Socially Induced Hyperactivity (SIH) in Children

(Introducing a Major New Etiologic Concept and Drug-free Treatment Approach)

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Abstract

There is an epidemic of ‘ADHD’ afoot. Legions of children line up daily at school for their ‘drug fix.’ But, are there instances of attention deficit, distractibility and hyperactive conduct that do not call for medication? I think so and show so. The incidence of neuro-ADHD to social-ADHD (SIH) is 1/25…

The diagnosis of ‘Attention Deficit Hyperactivity Disorder’ (ADHD) has mushroomed in recent years and most overactive, distractible children are nowadays likely to be placed on a stimulant drug. Is this a reflection of long overdue case-finding? Is it good treatment? My research says, respectively, yes and no…

Case 1: A schoolchild finds it difficult to sit still, can hardly concentrate and attend to the task at hand and is constantly reacting to every little thing going on. Marks are poor, conduct aggravating. It doesn’t take long for a smart teacher to boil such behavior down to the medical-psychological trio of hyperactivity, distractibility and short attention span. A light turns on in her head, “Eureka! This must be ADHD.” A trip to the family doctor is quickly, almost routinely, set up – for Ritalin.

The teacher in this scenario has a 25 to 1 chance of being wrong. The reason is that a hitherto unrecognized clinical entity accounts for the vast bulk of hyperactivity connected with distractibility and other behavioural and educational problems. This new brand of ‘hyperactivity’ shares almost identical subjective symptoms and objective signs with standard ADHD, but most importantly, it is not biological or genetic – it is a social-psychological disorder carrying with it absolutely no brain malfunction. A number of logical alternatives to reflexively routine drug tteatment thus flow from its correct diagnosis. As family doctors and pediatricians write most of the prescriptions for stimulants, they should be fully aware of Socially Induced Hyperactivity or ‘SIH’ as I call it. SIH is generated via a unique biphasic social-family mechanism. This newly-discovered source of hyperactivity is ecological. It stems from outside the child; a ubiquitous self-reinforcing process incubates in the family and spreads to infect the child’s wider social milieu. The school is usually a major, if often innocent, player. Nursed along by selected case examples, the biphasic mechanism can be explained nicely with two key diagrams:

 

PHASE 1, anxiety induction: A mother (M) and father (F) are in quietly hostile disagreement (+ / -) with each other. They no longer are talking about some key issues that are also important to their child. Such a two-person covert conflict is termed a split social field. While failing to speak directly with one another, each parent separately does so with their child, who in turn covertly relays the adverse message on to the other parent (arrows). Back and forth it goes. This three-person setup is called a Split Field Relayer System or SF:RS. A dysfunctional family triangle, it perversely entraps all three of the actors. But most importantly, the SF:RS induces structured anxiety in the child-relayer who is depicted above with hair standing on end and labelled with a big ‘A’ for anxiety.

PHASE 2: Anxiety converts to hyperactivity if a child is caught in more than one SF:RS. This easily happens when a parent is at covert odds with a teacher—or any other significant person outside the immediate family. Suppose, a child whose parents are separated, is in temporary protective care … then, as the number of care-giving persons (P) increases, so does the number of potential split social fields between them (1, 2, 3…n). For a child at the nexus, the intensity of hyperactivity goes up (as the original induced anxiety diminishes) in proportion to the number of entrapping split fields. Write in hyperactivity with a large ‘H!’ This augmented setup, involving a few to numerous noxious triangles, is termed Multiple Split Fields (MSFs).

The SF:RS (phase 1), was reported in 1972.i Phase 2, the biphasic SF:RS-MSF mechanism, which leads to SIH is presented here in detail for the first time.ii The situation is quite untenable for the child. But, parents are perplexed and entirely oblivious of the true source of their child’s distracted and hyper behavior. Most of the time the child is labelled with ‘ADHD’ and incorrectly put on medicine. Next, an unusual case vignette indicates the scope of SIH and hints at its surprisingly simple management:

C2: One notable 12 year old boy, whose distressed family was involved with a total of 19 different competing agencies, including court, school, children’s aid and several churches to boot, presented with such racing hyperkinesis that brain damage was surely presupposed. After just one clarifying community conference, with all key personnel present including parents, the lad spontaneously calmed down as if by magic.

