Tag Archives: ADHD

Bathroom Problems I: Soiling or Encopresis

Encopresis

Many of the children whose parents consult me suffer from a condition called encopresis, or soiling, a distressing problem that is diagnosed in children older than 4-years old. Encopresis usually starts with constipation. If a child experiences pain when passing a hard or large stool, it is common for the child to tighten up and hold back in response to the urge to defecate. This of course makes the constipation worse, and often soft stool from higher in the gut leaks around the hard mass in the colon, causing soiling.

The first step in dealing with this problem is to go to the pediatrician. Good medical care is essential to the treatment of these symptoms. If the constipation is not treated the withholding is likely to continue and may cause anatomical changes in the gut such as stretching of the muscular intestinal wall. Children who suffer from chronic constipation may also develop a disturbed coordination of muscle function in the anal sphincter. Medical treatment often involves stool softeners that draw water into the gut and soften the stool, making it easier and less painful to pass. There are other more vigorous and more intrusive interventions that can be used if necessary.

Pediatricians also often recommend behavioral plans. The most effective behavioral plan is for parents to gently but firmly insist that the child sit on the toilet after mealtimes – usually breakfast and supper – twice a day for 5-10 minutes. The natural movements of the intestines after meals aid in defecation. Sometimes small rewards or star charts help motivate children to follow through with this plan.

If this is a typical pediatric problem, why is it a concern for a child psychiatrist? The main reason is that there are three groups of children who might come to me for another reason who are also prone to having encopresis. The first is anxious children, the second is aggressive children, and the third is children with developmental problems such as attention deficit disorder (ADHD) or autistic spectrum disorders (ASD).

When I describe anxious and aggressive children as belonging to different groups I am only referring to their outward behavior. Most anxious children are afraid of the destructive potential of their own aggression (even if their general behavior is timid and withdrawn). Similarly, children with aggressive behavior usually struggle with the fear that their aggression will get out of control and hurt someone – especially a family member or themselves. What is a natural response to the fear of something dangerous getting of control? Control it! In other words, hold it in. Since children make meaning with and about their bodies even more than adults do, they “hold it in” concretely and physically. This psychological meaning almost always occurs simultaneously with the biological meaning of the threat of passing a hard stool. In my office practice, it is common for a child who allows himself to freely play an aggressive theme, such as dinosaurs biting each other, to interrupt the play and go into the bathroom to poop.

Children with developmental problems are even more interesting. In addition to all the other reasons mentioned above, they have difficulty picking up their body’s cues such as the urge to defecate. This is because they have trouble paying attention to their body’s signals and also because they sometimes cannot decipher them. Some children with ASD need to be told to put on a coat or mittens when it is cold outside since they don’t notice the cold feeling without help. (Readers may be surprised when I link the diagnoses ADHD and ASD in the general category of developmental problems, but I think that is the most sensible way to understand them.)

Helping children with their fears and helping them learn to pay attention to the signals their bodies send them is very important, but nothing can take the place of a regular bathroom routine of sitting on the toilet for 5-10 minutes after breakfast and supper. So why do parents find this so difficult to do? One reason is that the child who is afraid of passing a painful stool will object, and parents of fearful children often have trouble insisting that they face challenges that frighten them. Another reason is that the child with attentional problems or the child who has trouble reading body cues will often “tune out” while sitting on the toilet (sometimes get lost in a book). While “tuning out” will sometimes not prevent a bowel movement, the child who is not paying attention to his body will not learn how to respond to his body’s signals. That is why I do not recommend letting a child read or play with an iPad while sitting on the toilet. It is difficult, but it is a good exercise for both parent and child to help the child tolerate this routine.

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“Come here right now!”: The Iceberg Effect and More About Transitions

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I find myself talking about transitions to the parents I see perhaps more than anything else. A parent will say, for example, “When I call her to come to dinner and finally say, ‘Kate, I need you to come here right now!’ I will either get a nasty response or none at all. If she does respond it will take 10 minutes and more nagging before she comes! Why does it have to be that way?!” the beleaguered mother will ask. These parents are good parents of good children. Most of the children whose parents consult me have major or minor neurodevelopmental problems, ranging from autism to ADHD or the kind of organizational problem commonly called “executive function disorder”. All of these problems involve difficulty making transitions. The good mother who is explaining that her daughter does not come when she calls is looking at the top of an iceberg. She sees a little mound of snow or ice. It is a simple, reasonable request. Why can’t her daughter make a “normal” response? However, beneath the water is a huge iceberg of patterned behavior and the meanings associated with it that has been built up over the child’s life.

