Parenting Styles and ADHD Symptoms

 

In my continued effort to beat a dead horse, this post concerns yet another not-so-science-based characteristic of authors of the literature on ADHD: their refusal to consider any alternate interpretations of their data other than that they are studying some sort of brain disease. In this case, they do not consider the possibility that the symptoms of their subjects come as a result of environmental issues, such as a chaotic home environment and/or sleep deprivation.

One well-publicized study (Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD | American Journal of Psychiatry (psychiatryonline.org) purports to show that up to 90% of children who have attention-deficit/hyperactivity disorder (ADHD) may continue to experience residual symptoms of the disorder into young adulthood. Amazingly, the authors add that they may also have periods of remission along the way. In other words, ADHD is a disease with waxing and waning symptoms. Could it not be that other, environmental issues that create their symptoms are what is doing the waxing and waning???

In another publication, Greg Mattingly, MD, of the Midwest Research Group, tells us that, “Instead of resorting to positive parenting, many of them [parents of kids diagnosed with ADHD] have fallen back on what we call negative parenting: scolding, discipline, getting frustrated. As we shift into next year, we need to shift into how we shift into a positive parenting model. I want you to talk to your kids with encouragement about the school year. Share something each day that was something cool they learned in a positive way, and then complement them for sharing that fact back with you."

So the symptoms get better with positive changes in parenting style? The author doesn’t seem to consider the possibility that negative parenting styles were perhaps a big cause of the so-called disease in the first place. 

This reminds me of TARA, a support group for parents of people with BPD (at least those that weren’t physically or sexually abusive, since those relatively common parents-of-kids-with-the-disorder would never join a parent support group —other than perhaps the False Memory Syndrome Foundation). They teach parents how not to invalidate their kids but somehow don’t mention the DBT theory that an invalidating environment is a major cause of the disorder in the first place. In TARA's case, this isn’t a bad thing because if they did that, a lot of these parents wouldn’t attend their seminars. But researchers in the field ignores this issue as well.

The “Logic” of Researchers in ADHD

 

About 15-20 years ago or so, when I was still Director of Psychiatric Residency Training at the University of Tennessee Medical School, I went to a grand rounds (a teaching conference involving the whole department) to hear a talk by a doctor about adult ADHD. It turned out to be more of a drug commercial for some or other stimulant the sponsor of the talk was selling.

The guy basically said that this pseudo-diagnosis was in fact incredibly common – up to 14% of the adult population – and all of them should be taking significant doses of one of the most dangerous and addictive class of drugs that are available by prescription – classified by the FDA in the same category of abuse potential as opiates like morphine. Wow.

During the Q&A at the end of the talk, the subject of ADHD in children came up. Someone asked him why so many kids diagnosed with the disorder could go to a video game arcade (which had at the time only recently gone the way of the dinosaurs) and concentrate with tremendous focus on the game they were playing despite all sorts of buzzers and bells going off, flashing lights everywhere, and scores of people milling all around talking to each other. The speaker opined that this was “not concentration.” I’ve heard that sentiment many times before and since from Pharma shills. Well if it isn't concentration, I wondered, then WFT is it?

Another skeptic in the audience from child psychiatry asked him about the high incidence of alcoholism in the parents of ADHD patients. His response: “If you had a kid like that, you’d probably drink too!” Oh, I see. Alcoholism is caused by having rambunctious children.

I should have gotten up and cussed the dude out for saying heinous stuff like this, but my boss in the department might have frowned on it.

All this reminds me of another talk I once heard from someone from the National Institute for Drug Abuse during an outside medical meeting. He was going on and on about how cocaine, another stimulant BTW, depletes a chemical in the brain called Dopamine, which makes it nearly impossible for abusers to enjoy anything but the drug. Someone (again, not me) got up and asked, “But aren’t we doing that when we prescribe stimulants to our kids?” The speaker’s answer, “But the drugs work so well.”

So I’m guessing that the answer to the question that was actually asked, which the speaker completely avoided, was, “Yes.”

How Good Psychiatrists Evaluate New Patients

If you think you might need psychiatric medications, here's the minimum of what the doctors should cover in a GOOD evaluation. If they do not, FIND ANOTHER PSYCHIATRIST:

1. They should spend at least 45 minutes to an hour in the initial interview.

2. When asking about your symptoms, they should pin you down as to exactly when and in which psychosocial circumstances you experience them. To be relevant to any diagnosis, all symptoms should be present at the same time and significantly affect you over more than just short periods.