THE STEP-BY-STEP DEVELOPMENT OF ANXIETY-HYPERACTIVITY

I’ll now give the wordy details of the SF:RSMSFsSIH sequence: The seed of SIH is sown when parents stop talking openly/directly with each other (or important outsiders) in key areas that pertain to their child. They may be talking freely about family budget, vacations and other interests, but around one or more aspects of their child’s life – eating habits, bedtime, clothes, haircut-style, school, sports (issues will vary from one family to the next) – they have essentially given up. Here is an almost pure anxiety case in its incipient stages:

C3: Michelle, 6, was brought to clinic by her adoptive mother because of nighttime wandering about the house. Observation in her mother’s presence revealed her to be silent and apprehensively inhibited. Her posture at times was almost cringing, pulse rate rapid, pupils dilated. She was obviously an anxious little girl. Alone in the playroom, however, she became alert, fairly relaxed and talked easily. Probing brought out that Michelle was most anxious immediately upon returning home from school, especially on days when bringing home her school work. At school she was a model student, but reference to this later evoked an unusual response from her mother, who became notably irritated: “How can these teachers give a star for work riddled with mistakes? Teachers nowadays are altogether too soft. I prefer achievement over virtue.” It was apparent that her philosophy was that awards should be reserved for actual accomplishment, whereas the teacher was encouraging effort. Mother had never conveyed her sentiments openly and directly to the teacher, but her upset feelings and adverse comments about ‘modern education’ regularly got through to Michelle.

Michelle’s position was that of an unknowing potential transmitter of covertly held antagonistic ideas between her mother and teacher. With each piece of work she carried home, Michelle was effectively conveying the teacher’s philosophy, which was in disharmony with that of her mother. This resulted in unpleasant things being said about the teacher. Michelle never conveyed these negative feelings back, so in a sense she was a unidirectional relayer, a not uncommon state in the early phase of generation of an SF:RS. The outcome for Michelle was moderately intense situational anxiety.

Treatment consisted of a fairly simple compromise. Because of the mother’s rigidly held bias or theme interference (it stemmed from values acquired while herself in school, reinforced by an indifferent, passive husband), a meeting on the issue of educational philosophy between teacher and mother was deemed inadvisable. It might have turned into an unpleasant diatribe, unnecessarily alienating a teacher whose objective cooperation would be needed. Instead, it was diplomatically arranged that the teacher give gold stars for accomplishment and silver stars for effort. This pleased mother and a three-month follow-up indicated that Michelle’s acute anxiety, which had abruptly abated after the planning interview (!), had not returned. At this point, marital counseling for her adoptive parents began.

The ‘split field’ communication block usually happens slowly over time. Before the split field comes between them, parents openly argue about things crucial to their child. Maybe father considers eight o’clock to be the right bedtime, but mother insists the child drag off upstairs on its own when tired. Or, mother feels their child should judge for itself how much food to eat, while father insists that every last scrap be cleaned up. Possibly mother extols the virtues of doing well in school, but father downplays this, or even sneers at the idea. Maybe they actually agree on one or two points. But, overall they disagree and cannot agree to disagree. They simmer with topical anger. Many a child in such an environment manipulates the situation and sides with one or the other parent in order to get what it wants. Sometimes one parent will openly recruit a child to his/her side. The child will then show anger and may direct it at the vilified parent. The parent cut out of the circuit gets yet more irritated at the other parent and will see their child as two-faced. This sub-phase of ‘taking-sides’ (or pseudocoalitions) may be short-lived or go on for years. If nothing else, such a youngster will certainly grow up to be an accomplished manipulator.

Up to this point the situation is the simple ordinary problem of a child caught in the middle. The critical essence of the SF:RS goes several steps further. First, gradually, almost imperceptibly, the parents become tired of disputing each other and their direct communication literally shuts down. But next, and here is the crux of the matter, they don’t shut up. They begin to carp and argue surreptitiously through the medium of their child. It goes something like this:

1. A father is irritated at having to make last minute school lunches. Out of his wife’s hearing, he makes a pejorative comment to their child, “Your mother may have done okay in school, but she knows nothing about running a house.”

