ADHD, the aggressive child and the elephant in the room

(Three recent news items lead me to republish a post that predated my Boston.com days. The firstis a new study showing that antipsychotics and stimulants can be used together in treatment of aggression associated with ADHD. The second is a recent New York Times article, The Selling of Attention Deficit Disorder, the third an article from today's New York Times: ADHD Experts Re-evaluate Study's Zeal for Drugs. I am hopeful that 2014 will be a year of radical rethinking about what we now call "ADHD.")In the Tony award winning play God of Carnage two couples meet in an elegant living room for an ostensibly civilized conversation about the aggressive act of one couples child against the others. The meeting soon degenerates to reveal the underbelly of conflict in the two marriages. Husband and wife hurl insults, precious items and even themselves with escalating rage. We see, as they attempt in vain to focus on the childrens behavior, the proverbial elephant in the room.

It brought to mind another depiction of the nature of the elephant, presented by the pharmaceutical industry. A recent issue of The Journal of Developmental and Behavioral Pediatrics features prominently a two page ad from Shire, makers of drugs commonly used for treatment of Attention Deficit Hyperactivity Disorder (ADHD). A mother and her son sit at the desk of a doctor in a white coat. Behind them is a large elephant draped in a red blanket on which is printed the words, resentful, defiant, angry. The ad recommends that these symptoms, in addition to the more common symptoms of inattention and hyperactivity, should be addressed. This is the message: doctors should be treating these symptoms with medication.

From my vantage point of over 20 years of practicing pediatrics, where I sit on the floor, not in a white coat, and play with children, I believe that the plays depiction of the nature of the elephant is much more accurate and meaningful than that of the pharmaceutical industry. In the play the elephant is the environment of rage and conflict in which the aggression occurs, while in the ad the elephant is the childs symptom. Consider these two stories from my pediatric practice (with details changed to protect privacy.)

Everything was a battle with six year old Mark. Though I asked both parents to come to the visit, Mom came alone. She was furious.Tell me what to do to make him listen. We had a full hour visit, and as she began to relax, she shared a story of constant vicious fighting between herself and her husband. Mark, who had been playing calmly and quietly, took a marker and slowly and deliberately made a black smudge on the yellow wall. His mother was too distracted by her own distress to stop him. I said, You cannot draw on the wall, but maybe you are upset about what we are talking about. He came and sat on his mothers lap. She reluctantly revealed her suspicion that his angry behavior was a reflection of the rage he experienced at home. She agreed to get help for her marriage, and Marks behavior gradually began to improve.

Janes parents became alarmed when her aggressive behavior began to spill over into school. Her third grade teacher told them that not only was she distracted and fidgety, but she seemed increasingly angry. At our second visit, Dad became tearful as he described his cruel and abusive father. He acknowledged being overwhelmed with rage at Jane when she didnt listen. He yelled at her and threatened her. He longed for a positive role model to learn how to discipline her in a different way. He realized he needed help to address the traumas of his own childhood in order to be a more effective parent for Jane.

If the elephant in the room is the childs symptoms, as the drug companies would have us believe, then medication may be the solution. Children taking medication for ADHD often tell me that it makes them feel calm. The full responsibility for the problem then falls squarely on the childs shoulders.

For Mark and Jane, and countless children like them, the elephant in the room, however, is not the childs symptoms. It is the environment of conflict in which the symptoms occur. If the family environment is the elephant, the treatment of the problem is not as simple as prescribing a pill. Families must acknowledge and address seemingly overwhelming problems. The parents relationship with each other, and each parents relationship with his or her own family of origin, often contributes significantly to this environment.

In the supportive setting of my office, Mark and Janes parents were freed to think about their childs perspective and experience. Rather than focusing on what to do they understood what their children might be feeling growing up in an environment of conflict and rage. This ability for parents to think about their childs feelings has been shown, in extensive research at the intersection of developmental psychology, genetics and neuroscience, to facilitate a childs development of the capacity to manage strong emotions and adapt in social situations.

In another interesting link between this ad and God of Carnage, one of the fathers is an attorney representing a drug company. He speaks loudly on his cell phone, seemingly oblivious to the effect of his behavior on the other people in the room. His conversation reveals the profit motive of the drug company taking precedence over the well being of the patient.

God of Carnage was written by Yasmina Reza, a French playwright. While the play itself is hugely entertaining as a witty farce about family life, an important message was in a brief scene at the very end. The telephone rings. The mother answers. It is her daughter, all upset about the loss of her pet hamster, which the father had set free one night because he was annoyed by the animals habits. Suddenly the mood of the play, which was lively with scintillating dialogue throughout, becomes serene as the mother speaks lovingly to her distraught daughter. Perhaps most of the audience was barely aware of the sudden mood change. Yet it lifted this delightful play into universal significance. Freeing herself from the preceding chaos, she calmly gives her full attention to her daughters experience.

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ADHD, the aggressive child and the elephant in the room