Major mood disorders such as true major depression and mania are grossly over-diagnosed nowadays. The symptoms of these disorders are pervasive: you have to have them nearly all day nearly every day no matter what else is going on in your environment. Major depressive episodes need to last for at least two weeks straight, while mania requires a whole week. While these “duration” criteria are arbitrary, they are in the diagnostic criteria to distinguish major mood disorders from emotional reactions to purely environmental changes or relationship problems.

During a major mood disorder episode, your reactions to everyday stress should also be completely different from your usual, baseline reactions (how you react to your environment when you are not in a mood episode). They should also be out of character for you - Jeckyl and Hyde territory.

Mood and anxiety disorder diagnoses can NOT be made definitively if you are actively using psychoactive substances. Intoxication with drugs like cocaine can, for instance, mimic mania.

Stressors can trigger a new mood episode, but once episodes happen, they take on a life of their own.

3. The doctor should do a psychiatric "review of systems" to ask questions to rule out (at the minimum) a history of mania, substance abuse, panic attacks, OCD, and self-injurious behavior. 

They should ask you about whether there is a family history (among blood relatives, not adoptive relatives) of psychiatric problems or substance abuse. They should also ask you for your medical history and medications you take to try to rule out medical reasons for your symptoms.

In particular, panic attack symptoms are often ignored or falsely classified as symptoms of a mood disorder.

4. They should take a COMPLETE psychosocial history covering your family constellation, parental behavior, any parental divorces and subsequent marriages, any history of abuse or neglect, how far you went in school, and a complete history of your employment and relationships.

This part of the history has almost disappeared from psychiatry, blurring the distinction between psychological reactions and major mental illnesses.

A history of adverse childhood experiences such as abuse, neglect, violence, substance abuse or infidelity by parents can put you at risk for personality problems, low moods, anxiety problems or many other psychological symptoms. Again, a traumatic environment can trigger chronic problems that medication can help, but psychotherapy is the more important treatment. Even if your psychiatrist only prescribes medication, he or she should still refer you to a therapist in these instances. A good psychiatrist will focus on ALL the relevant variables amenable to different treatments and not focus myopically on just your symptoms.

5. If you are having trouble focusing or concentrating, this alone does not mean you have “ADHD.” You can have this symptom due to stress, sleep deprivation, boredom, preoccupation with something, or a wide variety of other reasons. A good doctor will ask questions to rule out these causes rather than just throw dangerous stimulants like Adderall (a methamphetamine clone) at you. 

6. If medications are prescribed, they should tell you what the most common side effects are, and if there are any dangerous ones even if they are rare, and also tell you that if you think you are having an adverse effect, that you should call the doctor's office.

Drug Abuse and Drug Companies

As most readers will know, opiate abuse and overdoses have increased dramatically in recent years, and it’s all over the news. Some of the public may even be aware of the role of drug companies and drug distributors in the process – the latter being recently profiled on an episode of Sixty Minutes. Let’s look at the role of the drug companies.

A Pharma executive, a billionaire, was arrested in October on charges of bribing doctors to prescribe opioid painkillers. (http://fortune.com/2017/10/26/john-kapoor-insys-therapeutics-arrested-net-worth/). The Department of Justice arrested Insys Therapeutics founder John Kapoor, 74, in Phoenix. Kapoor was charged with using bribes and fraud to prop up sales of a pain medication called Subsys, a fentanyl spray typically used to treat cancer patients suffering excruciating pain. Fentanyl is 50 to 100 stronger than morphine, and contributed to the overdose deaths of pop stars Prince and Tom Petty.

When it comes to drugs of abuse, the lunatics seem to have taken over the asylum in medicine these days. In their push towards huge profits, dangerous drugs are being hawked when cheaper, less toxic, and less addictive alternatives are available for treating some conditions. And as discussed in this blog, whole diseases such as “adult adhd” have been invented out of whole cloth.

For those readers who may not know, potentially addictive drugs are referred to by the Drug Enforcement Agency (DEA)  as “scheduled” drugs. Schedule I drugs are the illegal ones. Schedule II drugs are those with the highest abuse potential: narcotics and stimulants. Schedule  IV drugs are those considered to be of low potential for abuse. If you didn’t know how the drugs were scheduled, you certainly would never know it from listening to presentations by doctors working with Pharma.

