I’ve written a lot about attention deficit hyperactivity disorder (ADHD) over the years. In 2011 I was a lone voice questioning the new American Academy of Pediatrics guidelines extending the diagnosis from age six down to age four. My opinion piece in the Boston Globe Diagnosing ADHD Under 6: A Mistaken Idea earned me a lot of attention, most notably a spot on the Diane Rehm’s radio program where I raised concerns alongside three prominent academic pediatricians who enthusiastically supported the change. It was quite a moment. When I listen to the recording over a decade later, I hear that we were so far apart in our understanding of the issue that it’s as if we were speaking two different languages.
The subject has faded to the background as I have become more immersed in early relational health but came roaring back after two recent experiences. First, I was invited to be interviewed for a podcast ADHD is Over. The reviews revealed the polarizing nature of the subject -proclaiming either “Necessary listening” or “Dangerous misinformation.” Next, I read in a current issue of Pediatric News about “under prescribing of AAP recommended parent training in behavior management for preschool ADHD.”
The problem of polarizing certainty has been on my mind as I work on a book exploring lessons learned from listening to parents and young children. I’ve heard passionate opposing views: some claim ADHD is a “neurodevelopmental disorder” while others express conviction that the term quashes their child’s unique strengths and capacities. But perhaps both things are true. I wonder if a dialogue with time and space for micro-moments of mismatch to repair that characterize what I call “playing in the uncertainty” might not only bring these two polarized perspectives into alignment but also offer a path to healing. Whatever camp a family places themselves, these parents and their children have one thing in common: they are suffering. The passion itself reflects the depths of the struggle.
As I said on the Diane Rehm show, if a child as young as four exhibits behaviors that warrant a diagnosis of a psychiatric disorder, one can almost guarantee that the struggles are longstanding. Often parents describe babies that “noticed everything” from the moment of birth. That intense reactivity may translate in terms of behavior into an infant who doesn’t sleep, who pops off the breast while nursing, who cries at the slightest sound. Exhausted parents- often with additional challenges ranging from multiple young children to care for, marital conflict in the face of chronic sleep deprivation, and external forces such as poverty, community violence, or a global pandemic-struggle to contain their infant’s dysregulated behavior. Inflexibility transforms into frequent toddler tantrums, which, as language comes on board become the child who “never listens.” Place that child in a classroom with teachers who may themselves be overwhelmed by inadequate support, too many kids to manage, and now the added layer of pandemic stress, and a diagnosis may be the only path to helping that child to function and learn.
The rush to diagnose itself represents an intolerance of uncertainty. Sitting in the discomfort of not-knowing while taking time to make sense of the problem calls for a feeling of safety and community of support, both of which are lacking for parents and professionals alike. Parents feel judged about their child’s behavior. Clinicians feel urged to find the answer in unrealistically brief visits under pressure of a waiting room full of kids.
Qualities of short attention span, difficulty with state regulation, and high activity level can be present at birth, making them by definition biologically based. These qualities tend to run in families offering evidence for a genetic component. But everything we think and do is rooted in biology of our brain and body.
With an approach firmly rooted in observation, an alternative to the medical model of disease comes in the form of taking time to notice -starting from birth-what parents do right even under adverse circumstances. Listening for what a child’s behavior communicates often leads to “moments of meeting” between infant and caregiver that give a child a sense of being understood while promoting self-confidence in their parent. Infant researcher Beatrice Beebe describes the concept in psychological terms: “A match between how one knows oneself and how one is known facilitates developing agency and identity.” Interactions shift to set relationships and development in a different direction. The brain grows new connections that enhance capacity for regulation of emotion, behavior, and attention.
This model brings me back to the AAP recommendations for “parent training” and “ behavior management” for “preschool ADHD.” With young children and their families bearing the brunt of COVID almost two years into the pandemic, the typical sense of overwhelm for pediatricians on the frontlines with too many patients in too little time is magnified to almost inconceivable levels. I understand the need for certainty. The algorithms for treating a “disorder” offer containment. In contrast the approach I’ve gleaned from immersion in the field of infant-parent mental health- a field until recently largely siloed from pediatrics- is messy.
I believe that most clinicians caring for the next generation want to listen to the voices of young children and their parents rather than silence them with simple answers to complex problems. But pediatricians are placed in situations where they have neither the time nor the training. This story of preschool ADHD could serve as an allegory for all instances where people cling to certainty. It usually comes from a place of anxiety and overwhelm. The answer lies in systemic change that places value on protecting space and time for people- clinician, parent, and child-to feel heard and understood.