Let’s analyze the mother’s “simple request” to “come now”. First of all, she is requiring that the child take in the auditory command. This is harder for some children who have ADHD or who have what is called “auditory processing problems” than for others. The mother might not know that Kate has auditory processing problems or if she did hear that from a tester, she may not have entirely understood what it meant. Or even if she did understand what it meant when the tester was explaining it to her, it is hard to keep in mind during the course of family life.

Second, the mother’s command requires Kate to shift her attention from whatever she was doing at the moment to what her mother is telling her. That shift in attention can be much more difficult that you would think. It involves taking apart the current organizational state of the child – her attention, narrative (the story of what she is doing), and her motor activity. It requires Kate to change her postural position and her physiological state of excitement or of comfort, and prepare for something else. Usually, these shifts in our state of being take place out of awareness. We have an intention to change, and it all happens – we stop reading, get up, and walk to the kitchen to start cooking dinner. We don’t realize that all these small changes of everyday life take energy. Other transitions – sleep to wake, home to school, bedroom to bathroom, bedroom to kitchen table, pajamas to school clothes or even worse, snow pants, also take energy. For some children it requires more energy than for others.

In addition to all those shifts, there is the relational and symbolic meaning associated with the transition. For Kate’s mother it may mean, “Oh, dear. I shouldn’t have taken so long reading that paper. I need to get dinner started!” That may be slightly annoying, but no big deal. For Kate, her mother’s calling her may have a very different meaning. That may be something like, “She is bothering me again, just when I got comfortable watching t.v. I had a really hard day at school and Susie was mean to me, and Mom just can’t give me a break. Why is she always making me do things and not Freddie (little brother)!” I am not suggesting that these coherent sentences appeared in Kate’s mind, but that her mother’s reasonable request may feel entirely unreasonable to her, and this meaning comes together with all the other transitional demands – that she shift her attention, her body, get stirred up inside instead of comfortable, etc.

There are two general antidotes for the stress of transitions. One is routine and the other is what I call “herd mentality”. Herd mentality is more available to teachers than to parents of children in small nuclear families. I first noticed it at the orphanage in El Salvador when the little children – most of whom had suffered early neglect and abuse and therefor could be expected from a neurodevelopmental point of view to have difficulty with transitions – all seemed to manage transitions relatively well. I came to think that it was because they all did the transitions together. When it is time to come to dinner and all the other kids start heading in the direction of the dining hall, the stragglers seemed to notice the general movement and catch up, as if noticing that they didn’t want to be left alone. There is another factor – those children didn’t have the hypnotizing effect of video games or other screens to interfere with the process of the transition.

In addition to the herd mentality, there is the importance of routine. What I tell parents is that routine is their best friend. That is because a routine has momentum. The teacher of the children in the preK classroom in the photo above is using routine, herd mentality, and the rhythm of dance, to facilitate a transition. Once you have established a routine the child does not have to move into that state of limbo, an extended disorganized state, with all the stress that entails. (Remember that stress can be expressed as irritability or aggression!) Instead, although the child may not want to interrupt what she is doing to come to the table, it is easier for her to do it. Kate’s mother’s command does not “come out of the blue”. Dinner is at the same time every night, more or less. Kate’s mother has given her a warning five minutes ago, just as she always does. She may even have gone into the family room to join Kate temporarily in her present state (“That looks like a good program! How about if we record it so that you can finish it later!”) and then used her own body to generate a rhythm in the direction of the kitchen. She may also have initiated a conversation about something that interests Kate – “Remember that girl, Karen, who moved out of the school? I just heard that she was moving back!” All these things help establish a routine. Once the routine is established, it makes everything easier.