Pharma hires doctors to do research on as well as give talks to other doctors about their products, totally with the goal of increasing sales – if patients do happen to benefit in some way, all the better – but that is hardly a requirement. The slides that are presented during the talks are furnished entirely by the drug company after being approved internally; the doctors giving the talks are not allowed in most instances to use their own slides.

Pharma is particularly known for employing what they call “Key Opinion Leaders” (KOLs) to give promotional talks to doctors around the country. The more academic credibility they seem to have the better – that is one source of determining who might be a KOL. But it is not the only one.

Pharma can actually get any given doctor’s prescribing records from the pharmacy industry (unless the doctor “opts out” of allowing his or her data to be mined in this way. Most docs are not even aware of this option—and having the information publically available is the default position). Pharma then uses this data to see if prescriptions for their products increase after one of their KOLs makes a presentation. 

Those doctors that make the best salesmen are hired again and again, while those who do not measure up are dropped.

A colleague of mine has taken a course required in Tennessee for licensure that discusses the “proper way” to  prescribe drugs of abuse. The course was sponsored by our malpractice carrier. According to him, one year the leader of the course scolded the doctors present for not prescribing enough opiates to people with chronic pain. 

The doctors were told how much suffering they were causing these patients by withholding these medications. Just one year later, after the “opioid crisis” hit the news, the same course was given. Only this time, the doctors were scolded because they were prescribing these “suddenly” dangerous and highly addictive substances to their patients with chronic pain!

I have discussed in previous posts how the risks of that class of medication (Schedule IV) have been wildly overblown in the medical literature and in public news stories. As well as being classified as “low abuse potential” by the DEA, they do not cause intoxication, and have next to no side effects compared to just about any other class of meds in most patients. I am not saying they are never abused, but usually only by people that mix them with opiates and alcohol. 

And of course any individual can have a bad reaction to any drug. It seems benzo’s are never discussed without the admonition that the “are addictive,” or have a few side effects in (some) patients – while drugs like amphetamines (Schedule II) that are abused far more often, and have more potential adverse or toxic side effects, are enthusiastically pushed.

And I do mean pushed, as in supplied by pushers masquerading as drug companies. I recall a “grand rounds” (a major lecture at an academic department in a medical school) from maybe 18-20 years ago in which the KOL was saying that about 18% of all adults should be on high doses of speed, that the reason that many of the parents of kids diagnosed with ADHD were substance abusers was because, "If you had a kid with ADHD, you'd drink too," and that kids who had ADHD could concentrate intensely on video games in an arcade despite multiple and pervasive loud distractions all about because that is "not concentrating." (I always wondered what the heck it supposedly was). I kid you not.

As another amazing example of drug pushing, one news service for psychiatry called MDLinx devotes a whole e-mail newsletter to articles extolling the use and virtues of drugs like Adderall and Concerta. Some recent examples:

MDLinx Psychiatry 3/13/18 - Ranked, sorted, and summarized by MDLinx editors from the latest literature.

IN THE NEWS SHP465 mixed amphetamine salts effective, safe for ADHD in adults Liz Meszaros, MDLinx, 03/08/2018

Researchers investigate the link between ADHD and risk of self-harm Paul Basilio, MDLinx, 02/23/2018

Study of 23,000 people links ADHD with genetic signature for delay discounting. Paul Basilio, MDLinx, 12/11/2017

They also have a section of their more general psychiatric newsletters also devoted to this goal that is called the ADHD Resource Center: A collection of articles and features related to ADHD with articles like:

AAP Experience - American Academy of Pediatrics              National Conference & Exhib Conference Of course, none of these Pharma sales mechanisms would matter that much if there were not already a ready market for abusable medications. That market is growing, and adverse childhood experiences and family dysfunction are a huge part of that problem. Still, as Steppenwolf used to sing, “G-d damn the pusher man.”

Sleep, Discipline and Childhood Behavioral Disorders

A couple of news stories about some new “studies” recently caught my eye. They illustrate the downright ungodly lengths certain segments of the mental health industry, as well as dope-dealing drug companies like Shire Pharmaceuticals, will go to distract both the field and the public from the real cause of many childhood behavioral problems: family interactions. They do so in order to justify their mostly ineffective and potentially toxic treatments. 

