“…are we really being confronted with a bona fide neurobehavioural epidemic or are we simply using the ADHD stamp to legitimize our failure as a society to properly parent and control the behaviour of our children?” This is a quotation from a CBC news article, The Attention-Deficit Excuse, by Robert Smol, February 26, 2009.
“…are we really being confronted with a bona fide neurobehavioural epidemic or are we simply using the ADHD stamp to legitimize our failure as a society to properly parent and control the behaviour of our children?” This quotation is from a February 2009 CBC Internet news article, The Attention-Deficit Excuse, by Robert Smol.
Mr. Smol, if I read you right, you certainly are correct!
There is a ‘new’ syndrome around called Socially Induced Hyperactivity (SIH). It accounts for the vast majority of hyperactivity, and other ADHD-like symptoms (short attention span and distractedness), in children and teens and perhaps beyond (even in adults). While ‘ADHD’ has a neural basis and often is helped by the stimulant Ritalin ® (methylphenidate) and various other medications (1), in SIH there is absolutely no brain problem. The origin of SIH is within the nuclear family group and the child’s wider social environment—not inside the child’s head. So, the use of medicines to treat SIH is incorrect. Dead wrong, in fact! Use of stimulants worsens SIH symptoms! (2) The Rx of SIH is a specific form of brief family therapy along with clarification and correction of parent-outsider differences.
TYPES and INCIDENCE of hyperactivity
One important source of hyperactivity as an outward symptom is a diverse group of medical disorders. These include scurvy, rickets, anemia, intestinal pin worms, diffuse brain trauma, brain inflammation secondary to rheumatic fever and the post-encephalitic effects of influenzal meningitis.
Of course, ‘classical’ organic neuro-ADHD (a presumed dysfunction of the brain stem’s reticular formation) is also included in the biomedical sources of hyperactivity.
What about diet? Many people have associated child hyperactivity with ingestion of sweets. I too have seen children with neuro-ADHD, and adults, revved up by sugar. But, and this is an important distinction, sugar seems to be an aggravating factor more than a fundamental cause.
SIH, the single other main source of hyperactivity, is of familial-social origin. It is not biological.
For all practical purposes, despite the long list above, there are but two different kinds of hyperactivity: 1) that associated with bona fide neuro-ADHD and 2) socially-induced hyperactivity (SIH). Heretofore, they’ve been lumped together indiscriminately. Their recognition and distinction is very critical, for the treatments of SIH and ‘ADHD’ are as different as their causes. (3)
The prevalence ratio of these distinct entities is: ADHD/SIH = 1/25. Put simply, single-sourced SIH outnumbers all the rest by 25 to 1. Put bluntly, out of 25 hyperactive kids often already on stimulants, as many as 24 should not be. Stimulant drugs can—no, will—make SIH worse! (4)
From a wider epidemiological perspective, it is noteworthy that the incidence and prevalence of SIH have progressively risen since mid-20th century. The ‘epidemic’ of SIH parallels the rising divorce rate in Western society. This serendipitous observation fits snugly with the micro-mechanism of SIH which we shall now take a look at.
The CLINICAL SOURCE and COURSE of SIH
In a nutshell, here is the ‘mechanism’ that causes Socially Induced Hyperactivity in children. SIH is biphasic, occurring in two steps: the first is within the family; the second involves numbers of outsiders impinging on the child directly and on one or both parents, often indirectly through the child.
First, in the family, a child gets ‘trapped’ between two adults that are no longer talking openly with each other, at least as it pertains to their hyper child. Usually these are its mother and father, living together or separated. If the adults have closed off their mutual communication over disagreement on a hot issue that has to do with their child, it is bad news. In a suppressed sort of way they’re usually coldly angry at one another. So, instead of talking with each other, they talk—one at a time and separately—with and through their child. If the child is astute enough to notice and has the temerity to comment upon their conflicting views, s/he is hushed up with a ‘threatening’ frown or greeted with a perplexing kind of ‘sinister’ silence. A snide, off the cuff complaint by one parent about the other is usually thrown in for good measure. It adds up to a noxious paradox, a ‘double bind’ in which all three, both adults and child, are entwined, but with the child its main victim; the child is in a damned if you do, damned if you don’t position. Nevertheless, the child surreptitiously ‘relays’ their nasty complaints about each other back and forth. Repeatedly. Once this cycle starts, it’s an almost self-perpetuating system. Relaying may take place almost instantly or sequentially over some time. As tensions escalate in this toxic and totally untenable family triangle, the child becomes progressively anxious and mildly hyper. But the child somehow skillfully negotiates the parental rift, balancing all the while on a razor’s edge. The ultimate consequence is a buffering and veiling of adult hostility—with an increasing psychic debt of anxious hyperactivity emerging in the child.
