14, rather than when he was 40 or 75. I could not decide whether it was a good thing or a horrendous thing that he made no effort to deny what he did. Or perhaps he just wanted to appear honest to hide even greater atrocities.

Did I end up admitting this "patient" to the psychiatric unit? I would have preferred to send him straight to juvenile detention, but the hospital had a protocol: A serious suicide attempt like his had to be admitted if there were beds available. As a service to the community, of course. Even better, I had to admit him under a diagnosis of "depression not otherwise specified," since the hospital could not get reimbursement for an admission diagnosis of pedophilia. Walking out of the hospital that evening, I was glad to see the sun still visible low on the horizon, and that the darkness had not quite set in yet.

Psychiatry Leadership: Uneasy Lies the Head that Wears a Crown

Last Friday's Science Friday broadcast included a segment titled Bad Diagnosis for New Psychiatry "Bible", which featured 3 guests: Dr. Jeffrey Lieberman, the current president of the American Psychiatric Association, Dr. Thomas Insel, the director of the National Institute of Mental Health, and Gary Greenberg, author of the Book of Woe: The DSM and the Unmaking of Psychiatry. It's a fascinating half-hour, well worth listening to.

What is most remarkable to me about the segment is just how much more cogent and articulate Gary Greenberg was in making his arguments, compared to the two leaders of the field of psychiatry. Greenberg argues that though the DSM was a sincere effort at classifying mental illness, its disorders are man-made constructs, not real diseases, and this is a real problem when the DSM's diagnoses underlie psychiatry's authority and influence scientific research. Despite his sharp criticisms of the DSM, he is by no means anti-psychiatry or against the use of psychiatric medications. He hopes that psychiatrists can acknowledge that not all human suffering is pathological and needs to be treated with a medication, and that we can be more transparent about the fact that we don't know how the drugs work, and that they treat symptoms instead of actual diseases.

David Brooks makes a similar argument in his Heroes of Uncertainty column:

The problem is that the behavorial sciences like psychiatry are not really sciences; they are semi-sciences. The underlying reality they describe is just not as regularized as the underlying reality of, say, a solar system.
[...]
All of this is not to damn people in the mental health fields. On the contrary, they are heroes who alleviate the most elusive of all suffering, even though they are overmatched by the complexity and variability of the problems that confront them. I just wish they would portray themselves as they really are. Psychiatrists are not heroes of science. They are heroes of uncertainty, using improvisation, knowledge and artistry to improve people’s lives. 

Meanwhile, Dr. Lieberman, in defending psychiatry's lack of progress, said [at the 8:11 mark], "The brain is a tough organ, and the behavioral and mental functions of the brain represent the most evolved aspects of the human organism, and in all of the animal kingdom." He says essentialy the same thing in a letter to the editor in response to the David Brooks op-ed: "The brain has proved to be infinitely more complex than any other organ in the human body, and the functions that mediate behavior are the most highly evolved in the animal kingdom." Does he even understand evolution? What does it mean to be "most evolved" or "highly evolved?" Every other animal on this planet is the result of their ancestors having been able to survive and transmit their genes over billions of years; their behaviors have evolved just as much as ours have. The view that somehow there is an animal kingdom hierarchy with humans at the top is so anthropocentric, it's no better than the medieval view that the earth is at the center of the universe.

Dr. Insel, meanwhile, said something equally ridiculous when he talked about [at 10:34] "finding a way to deconstruct these classifiers, and to say hey, yes, this is what we currently call schizophrenia, this is what we currently call autism spectrum disorder, but perhaps that's not one problem, but multiple, 5, 6, 7, 8, different diseases, that are contributing." Does he realize that, in all likelihood, hundreds, if not thousands of different genes contribute to autism and schizophrenia, and that environmental influences can shape the expression of those genes as much as any biological factor? To think that the NIMH will eventually "discover" a handful of "diseases" underlying schizophrenia or autism is pure future-think fallacy.

When Gary Greenberg and David Brooks make more sense talking about psychiatry than the two supposed leaders of the profession, something is deeply amiss. At the 8:24 mark of the SciFri broadcast, Dr. Lieberman said, "Gary's argument is so philosophical, and abstruse, and so minimally relevant to clinical practice." When the head of the American Psychiatric Association can't understand why Gary Greenberg's arguments are critically relevant to all psychiatrists, our patients, and their families, I can only marvel at how far removed he must be from the day-to-day concerns of practicing clinicians and ordinary people.

Listening to the debate, I felt that Drs. Lieberman and Insel were somewhat uncomfortable in discussing the lack of progress in biological psychiatry over the years. I hope that this unease leads to some self-reflection about the fundamental flaws in biological psychiatry, rather than repeating the same platitudes and mistakes over and over again.