The stories were:

1    1. Poor Childhood Sleep May Lead to Behavior Woes in Adolescence by Molly Walker, Staff Writer, MedPage Today, December 04, 2017: Study suggests bidirectional association for some problems

“Young children who had greater sleep problems were more likely to have certain types of behavioral problems years later, Australian researchers found…There was a bidirectional association between sleep problems and externalizing difficulties, such as attention deficit-hyperactivity disorder, oppositional defiant disorder, and conduct disorder, in children when measured at particular time points through early adolescence, reported Jon L. Quach, PhD, of the University of Melbourne in Australia…Quach's group said that the directionality of the associations between sleep problems in children and later behavioral problems are "poorly understood," but argued that "addressing this knowledge gap will provide valuable information to inform the focus and timing of interventions aiming to improve children's sleep and behavior during the elementary school years...Sleep problems were defined by parent report. 

Of course they relied on parental reporting - to make use of parental denial to the maximum extent possible. 

“The directionality of the associations between sleep problems in children and later behavioral problems are ‘poorly understood?’” Poorly understood, my ass. See below.

       2.  ADHD and insomnia appear intertwined By: Bruce Jancin, Clinical Psychiatry News, November 30, 2017  (http://www.mdedge.com/clinicalpsychiatrynews/article/153175/adhd/adhd-and-insomnia-appear-intertwined?oc_slh=b7663e08a51cd61023636ca0354888a37f5bd7dbaf016b90aac8a66134946998&channel=296&utm_source=News_CPN_eNL_120417_F&utm_medium=email&utm_content=Self-harm+on+rise+in+U.S.+among+this+group)

“Converging evidence suggests that attention-deficit/hyperactivity disorder and sleep difficulties share a common underlying etiology involving circadian rhythm disturbance, J.J. Sandra Kooij, MD, PhD, declared at the annual congress of the European College of Neuropsychopharmacology…Having built the case for circadian disruption as an underlying cause of both ADHD symptoms and the commonly comorbid sleep problems…Multiple studies have shown that roughly 75% of children and adults with ADHD have sleep-onset insomnia.”

Shared etiology for sleep problems and certain childhood behavioral disorders like ADHD? Well, duh. Both are caused by parents who don't know how to discipline their kids. In the case of ADHD, they let them stay up half the night playing video games. And then the kids are too sleepy to concentrate the next day. 

This sleep pattern leads to the circadian rhythm disturbances (getting days and nights mixed up, in a way) described by Kooij. Of course, the discipline problems in the houses of these kids are hardly limited to bedtime. Inconsistent, abusive, and/or just plain absent discipline lead to children acting out. You know, “oppositional defiant disorder” and “conduct disorder.” Like I said, acting out.

Marketing Methamphetamine Clones for Fun and Profit

From 2010 (when I first started this blog) until 2013, I published several posts about the United States Department of Justice assessing huge fines against several large pharmaceutical company for off-label marketing and false advertising about several different psychiatric drugs. Somehow in September of 2014, I missed  a big one. 

That time, a large fine was assessed against my least favorite of all the drug companies, Shire Pharmaceuticals - the maker of the methamphetamine clones Adderall and Vyvanse. They also make a version of Ritalin called Daytrana.

As far as I'm concerned, this company is nothing but a dope dealer that cares only for profits and not a whit for their victims - er, I mean consumers. The company does its best to convince doctors to dope up kids who have various behavior problems - which in reality are mostly due to problematic parenting and/or chaotic home environments - with highly abuseable and dangerous stimulants. 

I have written several posts on the huge increase in prescriptions for these medications in children over the last twenty years or so. Now, we are seeing a huge increase in prescriptions of these drugs to adults for the adult version of "ADHD." While there may be both adults and children with minimal brain dysfunction who have a real disorder that requires this medication, most people who are given this diagnosis present with symptoms which are caused by other factors. The biggest ones: the effects of bad environments mentioned above which create anxiety and low moods, and amphetamine abuse. The later patients lie to their physicians in order to get the drugs. 

The drugs not only get people high, but are also used as performance-enhancing drugs for mental activities—much like steroids are used to enhance performance for physical activities.