This first phase of anxious hyperactivity induction, technically termed the ‘split field relayer system’ (or SF:RS), is shown by the diagram. Across its top is the parental rift, a split social field, depicted as a lightening bolt. The child relayer, portrayed ‘A’ for anxiety, is caught between its alienated parents. The arrows show how relaying of adverse messages escalates. (5)
Sometimes, in place of the relayer balancing act, a child may side with one parent against the other—and be seen as a nasty little two-faced manipulator. This kind of conduct, splitting off into convenient two-person coalitions, may temporarily relieve a child’s upset feelings. But the left-out parent may be offended or hurt at best, enraged at worst. S/he likely will start to see the child as fomenting the trouble. (Rather than judging the child’s conduct pejoratively, the enlightened parent, teacher or doctor should try hard to interpret it with empathy, as defensively self-protective.)
Now, step two: If this sort of setup (a child caught in the middle between two ‘close’ adults) extends to an important, significant, outsider such as a teacher, the child is then swept up in two ‘perverse’ triangles and gets more hyperactive. Hyperactivity builds up rapidly! S/he soon starts to display reduced attention span and impaired concentration. School performance drops and relationships with other children suffer.
It is easy to see how a false diagnosis of neurological ‘ADHD’ can be made; and any such child wrongly placed on a stimulant drug – which will only worsen things. But just imagine, if the same sad child has to deal with yet another outsider, say a child welfare worker (or a probation officer) who isn’t savvy to the situation, then things become progressively worse. Consider that some children nowadays may be under the ‘care’ of multiple, mutually isolated and non-communicating, ‘helping’ people. Each may be quite unaware that an agile child can relay bad messages between them too. In fact, the intensity-severity of hyperactivity increases almost exponentially with the number of ‘split field triangles’ a child is swept up in. This wider social-phase of SIH is shown by the ‘H’ diagram at the beginning of this article.
Incidentally, as hyperactivity goes up anxiety goes down, so the affected child or teen may appear quite calm on the surface. This surprising reciprocal effect was once termed ‘equivalent’ as in the behavioral ‘equivalents’ of child and adolescent depression or anxiety. SIH, in that old-fashioned monadic (one-person) perspective, is ‘equivalent’ hyperactive behaviour.
In young children SI-hyperactivity is quite reactive to immediate surroundings. It can rise and subside quickly with circumstances. As time goes on, however, the syndrome can become ingrained, habitual. By young adulthood the person with SIH may be compulsively creating multiple replicas of the old and familiar social environment. That is, setting up split fields all over the place! Thus, the problem is spread far afield in space and down through the generations in time. Adults with SIH often reveal their underlying anxiety physiologically—through ‘nervous’ sweating, etc. They may become ‘champions of a cause’ at work. By now they are likely on reams of Valium and such.
DIFFERENTIAL DIAGNOSIS: the ‘finger-twitch’ test
In neuro-ADHD the ‘brain’s’ short attention span leads to persistent hyperactivity. In SIH hyperactivity which can be intermittent leads to variable degrees of inattention. But, at any one point in time neuro-ADHD and SIH can be almost alike. The ‘finger-twitch’ is a test that is clinically helpful. Anyone, teacher or doctor, can do this little test and neatly distinguish between neuro-ADHD and SIH.
The HOW: The child is told that a game is to be played with the interviewer; its idea is to see who can sit longer without moving hands or fingers. Each faces the other, the hands hanging, dangling loosely, between the knees. The interval between the beginning of the game and the first twitch of a finger or hand is measured by stopwatch. (That is sort of hard, so an assistant can help by handling the watch.) Slow athetoid movements or fine tremors are disregarded.
Measured RESULTS: There’s a significant difference between potential stimulant-drug-responders (neuro-ADHD) and non-responders (SIH). ADHD shows a finger twitch much earlier (mean time 21 seconds) than SIH (mean time 38 seconds).
Clinical APPLICATION: If the child twitches early, consider starting it on a trial of stimulant medication. (4) If the twitch is late, call in both parents to arrange for a very focused, specialized interview to rule out or confirm ‘split-field triangles’ and SIH.
And I would add: The focused family exam should be done by a knowledgeable clinician, someone who fully understands the implications of SIH. That is, discovering SIH precludes stimulant drug use. (It should also be noted that in those relatively few children with true ADHD, the stimulant Ritalin starts working, often dramatically, within a couple of days. It is not necessary to run a whole month-long therapeutic trial as the pharmaceutical companies recommend in their handouts and thick CPS books.)
CLINICAL TREATMENT and SOCIAL MANAGEMENT of SIH
The remedy for SIH? It is simple, logical and ‘surgically’ precise! Namely: 1) Correct ‘diagnosis’ is absolutely essential! 2) Use NO drugs! Beware the reflex to prescribe. 3) Brief, focused family therapy is the core of treatment. The goal is to extricate the child from conflict by getting its ‘caretakers’ to open up and air the key differences between each other—not through the medium of their child. 4) Or through ones’ pupil! One guided parent-teacher get-together (possibly a community-wide conference, with parents present, when other front line workers are also involved) is a sound idea. 5) Showing the child how to self-control on its own, preferably within a family group orientation—and at the school—is very beneficial. (The latter may employ behavioral or cognitive approaches, individual play therapy, etc.)
While the child’s teacher may play an original, unwitting part in aggravating hyperactivity, that same teacher and the school are essential to the active treatment and long term prevention of SIH.