2. The child takes this in and later, perhaps when forbidden to stay up late, relays an edited version on to mother, “Dad says you’re smart, but sure act brainless around here.” It may not be that blunt, but mother instantly reacts.

3. “Is that so? Well let me just tell you about your father!”

And out come the criticisms. So it goes, back and forth, on and on, over time as shown in the first diagram. Children are normally excluded from hearing such parental differences. The child who is not, has a good chance of becoming a relayer of their mutually adverse messages across the parental split field. Children, who are dependent little beings, simply cannot handle this sort of perverse power reversal with equanimity. (In popular psychological terminology children internally experience cognitive dissonance.) Nor can they extricate themselves from it on their own. In the final step they become truly trapped. Should an astute child have the temerity to point out parental differences or complain about being swept up in them, a subtle metamessage (mm in diagram) is sent out by one or both parents—sealing the untenable nature of the SF:RS and firmly closing its trap-door on all three.

Key point: A metamessage, defined, is a message about the main message, that is, a modifier on a higher abstract level of communication. It is usually nonverbal. In the SF:RS it subtly denies any parental conflict (“This is not happening.”) and carries a covert threat of punishment if not heeded (“Don’t ever mention it, or else.”). Heeded, it betrays the child’s sense of reality, amounting to a quandary that locks—binds—all three into a conspiracy of silence about what is really going on.

This sinister metamessage is the final assault that seals the child’s fate. Any child (any adult for that matter!) caught up as a relayer of antagonistic messages between subversively warring authorities becomes progressively upset. The ‘upset’ assumes a specific form—anxiety with associated mild restlessness—akin to what was once called ‘free floating’ anxiety. (It was called such because nobody really knew where it came from. Now we do!) Early on in the natural history of the SF:RS, intense, short episodes of relaying result in bouts of acute pure anxiety. As the system gets fully ingrained the child develops persistent, chronic restless anxiety.

If the parents later separate or get a divorce the drama rarely ends, for a perfect setup is then created for perpetuating this perverse triangle and the child’s anxiety continues to wax and wane. For children of divorce, and there are lots of those in our society, increasingly so, every visitation with one of the separated parents is an occasion for probing the child about the other parent’s doings. If the child responds, the parent may make some demeaning remark. Thus, the child continues relaying messages back and forth between them. The child is literally used by the alienated parents to irritate, reconcile, or spy on each other! Every separated parent intuitively knows better. But they only rarely do better. And their child’s mysterious anxiety comes and goes and eventually becomes persistent.

ANXIETY AS A UNITARY SYNDROME: Freud’s famous Oedipal complex is simply an internal, or mind, representation of an SF:RS (or RPB).iii It is ‘vague’ in the sense that it lacks concrete representation in the here and now. For decades the anxious child, from the classical monadic one-person perspective of psychiatry and psychology, has been characterized by three symptom-sign clusters: iv

1. There are emotional signals expressed, including apprehensiveness in strange situations, undue fears, nightmares and sleeplessness.

2. Next, are exaggerated autonomic nervous system signs – dilated pupils, mild tremor, sweaty palms, stomach ‘butterflies,’ even diarrhea or worse.

3. Lastly, there is conforming, inhibited, dutiful, approval-seeking behaviour.

The discerning reader will observe that these standard diagnostic criteria do not include hyperactivity! It was long thought that hyperactive behavior and anxiety were mutually exclusive. But, as Jenkins put it in 1969, overactive children “usually do not appear anxious except as their hyperactivity may at times be interpreted as evidence of anxiety.”v

FROM ANXIETY TO HYPERACTIVITY: In 1972 I reported that “younger patients caught in the relayer position (of the SF:RS) display either apprehensively cowed behavior or hyperactivity.”vi Furthermore, I observed that the hyperactivity aspect climbs, “increasingly so, when (the child is) trapped in more than one split field.” Now we know with certitude – anxiety and hyperactivity are linked.

A frequency-plot shows the relationship. A single SF:RS induces mild through severe anxiety. Its incidence climbs under a normal distribution curve, reaching a peak at two split fields. After three SF’s, it rapidly drops off, tapering asymptotically towards zero as the MSF-generated hyperactivity rises in a straight line. The intersection-point of curve and line is a singularity-cusp at three SFs. The gray area represents coextensive anxiety-hyperactivity, 90/143 cases, recorded in my child-psychiatric medical practice. At graph’s right a reciprocal relationship between hyperactivity and anxiety also emerges.