Currently, medications to treat ADHD are one of the most lucrative sectors of the US drug market, totaling more than $10 billion in sales - 83 million prescriptions in 2014, according to data from IMS Health, ”with adults using more of these medications..." The “2013 edition of the Diagnostic and Statistical Manual of Mental Disorders... relaxed the definition for” ADHD in adults."

ADHD symptoms are easily faked. A 2010 study found that 22% of adults tested for ADHD exaggerated their symptoms. And that was probably only those subjects who would admit to it! Such exaggeration has been made much easier by the wide availability of online symptom checklists. 

Getting back to the matter at hand, Shire Pharmaceuticals LLC  paid a $56.5 million fine to resolve civil allegations that it violated the False Claims Act as a result of its marketing and promotion of these drugs. As one can easily see from the above figures, that's actually a very small cost of doing business. Among other things, they marketed Adderall XR based on unsupported claims that Adderall XR would prevent poor academic performance, loss of employment, criminal behavior, traffic accidents and sexually transmitted diseases. 

Shire medical science liaison allegedly told a state formulary board that Vyvanse “provides less abuse liability” than “every other long-acting release mechanism” on the market.  However, the government contended that no study Shire conducted had concluded that Vyvanse was not abuseable, and, as an amphetamine product, the Vyvanse label included an FDA-mandated black box warning for its potential for misuse and abuse. Shire also made allegedly unsupported claims that treatment with Vyvanse would prevent car accidents, divorce, arrests and unemployment. 

Interestingly, the Justice Department was alerted to these marketing practicing by whistleblowers. The allegations arose from a lawsuit filed by Dr. Gerardo Torres, a former Shire executive, and a separate lawsuit filed by Anita Hsieh, Kara Harris and Ian Clark, former Shire sales representatives. The lawsuits were filed under the False Claims Act’s whistleblower provisions, which permit private parties to sue for false claims on behalf of the government and to share in any recovery. 

The marketing of stimulants for "adult ADHD" is as heinous as the marketing to children and teens. According to an article published by Medscape, "... the prevalence of [supposed] ADHD in adults these days is about half that in children. For years, the legitimacy of the adult ADHD was based on the belief that it was a condition that started in childhood and, for some, persisted into adulthood. 

But last year that hypothesis was shaken by the publication of a provocative, long-term study that followed more than 1,000 New Zealand children until age 38. In that study Terrie Moffitt, PhD, a psychologist at Duke University, and her colleagues found that in childhood, 6% of those in the study had ADHD. At age 38, that number had dropped to 3%.

And the biggest surprise was the lack of evidence of significant overlap between the two groups. Only 5% of those with ADHD in childhood still met the criteria at age 38. And only 10% of those who met the definition at age 38 were among those with the supposed condition in childhood.

The Medscape news article concluded from this data that "Studies suggest people diagnosed with ADHD as adults may have a condition that differs from ADHD seen in children." Wow. I would come to a different conclusion. Namely, that most of these patients did not have "ADHD" at all, but something else entirely.

And in yet more marketing-of-dope-to-children news (without a peep out of the pesky National Institute for Drug Abuse or the FDA), there’s a new, candy-flavored amphetamine on the market. Adzenys is chewable and fruity! Dr. Alexander Papp, affiliated with University of California, San Diego, asked, “What’s next? Gummy bears?”

Antipsychotic Medication Used to Dope Up Unhappy Children.

There were two interesting editorials in the September 2015 issue of JAMA Psychiatry, a journal that used to be called the Archives of General Psychiatry and which is published by the American Medical Association. On the surface, the articles seem to address completely unrelated subjects, but on closer inspection, they both involve a common theme.

The first one is entitled "Antipsychotic Use in Youth Without Psychosis: a Double Edged Sword." I have of course railed in many of my blog posts about the use of antipsychotic medication for patients who do not have psychosis, because these agents can have serious drawbacks, and because better alternatives exist. In many cases, the better alternative is psychotherapy that can help the anxiety and mood symptoms that used to considered to be part and parcel of, and caused by, neurosis - behavioral disorders based both on internal ambivalence about one's life choices as well as interpersonal conflicts.

I have been particularly critical of the use of antipsychotic drugs in children who are almost never actually psychotic, and who are being diagnosed with bipolar disorder when they are in fact just misbehaving because of stress and family discord. As the JAMA Psychiatry editorial points out, the long term effects on the brains of developing children of antipsychotic drugs are unknown, although changes in the density of neurons have been observed.

The editorial mentions recent statistics that really do prove that the medications are being used in children primarily to shut them up. I quote: "All signs suggest that [antipsychotic medication use] among children is chiefly in those with aggression and behavioral dyscontrol, ADHD, and disruptive behavior disorders, but not for those with psychosis, bipolar mania, Tourette's Syndrome, or autism spectrum disorders." They are also being combined more and more with stimulants. 

Repeat after me, "Uppers and downers, and bears, oh my!"

Fewer than 25% of the young people in this study had any recorded psychotherapy of any kind. 

These drugs are effective for aggressive behavior - but not because they are specific for that problem, but because they are sedating and at times mind-numbing - as a side effect. Heroin would probably work just as well! After longer term use, however, the sedation side effect diminishes, so the drugs don't seem to work as well any more, which is when second and even third drugs are added.

The second editorial is titled, "Why Are Children Who Exhibit Psychopathology at High Risk for Psychopathology and Dysfunction in Adulthood?" Somebody actually did a study about this question, which should be high on my all time list of studies appropriate for the journals Duh! and No Shit, Sherlock. The study wasted time and money actually investigating the question of whether or not the proposition in question was even true. Turns out it was. Surprise!

Gee, childhood conduct disorder predicted antisocial tendencies. Who'd'a thunk? However, behavior problems in childhood predicted a wide range of different mental disorders, and was therefore a non-specific risk factor for a whole host of problems. 

Even less surprising, "a subthreshold or threshold mental disorder at some time from late childhood through adolescence predicts lower levels of adaptive functioning." So poorly functioning children become poorly functioning adults. I wonder why?

Actually, the question of why childhood behavior problems are non specific in being risk factors for various other psychiatric disorders is addressed in the editorial, and this part is where this editorial touches on the issues addressed by the other editorial discussed above. Three possible "causes" of why disturbed children become dysfunctional adults are listed. 

While there is some truth to the possibilities, which are not mutually exclusive by any means, it is simply amazing to me how the editorial author studiously avoids any clear-cut mention of ongoing family dysfunction as the culprit.

Family dysfunction is often chronic and ongoing and is rather widespread in our culture. To name just a few: parental drug abuse, divorces with multiple lovers coming and going and/or with children being passed around to different relatives, child abuse (physical, sexual, psychological), domestic violence, parenting issues (parents leaving children unattended or neglected for long periods, putting childcare entirely on the backs of older siblings, catering to children's every whim, invalidation, screaming and yelling, undermining the disciplinary efforts of one another), parents having multiple affairs, bad mouthing the other parent in front of the children and enlisting them as allies (triangulation), and general chaos at home. Is the author of the editorial really saying that none of these problems might explain the connection between childhood and adult psychiatric problems? Is that their argument?

If you don't believe that these patterns are common, I have two words for you: country music.

The closest the author of the editorial comes to this issue is reason #3. But notice the wording: ongoing instability is mentioned, but mostly things like poverty and living in bad neighborhoods. The nearest thing to family dysfunction that is mentioned is "lack of stable social support." Vague enough for you?

In reason #1, the authors seem to be blaming the child for the problems of the adults, rather than the other way around! They say, "exhibiting the behaviors that define conduct disorder in childhood may alienate peers and family."

Which do you think is more powerful and important: adults' behavior negatively impacting children, or children's behavior negatively impacting adults? This reminds me of a speaker touting Adderall at a grand rounds in our department who said, "If you had kids with ADHD, you might drink too much too!" In other words, he was saying that rambunctious children are a cause of alcoholism.

In reason #2, the authors do refer to environmental factors, but over-emphasize early ones. I guess the authors think either than family dysfunction ceases miraculously by virtue of a child turning 18, or that adults are not affected much any more at all by what their family members are doing to and with them. Sorry, but those assumptions are just plain nuts.

Before I quote what they listed as the three reasons, what is the connection I am implying to the issue of antipsychotic use in kids? It is this: instead of recommending family therapy, the doctors are just drugging the kids who act out in response to these problems.

Anyway, here are the reasons as they described:

1. Child psychopathology and adult psychopathology could have different causes, but experiencing mental health problems in childhood may directly or indirectly increase the risk for adult psychopathology. For example, exhibiting the behaviors that define conduct disorder in childhood may alienate peers and family, lead to curtailed education and incarceration, and increase the risk of brain and spinal cord injuries. In turn, these adverse consequences of childhood conduct disorder may place the individual at increased risk for later psychopathology and compromised adaptive functioning during adulthood.

2. It is possible that some or all of the causes of psychopathology across the life span operate early in life. That is, childhood psychopathology could predict psychopathology and compromised functioning in adulthood because they are both influenced by at least some of the same genetic and early environmental factors. Although there may also be later age specific causal influences, such enduring effects of early causal influences would foster the observed predictive association. At the level of mechanism, child and adult psychopathology would at least partly share atypical functioning in the same neurobiological processes in this case.

3. The predictive association between child psychopathology and adult psychopathology could reflect chronic or intermittent exposures to conditions that give rise to psychopathology when encountered across a life span. For example, psychopathology at all ages may be fostered by chronic economic instability, pollution, living in disorganized and violent neighborhoods, and lack of stable social support. To the extent that these causal environmental factors are stable across a person’s life, childhood psychopathology would reliably predict adult psychopathology even in the absence of a shared causal or mechanistic link between them. 

More Great Quotable Quotes from People Who Agree with Me About Stuff

Today's post is the second of a series of two containing some of my favorite recent quotes that center around themes discussed in this blog. 

As mentioned, I have been collecting the quotes and putting them on my Facebook fan page at http://www.facebook.com/pages/David-M-Allen-MD/80658565761?fref=ts. The ones posted here started in January of 2014, and are loosely organized by topic. 

Family Dysfunction

"Taking responsibility for something and self-blame are horses of two entirely different colors. The former is empowering; the latter is paralyzing." ~ John Rosemond, Ph.D

Chronic Mental Illness

Our prison population is bigger than Slovenia
Cause we put people in jail instead of treating schizophrenia 
        ~ John Oliver

On trying to find the cause of schizophrenia: "30 wasted years of looking for bad mothers followed by 30 wasted years looking for bad genes." ~ E. Fuller Torrey, M.D.

Psychiatric Practice, Electronic Medical Records, and Managed Care

"The shift from benzodiazepines [for anxiety disorders] to antidepressants is one of the most spectacular achievements of propaganda in psychiatry." ~ Giovanni Fava, M.D., clinical professor of psychiatry at SUNY in Buffalo.

"You're complaining about a Freudian slip? Freud should be able to wear whatever he wants." ~ Tony Kreitzberg

"Why would anyone want to teach me to tolerate my pain? My only interest is in removing it!” ~ Cynthia Mueller, a blog reader, when first exposed to the DBT treatment model for borderline personality disorder.

"Methadone and Buprenorphine [suboxone] should be our first line opiates for use in the treatment of severe acute pain. That way, if patients become addicted to them, they would already be taking the appropriate treatment for their addiction!" ~ Steven A. King, M.D.

"The current EHR has destroyed the narrative, especially in psychiatry, and converted the basis of care to a checklist." ~ George Dawson, M.D.

"It's not just about doing the right thing for your patients, it's about proving to someone else that you've done the right thing, and sometimes "I can't quite remember if I'm an underpaid physician or an overpaid data entry clerk!" ~ Dr. J.D., Family physician.

"The proving [that I did right by a patient] takes longer than the doing." Chrisitine Sinsky, M.D.

"You don't need any research to show that if you are cycling people with serious mental illnesses in and out of short stay psychiatric units in 3 - 5 days and basing their stay there on whether or not they are "dangerous" and using treatments that take weeks to work that by definition you are appearing to treat many more patients but providing adequate treatment to very few. You don't need any research to show that when you shift mental health care from psychiatric units run by psychiatrists to county jails that the outcomes will be worse. You don't need any research to show that when people do not get research-based psychotherapies in the manner that they were designed and instead get a few crisis oriented sessions that do not address their basic problems that outcomes cannot hope to be better. When your attitude is that all mental health treatment can proceed by treating common problems with definite social etiologies with medications as fast as possible and not having an intelligent conversation or working alliance with the person affected - it is logical that treatment outcomes will not improve. Treatment outcomes do not improve if you do not provide effective treatment and that is the mental health landscape at this time." ~ George Dawson, M.D.