Infant Parent Mental Health Weekend: Bruce Perry

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Bruce Perry came to speak to the Infant Parent Mental Health course last weekend. As usual, I was impressed by his discussion, and I agreed with him that his thinking has changed and grown more sophisticated and complex even from when I first met and was inspired by him a decade ago.

This time I was especially gripped by the notion of “dosing” the interventions that are aimed at growing the brain. I put that idea together with two other primary principles of Perry’s Neurosequential Model of Development – changing the environment to meet the developmental needs of the child, and repetitive, rhythmic patterned activity – to create the mnemonic, “RED”. Here is a summary of my thoughts after the weekend. These thoughts are directly relevant to the subjects of ADHD and Executive Function Disorder.

R: Perry frequently talks about the regulating function of repetitive rhythmic patterned behavior. This makes sense, since the body has many rhythms that are repeated over and over again mostly out of our awareness, creating micro patterns that then coordinate to create macro patterns, that help to organize and integrate our human body and mind. For example, we don’t usually pay attention to our heart rate or respiratory rate unless something is going wrong, such as the rapid heart rate associated with anxiety or panic. But our sense of well being emerges from among other things the signals these rhythms send us. An example of the coordination of these rhythms is the coordination of respiratory rate with walking. If walking at a comfortable pace, many people tend to take two strides for one inhalation and between two and three strides for one exhalation. Perry refers explicitly to walking as a regulatory activity, as well as dancing and drumming, and many other repetitive rhythmic patterned activities. In fact, music and dance often provide refined regulatory procedures that make one feel good – calm (“music soothes the savage beast”) or invigorated.

A child develops regulatory capacity through a process of mutual regulation with a caregiver (Cohn & Tronick, 1988, Tronick, 2005). This helps to explain why regulatory activities done with another person are often even more effective than done alone, for example, taking walk with another person. Even having a conversation with another person involves rich processes of turn taking that creates coordinated rhythms between the two people and also simultaneously within each individual (Beebe et al, 1992).

E: One of Perry’s key points is the importance of changing the environment to accommodate the child’s developmental needs for both regulation and for engagement.

From the point of view of regulation, that means more than adding regulatory activities to the child’s schedule. It also means evaluating the child’s capacity for processing sensory input to make sure that the noise, the visual stimulation, and the touch occurring in the child’s daily life is not overwhelming to the child. A crowded classroom or a disorganized routine can be modified to make life easier for a child with sensory sensitivities and that makes life easier for everyone in the family. Sometimes this is called a “sensory diet”.

From the point of view of engagement, this means that the child’s vulnerabilities must be engaged. As Perry says, “You can’t change any neural network unless you activate that neural network.” (Perry, 2015). Not surprisingly, children resist activities that require them to exercise functions that are hard for them, especially if their development is uneven and they do other things quite well. In that case they will tend to stick to what they do well and avoid what is hard. To help them grow, their caregivers must support them in attempting the difficult or uncomfortable task. For some children who are socially skilled but have a learning disability, this means practicing academic tasks that are difficult for them. For other children who have academic strengths but are stressed by interacting with other people, it means drawing them into social interactions, usually in play.

D: But how does one engage a child who is highly stressed by, for example, social interaction, such as very shy children or children on the autistic spectrum? Perry’s idea, which I find very useful, is that of dosing. By paying attention to the child’s cues, you can “read” the child’s intentions to “do something with you” or not. In the rather extreme case of an ASD child, you can’t just let him remain in a withdrawn position without attempting to make a connection; you often have to take the initiative yourself. I recommend small gestures that take place in short time intervals and are over quickly, and also that are of low to medium level of intensity (in noise, visual stimulation, affective tone, and arousal). After you have taken the initiative, you watch for the response. If the child seems not to respond you might try one more time. If the child pulls back further, you might wait. If the child looks a little interested, you might repeat the gesture.

The beauty of this notion of dosing is that it is coordinating intention with the child, and dosing is repetitive and has a rhythm to it. Together with the child you are creating patterns of ways of being together. So you are putting together regulation-enhancing activities with growth-stimulating activities. Another good thing about dosing is that it takes the emphasis off success or failure and places it on creating a balance. If the child indicates, “no”, then you don’t feel, “Oh, I lost him.” Instead, you think, “OK, that was a “no”; I will wait and try again. The “no” is part of what we are doing together. It is part of the back and forth.” And, of course, back and forth is a rhythm too.