As hyperactivity level increases, the overt signs and symptoms of anxiety diminish to the extent that the end result is pure hyperactivity. Notably, the child may appear emotionally calm, but be wildly, almost constantly, active. So, SIH is a ‘behavioral equivalent’ of inner anxiety.vii

Split fields may involve relatives outside the nuclear family or go well beyond the extended family altogether, with other significant adults. Thus, one or both parents may be at covert odds with grandparents—or the school. If parents fail to visit the school to discuss progress a teacher never really knows how they feel or what they think. Nevertheless, messages get subtly passed back and forth: A slurring comment about lack of parental involvement perhaps is written on the report card. When the parents read it they may slur right back—mumbling or grumbling to the child about the teacher. Whether parental comments actually get back to the teacher or not, the child is essentially again in the thick of it. So we have another split field (parent-teacher) for the relayer child to maneuver. A child on probation or in foster care can be enmeshed in several, even multiple, split fields and may present with marked hyperactivity.

The SIH-drama is unique in other ways. Noxious sequences in perverse triangles do not spontaneously heal as does injured tissue—the processes simply chase around in never-ending cybernetic circles. Unlike neuro-ADHD, SIH is not unitary; the child alone is neither the proper focus of assessment nor the correct locus of treatment: the child’s family and social environment are. To conclude this formulation of the biphasic SF:RS-MSF complex, it is moot to point out that anyone growing up constantly exposed to this mechanism may later spread it far afield and definitely down to his/her own family—and children. It is passed through the generations, socially ‘inherited’ as it were. As an interesting case-in-point, consider SIH in its fullblown ‘maturity’ in a strategically-placed adult:

C4: A nurse (secunded to a public health school clinic) displayed symptoms of chronic anxiety at work. She was jumpy, too eager to please, had constantly damp palms and sweat stains under her axillae, a strained voice pitch and tended to stutter. She seemed regularly involved at the edge of little squabbles. To her supervisor she brought bits of gossipy information about her colleagues, but always in a ‘helpful’ way. Before long on the job, she began to miss too many days with minor ailments. An administrator called her on the carpet and wanted to fire her because she was a “hopeless neurotic.” Enquiry of a previous hometown employer indicated that her family was composed of a “bunch of neurotics” also. On the positive side she was energetic, original, and, when present, genuinely devoted to work.

She was raised in an environment bearing all the earmarks of a split social field between her mother and father. Throughout her developmental years she had learned to become an adept relayer between them. Now she could be described as a chronic, compulsive relayer who attempted to recreate rifts wherever she went. She was most successful, being a well-trained expert in the field of triangular architecture. At work she exercised an uncanny sense in recognizing subtle differences between essentially friendly co-employees, and she craftily played these up behind the scenes. Her reward: a bit of limelight and the establishment of, to her, a familiar system of interpersonal relationships. The one psychological drawback for her was the continued high level of chronic anxious restlessness she suffered. Getting caught and almost dismissed was her narrowly missed punishment. (Do you know someone like this on your job?)

Treatment consisted of a forthright, hard-nosed but kindly, discussion. She responded with an Aha! reaction of flooding insight. She agreed to stop searching out covert differences between colleagues and the transmision of their conflictual messages. Her resolve was reinforced by a period of work probation under the attentive eye of an enlightened supervisor, who, if she slipped back into the old pattern, arranged for a get-together between the parties. Results were dramatic. Her productivity at work increased, her natural creativity gained fuller expression, her basically empathic nature soon came to the fore, and she emerged as one of the best-liked work group members. Incidentally, as a side effect, her marital relations, which had been strained, improved concurrently with the virtual disappearance of her jittery anxiety.