"I don’t know if anyone has ever not tensed at being told to relax." ~ Carolyn Hax

"Health care systems that allow patients to rate their doctors on satisfaction ratings without considering that patients might be dissatisfied with reality should be held to task." ~ George Dawson, M.D.

"You want a tale of two cities...look how the financial services industry has captured regulation to their advantage vs. how doctors have been battered by regulation. But it's based on the mind-set of Goldman Sachs vs. the mindset of the family practitioner...who politically shows up for a gunfight with a butter knife." ~ James O'Brien, M.D.

"Managed care has done an expert job of cost shifting by developing business friendly treatment criteria, abandoning the social and community mission of treating difficult problems associated with mental illness and addiction, and removing the element of humanism from psychiatric treatment. When I first started to practice, discharging people from a hospital when a psychiatrist had serious concerns about whether or not they could make it or whether they would be safe was very uncommon. Today those discharges are the rule rather than the exception largely due to the imaginary dangerousness criteria. "~ George Dawson, M.D.

Drug War

"When we talk about marijuana as a gateway drug, we have to remember that the last three occupants of the White House have smoked marijuana. We can very well say marijuana is a gateway drug to the White House” ~ Carl Hart, Ph.D

Psychiatric Diagnosis

"Then there’s the matter of testing a child to determine if he has ADHD. The plain fact is that none of the published diagnostic criteria depend upon test results. They refer to behavior, period." ~ John Rosemond, Ph.D.

"A [mental] disorder does not operate with [social environmental] discrimination. If something was “wrong” with [your child], she would be obnoxious in front of friends, their parents, teachers, and the people in white coats who came to take her away (tra la, for those who appreciate the reference)."
~ John Rosemond, Ph.D.        

            ("Actually, "Ha Ha" and not "Tra La" ~ Napoleon XIV)

A reader writes that her friends 'recently spent around $300 on their daughter’s birthday party—her first. They bought lots of stuff to entertain their young guests and extended family. The child, a baby, obviously had no clue what was going on. I should mention that the parents are struggling to make ends meet.' As my readers know or should know, I am a psychologist. That qualifies me to determine and assign psychological diagnoses. As such, it seems obvious to me that these parents suffer from a now-commonplace parenting malady known as just plain nuts." ~ John Rosemond, Ph.D.

"One symptom does not make a diagnosis " ~ John Rosemond, Ph.D.

"Test anxiety is frequently not an aberrant psychological response - it is instead the normal anxiety anyone would feel in facing a situation for which they were inadequately prepared." ~ Barbara Oakley, Ph.D.

"Under the influence of intense affects, EVERYBODY becomes an idiot."~ Otto Kernberg, M.D.

"Only in America does 'gotta' substitute for 'wanna' so we can avoid the guilt. " ~ The Last Psychiatrist

ADHD

"An often trivialized cause of irritability, difficulty concentrating, reduced vigilance, distractibility, decreased motivation, lack of energy,and disturbed mood: insufficient sleep syndrome. People with this syndrome, common in our 24 hour society, intentionally curtail sleep for work, social, family, or other reasons. According to the International Classification of Sleep Disorders, a practical and effective remedy does exist: more sleep." ~ Psychiatric News.

"The maps of child obesity in the U.S. look suspiciously like those of the ADHD epidemic, with the highest rates in the deep South." ~ Psycritic

"It’s truly surprising how many parents have been told that if their child did not have ADHD the child would not respond to stimulant drugs. In the blitzkrieg of World War II, German bomber pilots took a stimulant drug with a chemical structure similar to that of Adderall. When the American military discovered how much the stimulants helped German pilots, they put stimulants in the kit of every American and British bomber pilot to improve their concentration and alertness on long-haul missions. Surely not all these pilots had ADHD." ~ Marilyn Wedge, Ph.D.

"...after taking the [drug company-designed screening] ADHD quiz, I've realized that both I and my cat have the dreaded disease. I'm off to get us both the treatment we need." ~ Anonymous comment on one of my blog posts.

Evolutionary Psychology

"Selfishness beats altruism within groups. Altruistic groups beat selfish groups. All else is commentary." ~ David Sloan Wilson, Ph.D.

"We mammals are curiously preoccupied with social hierarchy. You may say you don’t care about status, but if you filled a room with people who said that, they’d soon form a hierarchy based on how anti-status each person claims to be." ~ Loretta Breuning, Ph.D.