How is this discussion related to ADHD and EFD? Both ADHD and EFD can be thought of as regulatory disorders (or difficulties on a dimension, if we use my preferred terminology). I will discuss this further in another blog posting.

References:

Beebe, B., Jaffe, J. & Lachmann, F. (1992). A dyadic systems view of communication. In N. Skolnick & S. Warshaw (Eds.), Relational perspectives in psychoanalysis (pp. 61-81). Hillsdale, NJ: Analytic Press.
Cohn, J., & Tronick, E. (1988). Mother-infant face-to-face interaction: Influence is bi-directional and unrelated to periodic cycles in either partner’s behavior. Developmental Psychology, 24, 386-392.
Perry B (2006). The neurosequential model of therapeutics: Applying principles of neuroscience to clinical work with traumatized and maltreated children, In: Working with Traumatized Youth in child Welfare (N Webb, Ed). The Guilford Press, New York, pp. 27-52.
Perry B (2015). Presentation to the Infant Mental Health PGC Program, U Mass Boston, Feb. 25-26.
The Child Trauma Academy (2015). Overview of the neurosequential model of therapeutics, www.ChildTrauma.org
Tonick E (2007). The neurobehavioral and social-emotional development of infants and children, New York, WW Norton.

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ADHD – What is it and What can we do about it? I

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Why write about ADHD?

I was recently asked to write a paper to contribute to a volume addressing changing trends in child psychiatry. I chose to write about ADHD. I made this choice for many reasons. One reason is that more parents bring their children to me with ADHD as one of their stated concerns than any other problem. Another reason is the evolution of thinking about ADHD has grown to appreciate the complexity of the problem (though back in 1992, Leon Eisenberg warned about the rush to medicate) (Eisenberg, 1992). That makes it interesting. And yet, despite the greater complexity of what is currently known about ADHD, many clinicians still behave as if it were a simple disease entity with a single etiology, and consider medication the first and often the only treatment option. Finally, I think the young child psychiatrists I teach and the parents and teachers I consult to should have access to contemporary knowledge on the subject.

Executive function

I know I promised to blog more about executive function. I intend to do that. However, my reading about ADHD interrupted my agenda for a good reason. There is a large overlap between ADHD and EFD. That is due in part because there is no clear definition of executive function in the literature. Basically, executive functions refer to the internal processes an individual uses to organize the knowledge he has in the service of accomplishing goals. Problems with executive functioning include difficulty organizing oneself in time and space; initiating and formulating a plan of action to accomplish a goal; maintaining motivation during a goal oriented activity; avoiding distractions while working; and following through to a satisfactory result. You can see the similarities between dysfunction of these processes and ADHD.

I am going to write several installments on the subject of ADHD. They will be somewhat academic and may try the patience of readers who want a quick explanation and a “how to” section, but unfortunately (or fortunately) life isn’t that way. Our children are complicated, and in order to understand them we have to be patient and learn all we can learn about what makes them tick. Here is the beginning.

What is ADHD?

Among many stated claims that are unclear about ADHD, there are three facts are clear.

The first is that the number of children diagnosed with ADHD is growing. Between 2003 and 2011, 2 million more children in the U.S. aged 4 to 17 were diagnosed with ADHD (Visser et al, 2014, p. 34).
The second is that there is a central nervous system basis for ADHD symptoms. This fact is supported by many candidate gene studies that show associations between ADHD and dopamine transporter and dopamine receptor genes (Lou et al, 2004; Bralten et al, 2013), and also by neuroimaging studies that identify functional connectivity abnormalities in particular neural networks in the brain (Konrad et al, 2010; Liston et al, 2011; Levitt et al, 2013).
The third is that a multi-dimensional assessment and treatment approach is far preferable to a rush to medication.

ADHD is characterized by inattentiveness, distractibility, impulsivity, and overactivity. It is certainly not a disease. Many attest to the heterogeneity of ADHD (Jensen, 2000; Musser, 2013; Arnold, 2014). Some even question whether it is a disorder rather than an extreme of temperamental variation (Jensen, 2000, p. 195). This consideration is based on the observation that a significant group of children with ADHD seem to “grow out of” ADHD (Hechtman, 1992), as well as studies that demonstrate the influence of social and school environment on the diagnosis of ADHD (Schneider & Eisenberg, 2006). It does seem likely that the demands our current culture places on children to sit still and pay attention, to manage frequent transitions, and to multi-task, may not be as easy for some “normal” children to accommodate as for others. This kind of consideration has led some to argue for a “dimensional” rather than a “categorical” diagnosis of ADHD (Vande Voort, 2014).

In the next installment I will write about some of the neurodevelopmental findings on ADHD.

References

Arnold L, Ganocy S, Mount K, Youngstrom E, Frazier T, Fristad M, Horwitz S, Birmaher B, Findling R, Kowatch R, Demeter C, Axelson D, Gill M, Marsh L (2014). Three year latent class trajectories of attention-deficit hyperactivity disorder (ADHD) symptoms in a clinical sample not selected for ADHD, JAACAP 53(7):745-760.

Bralten J, Franke B, Waldman I, Rommelse N, Hartman C, Asherson P, Banaschewski T, Ebstein R, Gill M, Miranda A, Oades R, Roeyers H, Rothenberger A, Sergeant J, OOsterlann , Sonuga-Barke E, Steinhausen H , Faraone S, Buitelaar J, Arias-Vasquez A (2013), Candidate genetic pathways for Attention-Deficit/Hyperactivity Disorder (ADHD) show association to hyperactive symptoms in children with ADHD, JAACAP, 52(11):1204–1212.

Eisenberg L (1972). The clinical use of stimulant drugs in children, Pediatrics 49:709-715.

Hechtman L (1992). Long-term outcome in attention deficit hyperactivity disorder. Child Adolesc Psychiatr Clin North Am 1:553-565.

Jensen PS. Commentary: The NIH ADHD consensus statement: win, lose, ordraw? J Am Acad Child Adolesc Psychiatry 2000; 39: 194-197.

Konrad K, Eickhoff SB. Is the ADHD brain wired differently? A review on structural and functional connectivity in attention deficit hyperactivity disorder. Hum Brain Mapp. 2010;31:904-916.

Lawrence K, Levitt J, Loo S, Ly R, Yee V, O’Neill, Alger J, Narr K (2013). White matter microstructure in subjects with Attention Deficit Hyperactivity disorder and their siblings, JAACAP, 52(4):431-440.

Lou, H. C., Rosa, P., Pryds, O., Karrebaek, H., Lunding, J., Cumming, P., & Gjedde, A. (2004). ADHD: increased dopamine receptor availability linked to attention deficit and low neonatal cerebral blood flow. Developmental Medicine & Child Neurology, 46, 179–83.

Liston C, Malter Cohen M, Teslovich T, Levenson D, Casey BJ. Atypical prefrontal connectivity in attention-deficit/hyperactivity disorder: pathway to disease or pathological end point? Biol Psychiatry. 2011;69:1168-1177.

Musser E, Galloway-Long H, Frick P, Nigg J (2013). Emotion regulation and heterogeneity in Attention-Deficit Hyperactivity Disorder, JAACAP, 52(2):163-171.

Vande Voort J, He J-P, Jameson N, Merikangas K (2014) Impact of the DSM-5 Attention-Deficit Hyperactivity Disorder age-of-onset criterion in the US adolescent population, JAACAP, 53(7):736-744.

Visser S, Danielson M, Bitsko R, Holbrook J, Kogan M, Ghandour R, Perou R, Blumberg S (2014). Trends in the parent-report of health of health care provider-diagnosed and medicated Attention Deficit/Hyperactivity Disorder: United States, 2003-2011, JAACAP, 53(1):34–46.

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More on Executive Function:

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Executive functioning (EF) is a real “lumper”, as in “lumper or splitter”, term. That is, it refers to a very broad class of skills that we use to get through the day at home, at school, and at work. Not only that, but for executive functioning to work well, all these skills have to be coordinated with one another. It is conceptually confusing to try to collapse all this complexity into one “thing”, but since it is frequently used to describe children, we will use it here too. EFD has a big overlap with ADHD, as you might imagine.

EF is used to help plan, organize, make decisions, and shift between situations or thoughts (make transitions), control emotions and impulsivity, and learn from past experience. It includes cognitive processes referred to as “working memory”, in which facts that are needed to solve problems – in academic tasks, social situations, or tasks of living, such as what is involved in getting ready in the morning – are kept accessible for use when necessary. A figurative image that is often used for working memory is facts on a shelf in the front of the brain, so that if a child is trying to solve a math problem, she may need to be able to find the multiplication tables right away and not stumble as she tries to retrieve them. Or if he is in a tricky social situation, he may need to recall a fact about another boy he wants to play with – such as that this boy does not like to be called a certain nickname – if he wants to make a good connection.

A child with EF difficulty, “executive function disorder” (a term I dislike because of the word “disorder” since there is no discrete “disorder”), has difficulty with organizing his life. He often has difficulty with handwriting (visual motor integration), trouble managing the multiple transitions of his daily life (getting ready in the morning, going from one activity in school to another, managing the bedtime routine), making sense of the complex social communications of the playground, inhibiting impulses (“using your words instead of your body”). Children with this type of difficulty also often have trouble with team sports in which you have to coordinate with multiple other players as well as manage your own body.

What can you to help your child who struggles with executive function problems? Well, to begin with, consider not that you are helping him “compensate” for deficits (which may be true in the immediate situation, of course) but rather that you are “growing his brain”. You are helping him to develop more robust capacities than he has, and you are doing that by making it possible for him to use his less developed capacities in a less demanding situation (so that he can be successful) and practice them over and over so that they can become stronger and more versatile. You are helping him build good habits. You are helping him expand his repertoire of competencies. You are helping him grow his brain.

You would like to ensure success through these considerations:

1. Context – The first thing to do is to identify the contexts in which your child can most easily succeed. Some kids can regulate themselves well in a highly structured setting such as many school classrooms. Others require the reduced stimulation of a small group of children. Some may be able to sustain attention on a simple, structured task such as simple Lego kits or simple academic worksheets, but get frustrated and fall apart with less structured writing assignments or more complex Lego kits. It is common for some kids to do well on tasks requiring information that the child has learned well by practice but be unable to grasp novel concepts easily. Often children with these challenges are more vulnerable to physical or emotional distress interfering with their concentration – a cold or a conflict with a friend. Recognizing the context means you are empathizing with your child, which is at the core of successful parenting of a challenging child.
2. Take Your Time – No matter how much hurry you are in, slow down. Rushing will make everybody anxious and make matters much worse.
3. Break it Down– Then break down the information you want the child to learn into small enough pieces that he can take it in. Directions should be simple (“First, hang your coat on the hook.”); beware of multi-step directions (“Hang your coat on the hook and put your boots, and then come into the kitchen to have your snack.”). Or, teach morning routine in pieces, such as (1) use the toilet; (2) brush your teeth; (3) wash your hands and face; (4) put on your clothes; (5) come down to breakfast.
4. Make Checklists – Help your child by making checklists. Often these children get so preoccupied by making the first decision, that they cannot even start working on the task they have decided on. Setting out the requisite tasks in order ahead of time can make all the difference in a smooth transition. Checking off all the steps can create an experience of mastery. It is also helpful to do as many of the tasks involved in transitions ahead of time, such as laying out the clothes for the next morning the night before, putting everything in the backpack, making the lunch.
5. Write it Down (or Make Pictures) – For younger children, it is helpful to make a schedule strip of Velcro with words, or pictures (depending on the maturity of the child) to document the child’s daily routine. For older children, weekly planners are very useful.
6. Routines are Your Best Friend – Routines establish a comforting predictability that ease tension by making transitions easier. When children know what is coming, the momentum of the schedule can carry them into activities that they would otherwise refuse. Routines help you practice, and practice is essential to building a bigger repertoire.
7. Rewards – I think of rewards – stickers, treats, or special time with parents – not as bribes but as acknowledgement for an accomplishment hard won. Especially for kids with attention problems, rewards given quickly after a good effort can promote motivation.

Photo by Ginger Gregory

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