DEFINITIVE ASSESSMENT FOR SIH

Most clinicians are used to a 1:1 approach. The flood of data when family and beyond is added can seem confusing at first. A systematic attack, focusing in on possible split fields, helps. Vis, a typical bout of SIH in a little girl:

C5: Annie, 7, was urgently ‘referred’ by her grandma. In her “very loud voice” Annie had screeched at her grandpa at a flee-market, accusing him of physically abusing her. “But he simply restrained her wrist and snapped at her for grabbing at a fragile display item.” A bystander, “a complete stranger who didn’t see the whole thing,” publicly reprimanded him. This unpleasant episode terribly embarrassed and distressed grandpa. Both grandparents wondered whether they should baby-sit anymore for their son and daughter-in-law. Of course, grandpa, an elderly retired cleric, still convalescing from a recent heart attack, could do without that sort of stress and was so advised. Listening to this story opened Pandora’s Box. Out it came that Annie’s mother was too lenient with her “only child” and had long vetoed all of father’s efforts at discipline. He, apparently to keep the peace, withdrew to the family’s edge. His job as a long-distance trucker helped him keep his distance. Grandma vaguely recounted that Annie had had “some problem with other children in the neighbourhood” involving the police. “She also is having trouble in school. Not long ago, she was put on something for ADHD.” Grandma disagreed with the doctor’s methods: “She’s a perfectly bright child. There’s nothing wrong with her brain.”

Does this seem like a complete confusion of nuclear, extended family and outside relationships? I asked the grandmother to phone the parents and convey my offer of help. Annie’s father (reportedly unenthusiastically) said he would try to persuade his wife to attend a ‘nuclear’ family meeting. Before seeing them, a hypothetical MSF-picture was running through my head. One must be careful of preconceived notions, but in this instance multiple split fields impinging upon Annie, the Identified Patient (IP), were born out.

During the assessment, Annie (the IP) squeezes between her mom (M) and dad (F) and wriggles restlessly. When they speak to each other she interrupts. Although on Ritalin, by ‘finger twitch test’ evidence (we’ll see how it is done later) she most likely does not have neurological ADHD! Father, glancing at his wife, reveals that Annie is not his child. His own boy, the same age as Annie, visits biweekly. Annie’s mother tries to undercut her husband, but he passively wiggles out, so that she finds it impossible to pin him down. I encourage them both to talk about their differences vis a vis Annie, whose eyes almost pop out at the prospect. Struggling to override the adverse effects of Ritalin, she settles down.

The meeting was brief. Annie already appears less hyper – confirmed by all. Everything points to SIH. A call to the family doctor is encouraging. She does not really like the idea of prescribing Ritalin for Annie and is quite prepared to stop it if (focused) family intervention works. It may be tricky dealing with the teacher (T). Next session will include grandparents (GP). What’s up with the police (P)? The other child? Another SF:RS on top of all the rest?

BASIC DIAGNOSTIC POINTERS

In order to assess for induced hyperactivity we need to keep in mind three system levels while focusing on one at a time: 1) the ‘symptom’ is the hyperactive, distracted child, otherwise known as the IP, 2) the next level up is the immediate nuclear (or single parent) family with a possible split field triangle (SF:RS), and 3) beyond that is the extended family, more distant relatives and the child’s wider circle of social systems (school, agencies, sports and so on) that may reveal the presence of ‘spreading’ MSFs. This comprehensive approach is not a daunting task. But it takes some concentration. With practice it becomes quite natural for the diagnostician to hold it all up-front in the head while juggling focus.

Foremost, however, diagnosis and assessment of SIH requires an awareness that it actually exists as an entity. First, think of it! Then pause to consider that the child about to be prescribed that powerful stimulant drug could be a relayer trapped in a nasty social drama – not suffering true neuro-ADHD. Ask of yourself: Is the right answer really stimulant medication? Would you advise an insomniac to drink coffee at bedtime? Then try this useful little screening test:

THE FINGER-TWITCH TEST: viii The child is told that a game is to be played with the interviewer to see who can sit longer without moving hands or fingers. The hands hang between the knees. The interval between the beginning of the game and the twitch of a finger or hand is measured by stopwatch. (Slow athetoid movements or fine tremors are disregarded.) There is a significant difference between potential stimulant-drug-responders (true neurological ADHD) and non-responders (SIH and other non-organic varieties). Neuro-ADHD, shows a finger twitch much earlier (mean time 21 seconds) than SIH (mean time 38 seconds). If the child twitches early, start it on a trial of stimulant medication. And I would add: If the twitch is late, call in both parents for a specialized SF:RS interview.