No offense intended, but many modern teachers tend to be too politically correct. They refer to children as ‘special’ or ‘exceptional’ or having ‘issues’ or with some other imprecise appellation. They may hesitate to call a spade a spade. Avoiding precise labels is dangerous. For, in such a falsely ‘kind’ fashion teachers may fail to properly ‘assess’ or ensure that others properly assess the hyper children they teach. It makes a hard job harder. But more important, such sloppy-cautious cruelly-kind thinking can lead to a lifetime of disaster for many kids. Or at least many years on unnecessary stimulant drugs. Many teachers advise parents, “Please take Johnny to the doctor and get him on medication.” Put the brakes on that! (But, in all fairness, the big TV drug peddlers have brainwashed parents and teachers alike.) Irregardless, professionals must be crisp, precise and differentially diagnostic in dealing with hyperactive children. Even many doctors and psychologists (1) need to learn that lesson all over again.
So, please teachers, make sure that your hyperactive students are assessed and ‘diagnosed’ correctly or they’ll be very badly (incorrectly) treated. Make sure your consultant is well up to date … SIH knowledgeable.
Family doctors or pediatricians are the usual MDs who write most prescriptions for hyperactivity. In light of the knowledge presented herein, a very careful eye has to be kept out to see that scripts are not overdone. In this regard, it is absolutely shameful to see any child, with SIH or ADHD, on potentially addictive sedative tranquilizers, which mask and muddy-up the entire picture. Finally, as you may now surmise, some children have a so-called dual diagnosis, i.e., neuro-ADHD with SIH layered on top. Their Rx is complex and requires a child psychiatrist, one who has knowledge of both.SIH and neuro-ADHD.
1. Russell A. Barkley PhD, a clinical neuro-psychologist who has vocally promoted the cause of neuro-ADHD on The Today Show and Good Morning America, upon getting a question from me and presumably after reading my detailed research, quickly asserted that “There is no recognized category of socially induced hyperactivity within the current scientific literature. In fact, the available research would suggest that it is not possible to make a child who is normal develop ADHD by exposure to any social factor.” My considered response: Certainly, socially induced hyperactivity is not ADHD! That’s my whole point. ADHD is neurological. SIH is social. SIH is a distinctly separate, non-neurological, social entity. SIH has probably been around a long time, but has been on the upswing for some 50 years, in association with family splits. It’s newly discovered. Is it now clear? The next note will explain why the reality of SIH is, as yet, not widely known, or found in the ‘current’ scientific literature. (The SF:RS-anxiety concept was published some years ago in the top journal, Psychiatry.)
2. Big pharma may not be all that happy about this new discovery. Publication of work on SIH has been quite consistently blocked by medical journals that rely upon drug advertising to generate revenue! Dissemination of an imbalanced knowledge about neuro-ADHD, especially on TV, understandably sells lots of drugs. But SIH ‘sells’ nothing. That is, unless it is dealt with, wrongly, as if it were ADHD!
3. Stimulant drugs used in neuro-ADHD seem to work paradoxically by toning down the whole child. In actual fact, they specifically rev up a defective, under-active brain-stem reticular activating system or RAS; it doesn’t become normal but it begins to work a bit better. Thus, extraneous stimuli are better screened out and distracted hyperactivity is thereby reduced. On the other hand, if stimulants are used on an SIH child who has a perfectly normal RAS, the entire child is revved way up. So, the child is made more hyperactive and hence becomes easily distracted and inattentive. I consider it most alarming to see so many children taking anti-ADHD medicine so unnecessarily. (And it is frustrating to see ‘authority’ ignore or block dissemination of the problem’s solution. I can understand how Semmelweis must have felt when his empirical prevention of puerperal sepsis was rejected by the ‘blind’ academics of the 19th century.) Hyperactivity incorrectly diagnosed as ADHD, pseudo-ADHD, is generally viewed as an epidemic. It’s definitely a real epidemic improperly dealt with by teachers, psychologists and doctors, alike! It needs emphasis that medical ‘misuse’ of stimulants can be an iatrogenic aggravation of the symptom, hyperactivity, that must be sorted out at the very outset of rational clinical assessment. SIH should not be overlooked! Stimulants should not be overused—let alone misused.
4. Caution! Stimulant drugs can kill. Do not use if you suspect a child may have rheumatic fever. Case example: A very restlessly hyperactive and ‘toxic’ little girl was found to be on recently prescribed Ritalin. An appropriate physical examination and lab tests quickly revealed she had acute rheumatic fever with inflammatory carditis and encephalitis. The treatment for those serious complications of a (beta-hemolytic) strep throat is RAP (rest, aspirin, and penicillin), not Rit.
5. In this short article, especially in describing the biphasic social-family mechanism, I’ve left out some crucial details, including the deeper concept of paradoxes (in the form of noxious meta-messages, ‘mm’ in the ‘A’ diagram), that literally, helplessly, double-bind a child into the dysfunctional family triangle and many malignant multiple split fields abroad. The entire idea of the external generation of anxiety and the reciprocal induction of hyperkinesis in SIH is contained in a longer Google Knol. Observational and statistical data is also included. Although not exactly easy reading, that Knol has several diagrams that make it all quite clear. Here is its URL: