Helping Mom and Dad Help Johnny
KRISTA FOSS, Globe & Mail Health Reporter
A new book by Canadian author Gabor Maté argues that ADD -- found mainly in children and overwhelmingly in boys -- begins as a parenting problem that morphs into a biochemical one.
This is the story of a boy who didn't get Ritalin.
He was always a busy baby, says his mother Paula Stevens. He crawled before he sat. In school, he was too busy to get down to the business of reading; he was still struggling with simple books at the age of seven.
Being busy got him into trouble with other kids and with teachers. There were subtle hints about the problem from the teachers, a less-subtle package of information from the school guidance counsellor and a best guess from a pediatrician. The headlong rush into a diagnosis began.
The label they were trying to stick on this boy, if he sat still long enough for them to pin it on him, was Attention-Deficit Disorder or Attention Deficit Hyperactivity Disorder. The indisputably most popular and effective treatment for both is the drug Ritalin.
But the Stevenses resisted. Their family doctor supported them; he believed the boy was normal.
Then the story took an unexpected turn. Paula Stevens (not her real name) and her husband took their son to see a psychiatrist. He asked them to return with the boy's two sets of grandparents. They did. Then the psychiatrist asked the parents to come back by themselves, without their son.
For the next year, he concentrated all his treatment on the parents. During that time, the boy started reading and stopped fighting.
For the last two decades, there's been much controversy over the idea that some children's dervish-like energy level, their lack of focus, impulsive actions and stunted learning constitute a singular medical problem. Many doctors believe ADD or ADHD is a genetic failing that causes the brain chemistry to go awry. Many others call it a garbage-can ailment: a detritus of quintessentially '90s flightiness. The conspiracy theorists think the disorder was cooked up to give an instant market to Ritalin.
Now a provocative new book by Canadian doctor Gabor Maté, who suffers from ADD and has children with the disorder, suggests it might be a parenting issue that morphs into a biochemical one. He says the stressed-out tenor of our child-rearing and '90s lifestyle affect the biochemistry of our children's developing brains, especially if the youngsters arrive in this world with an inherently sensitive temperament.
This new angle on ADD and ADHD will be unwelcome by anyone who is looking for a simple, easy answer. It is, however, a slight vindication for the minority of the child-psychiatry set who have wondered aloud and alone if ADD and ADHD have more to do with mom and dad than with a physical problem.
"I hate to blame parents, but plenty of them don't pay attention to their children," says Dr. Felix Yaroshevsky, a Toronto-based psychiatrist.
Five years ago, Paula Stevens, her husband and son landed on Dr. Yaroshevsky's doorstep. Today, her son is 12 years old, reading at the same level as his peers, and just "a normal kid."
From 1994 to 1998, the number of Canadians being treated for ADHD grew from 191,000 to 368,000, according to health-information company, IMS Health Canada. At the same time, the number of prescriptions for Ritalin (methylphenidate) doubled to 710,000. The vast majority of customers are school children, with 43 per cent of prescriptions being dispensed on behalf of children younger than 10; children aged 10 to 19 account for another 50 per cent of prescriptions. Eighty per cent of those downing the pills are boys.
All this is happening while the continent's best child-psychiatry minds concede that much of the treatment and assessment of ADHD is up in the air.
Last November, the U.S. National Institutes of Health asked the most eminent experts in the field to come to a consensus on the diagnosis and treatment of Attention Deficit Hyperactivity Disorder. At the same time, an exhaustive Canadian perspective on ADHD commissioned by the Canadian Co-ordinating Office for Health Technology Assessment was being completed.
Both came to nearly the same conclusions: ADHD is a big problem affecting a lot of children; the quality and manner in which it is diagnosed varies widely; Ritalin is still the best treatment -- more effective than classroom interventions and behaviour-modification programs; treatment overall is inadequate and spotty.
The Canadian report says 10 to 40 per cent of Ritalin prescriptions for children are inappropriate, which means as many as 147,000 children in this country are taking a drug they might not need.
Both the Canadian and U.S. experts say more research is urgently needed.
In the meantime, Gabor Maté has done his own research, encapsulated in his new book Scattered Minds: A New Look at the Origins and Healing of Attention Deficit Disorder.
The 55-year-old family physician from Vancouver sits -- calmly -- in the Toronto offices of his publisher talking about the years it took to thread that research together. Calmly, that is, until the subject turns to a review of his book.
"He said I blamed my mother!" he gasps, referring to the reviewer, and leaves his chair, spinning it in a moment of mock drama. "Blame my mother? He completely missed the point."
This is, of course, exactly what makes Dr. Maté's book most incendiary. Parents bristle at blame and it's easy to conclude that is what he wants to do. But his case is more subtle.
Dr. Maté believes ADD starts when the bond between a parent and a new baby is fractured by one or many factors: stress, conflict between the two parents, maternal depression, money worries, separation and divorce, alcoholism, even abuse.
According to his survey of current research on the brain, the prefrontal cortex -- behind the forehead -- is the part of the grey matter that has the most sway over attention, impulse and motivation -- the very things that children with ADD and ADHD can't control.
An infant's developing brain needs "fully attuned" response from a caregiver in order for the dopamine-making circuitry in the prefrontal cortex to be laid down, he suggests. With inadequate parental stimulation, the baby doesn't develop enough of the biological machinery to produce dopamine. Without enough dopamine, he is jumpier than a caffeine-crazed TV producer. (Ritalin is like artificial dopamine.)
For the child, there is both an emotional injury -- an "attunement wound" -- and physiological changes to the brain. The search for relief is constant. "It's like you've been shot. Rather than collapse, you tune out the pain so you can keep running," Dr. Maté says.
When Russell Schachar, a child psychiatrist at the Hospital for Sick Children in Toronto and one of Canada's best-known ADD researchers, hears a journalist's quick version of Dr. Maté's theory over the phone, he instantly dislikes the idea that parents are left holding the gun.
"It's double-blaming for the parents," says Dr. Schachar. "Not only have you passed on faulty genes but you're also responsible for aggravating the situation with the home environment you created."
Many children with ADHD come from chaotic families, he says, but many don't. "We're pretty sure there is a genetic predisposition. There are differences in the genes of those with ADHD and there is some evidence that their brains are different."
As an adult with ADD, Dr. Maté fathered three children who developed the ailment. Were they predisposed by the genes they inherited from him? Sure, he says, but there were plenty of other factors: "I was a workaholic, running a palliative-care clinic, writing a weekly newspaper column, working on a book. My wife Rae was left with all the work of raising the children, which put us in constant conflict and left her unable to pursue her own interests."
Dr. Maté says parents love their children; he knows his parents loved him fiercely. But he was born in Budapest in 1944, a few months before Hungary was occupied by the Germans and at a time when his father was interned in a forced-labour camp. Six months after his birth, his maternal grandparents were sent to Auschwitz.
"After her parents were taken away, my mother wanted to kill herself," he writes. "She would lie on her bed for hours."
Certainly, there are wounds that parents can't help but inflict, being so wounded themselves. But his book exhorts parents to change, if they can. And his prescription for change is a big one: It entails reinventing one's parenting methods, one's lifestyle and perhaps, tending to a deeply troubled, conflict-riddled marriage.
The "attunement wounds" of children with ADD can heal, he says, the brain is constantly regenerating itself. But you have to create an environment in which calm attunement can be attained.
"He's right that the environment can help minimize the impairment associated with ADHD," says Dr. Schachar. "The more parents can do to assist the child the better. But that is true of parents of stingy children, of aggressive children."
Yes, Paula Stevens confesses, she felt guilty when she realized she might be part of the problem. "But I wanted to make changes," she says. "If what I was doing was affecting my children, I could change."
AT HOME WITH ATTENTION DEFICIT DISORDER
New thinking around Attention Deficit disorder/Attention Deficity
Hyperactivity disorder suggests that stress and adversarial parenting may harm an
essential bond that needs to form between parents and children, most importantly while
they are infants. Chaos in the family later on only reinforces ADD behavior.