Diagnosis should not be made merely by exclusion, but in a direct and positive sense. See the family together at least once. This is important, too, with separated/divorced parents. They should be exhorted to come in for the sake of their child. (It may not be easy or even possible in single parent families if a lone boy/girl friend lurks furtively in the background; a delinquent, deadbeat dad/mom can still be at one-corner-removed of an SF:RS-triangle!) Thirty minutes is enough time. Watch parent-child interactions closely. SIH-children, on guard at first, may nestle beside mother, relatively quiet and well-behaved. You may have to precipitate action. Casually, innocently, inquire about potentially taboo topics—bedtime, curfew, eating habits, allowance, clothing styles, forbidden movies or internet sites. Be assured, many of these things are potently relevant to all children, depending on age. Note if the parents try to avoid talking about them or conversely start arguing again. Then ask more pointed questions: Is there tale-bearing going on? If separated, is one parent probing the child about the doings of the other? If the child begins to wriggle, or better yet, moves to sit in-between the parents, and tries to distract or interrupt them, you could well have right in front of you an SF:RS-triangle in vivo.

Seek evidence of multiple split fields. Ask about relatives: over-indulgent grandparents, disaffected or busybody aunts/uncles. Are a little friend’s parents doing things differently and used as leverage by the child? In particular, find out about parent-school conflicts in which the child is likely to be enmeshed: punctuality, homework, differing educational philosophies, marks. When a child comes home complaining about a teacher, and parents automatically side with the child, the makings of a split field between teacher and parent, with child in the middle, are present. Go a step farther: If a number of social agencies is involved with the family, and the child is getting increasingly hyper, you can almost be certain there are unresolved differences, resentments. MSFs well could be operating. Draw a diagram for yourself showing the MSFs you suspect. It is unlikely that you will be able to confirm all possible split fields by direct observation, but a parent-grandparent-child session is not too hard to arrange and a parent-teacher-consultant conference is always desirable. In these 2 meetings you might find 3 SF:RSs.

Important: Any adult—parent, teacher, worker (right along with the IP child)—in the clutches of an SF:RS-MSF, although vaguely aware of its noxious effects, is oblivious to its existence as the prime cause. It takes a knowledgeable outsider to recognize SIH for what it is. The onus is on the professional to act: 1) directly to cure a family or 2) preemptively to stop SF:RS-MSF spread. Once pointed out, willing parents can correct a split field with fair ease. They don’t need personal psychoanalysis to sort it out!

It has been stated that “The best measure of diagnosis is response to therapy.”ix That may well be so in the hands of a master, but a wide-sweeping assessment is best for all ordinary mortals. Diagnostic nihilism has no place. Furthermore (I cant resist saying this), those using politically correct euphemisms—‘challenged’ or ‘special’—in referring to ‘unusual’ children may be doing themselves a disservice. It’s laudable to deal with strengths and show sensitivity for feelings, but we must be realistic and allow specific pathology in, if only to guide our work—whether rational treatment or sound teaching.

DIFFERENTIATING SIH AND ‘ADHD’

All front line professionals dealing with children should 1) keep a sharp eye out for hyperactivity caused by improper administration of a stimulant drug and 2) be able to distinguish between true-organic, ie., neuro-ADHD and SIH.x This table on the next page should help in the latter task.

neuro-ADHD

SIH

DEFINED: ADHD is a structured syndrome disorder—a medical-psychological mix with educational and social consequences. There is a familial pattern, probably inherited.

SF:RS hyperactivity is a sign of family distress often extending to the school and other social environment giving rise to MSFs. A child plays the signal relayer role. One IP per family.

INCIDENCE: Much lower than commonly thought. 1/25 cases. More boys than girls (ratio of 3-4 to 1).

Strictly by the odds an SF:RS source will win out: the ratio of SIH to neuro-ADHD is 25/1. Girl-boy 1:1.

SYMPTOMS: Commonly listed for diagnosis are short attention span, distractibility, hyperactivity, and impulsiveness. Emotional lability is mentioned in the literature, but anxiety is not common. Learning disability can accompany the disorder. True ADHD is distinguished by its continuous and relentless nature. That is, the badly afflicted child, except when asleep, is restlessly overactive, twitching and jiggling constantly, and the degree of inattention is very hard to overcome.

Note: Distractibility primes the hyperactivity.

SIH children may variably display the triad of short attention span, distractibility, and hyperactivity. Symptoms come and go: definitely ‘on’ when in proximity to a split field. They are overactive and inattentive only some of the time. There is no real attention deficit, often the reverse—hyper-vigilance. If the above triad is intense, concentration diminishes and learning in school may be affected. Anxiety, visible or not, underlies hyperactivity.

Hyperactivity primes the distractibility.

CAUSE: It is hypothesized that in ADHD the brainstem reticular system is not working up to par. A definite organic, neurological flavor with soft, non-localizing signs and a diffusely abnormal EEG is common.

No organic clinical flavor. In the family, blocked communication between the parents sets up a relayer system (SF:RS). At a higher social level there may be multiple split fields (MSFs) involving outsiders.

Rx: Stimulant drugs work favorably in just a day or two. A whole month’s trial, as recommended in the pharmaceutical sales-blurbs, is not at all necessary.

If a stimulant is tried it usually makes SF:RS-MSF children worse, revs them up! Sedatives just make them dopey. Family Rx, community conference.

Key point: Some clinicians make their diagnosis on the basis of a differential response to drug treatment, that is, a short trial of Ritalin—which is only partly okay. Before doing such a ‘trial of treatment’ try the ‘finger twitch’ test. And always see parents and child together at least once.

SPECIFIC RATIONAL TREATMENT OF SIH

Psychologists usually recommend a combination of drugs and behavioral modification for ‘ADHD.’xi No one can deny the seemingly good sense of such—hitting the problem with both barrels. But such a shotgun approach, it must be admitted, is pretty nonspecific. The essential difference I emphasize is: Management of hyperactivity should not be blind; its diagnosis should be accurately focused and its treatment tailored, i.e., varied according to specific cause.

ONE SPLIT FIELD: Dealing with a family SF:RS is simple and direct. The problem and its resolution can be seen first hand. It doesn’t require tedious and long drawn out individual therapy sessions. It can be as incisive as a surgical operation. And it cannot be overemphasized that it is worth trying before committing any child to any ‘trial’ time on any drug, let alone years on Ritalin. General steps, once an SF:RS is discerned, are:

1. Dissolution of split fields: First and foremost, get the parents talking together! Facilitate talk between parents and teachers. When communication across a split field is opened up—if secret, emotionally important disagreement is pointedly externalized—a relayer is no longer necessary: the position becomes redundant. If the relayer is very young or the SF:RS of recent onset, anxiety-hyperactivity level subsides, often abruptly.

2. Carrot and stick: If the relayer is older and compulsive (like the school nurse), controls need to be invoked lest s/he set up new triangles or reactivate old ones. When controls are successful, not only does the relayer’s anxiety-hyperactivity level drop but intrigues cease.

3. Innovations: In dire emergencies separation of the principle parties (eg., Timmy from mother, as we’ll later see) may be a necessary short-term expedient. In special instances tricks that skirt covert conflict with outsiders may be initially advisable (as in Michelle’s case).

Right after a diagnosis of SIH is established, it’s best to get the child out of the room and temporarily deal with parents only. This has symbolic as well as practical value. It conveys a message that the child is not ‘the sick one’. Carefully explain the SF:RS. Show them what is happening; draw a diagram. Then get the blocked parents talking with each other about taboo child-related topics. Teach them to agree to disagree! Firmly instruct them not to get sucked into sending pejorative messages about each other through their child anymore. Insist upon it! A child may be unable to extricate itself from a humming split field, but even half-intelligent adults can do so—once they are informed. Don’t let them wiggle out of it. They must make a decision to end and exit this noxious triangle.

Once the parental split field is opened up, and that is the instant they start to talk again, once a child realizes there are no more hostile messages to relay, it all stops. Parents will report their child’s cure with awe. Some very long-standing, older relayers may try to reinstate the familiar system, but little kids welcome their rescue from it. “Someone has finally got me out of this mess with mom and dad.” A very occasional refresher course to follow-up on parents and reinforce their good intentions is enough. The fact that the child needs no medicine is a most happy verification of success in itself.

MANAGING MULTIPLE SPLIT FIELDS: Handling MSFs that involve the extended family can be hectic and complicated. It’s wise to pass the problem on to a knowledgeable specialist. But the informed family doctor can give it a first, front-line try by advising ‘converted’ parents to be firm with interfering relatives, and if necessary, cut them out of the circuit, unless they stop mixing in and messing up. So, help parents set conditions and limits.

Expanding circles of people potentially harboring MSFs must be considered. Some fervent workers would go so far as to include everyone in the hotbed of intimate therapy. At the other extreme some doctors hand out scripts without ever seeing both parents together with their child. Much better: approach them all through a well-organized conference. Conferences, however, pose added issues of coordination and confidentiality. The latter can be knotty indeed. Institutions that dole out money to the poor have an inherent conflict of interest. Nevertheless, responsible child welfare agencies, correctional services, schools, etc., should insist upon a community conference of all persons constructively involved with a particular child. Parents must be included! Doctors usually cannot find the time to attend, but some will, so they should always be invited. Simply getting key people together may be enough to start the healing process. The climate will be relaxed, friendly and informal, with refreshments.

1. There will be an exchange of information that airs differing approaches. You’d better believe that agencies, schools, courts have them! The chairperson should highlight and praise areas of agreement and success. Never be critical. Insist upon total confidentiality.

2. There should be an attempt to develop a short agreed-upon operational plan with overall reachable goals. This plan must include parental input. It cannot be arbitrarily ‘laid-on’ with much success.

3. Finally, it is even better if the conference can agree to select or elect a case coordinator from its midst—not a supervisor—to henceforth actively follow all aspects of the case, later calling periodic sub-conferences as indicated.

From a practical standpoint it is worth bearing in mind that the ‘virus’ affecting split field relayer families often spreads far afield. If you can correct the family itself, complicated dealings with multiple agencies might be forestalled. Primary prevention of socially induced hyperactivity is not yet practical. But some degree of secondary prevention is; dealing head-on with SIH reduces secondary learning and conduct debilities.

DRUGS: As SIH does not require medication, it behooves us to know a bit about medicines, where they work and when they do harm. An intact brainstem ‘reticular formation’ (RF) screens out irrelevant incoming stimuli (see next illustration). It is surmised that in neuro-ADHD the RF is not working up to par, so that the rest of the brain, flooded with massive input, becomes overburdened. The result is that the afflicted child is distracted, cannot concentrate very well or easily sit still. Correct treatment, seemingly paradoxical, is a stimulant drug to perk up the lazy underfunctioning brainstem and thereby tone down the hyperactive child. However, other kinds of hyperactivity, as well as SIH, are worsened by stimulants!

Years ago Ritalin ® (methylphenidate) for children was highly controversial. Only child psychiatrists, not even pediatricians, were allowed to prescribe it in the mid-1970’s! Protest groups faught it. But their voices died out. With the advent of new related drugs, caution flew out the window. Now, the CPS (Compendium of Pharmaceutical Specialities) and the Internet carry page after page dedicated to anti-ADHD drugs.xii Stimulants are widely accepted, promoted, overused. Stories paint nightmarish pictures of children at school lining up in droves to get their ADHD drug-hit! Detail-reps aggressively promote anti-hyper drugs in doctors’ offices. One wonders if the remedy is driving the diagnosis. Obviously the big pharmaceutical companies are cashing in. But it is not entirely as underhanded as that. Certainly, the populace wants a pill for every ill. As an MD I’m all for medication, but I am dead against its excessive and incorrect use, especially in children. Unfortunately, many family doctors and teachers seemingly find it convenient. Is it their placebo? Ritalin is a stimulant drug. It works on the brainstem’s Reticular Formation (RF) and the cerebral cortex (shown at left). If it is going to calm down children with true ADHD, a favourable response can be expected within a couple of days, not the entire month that the pharmaceutical brochures recommend. Several methylphenidate homologues of Ritalin are now on the market: Concerta, released in 2000, and Metadate in 2001 are two examples. Another CNS stimulant now being promoted, Cylert (pemoline), is more powerful than Ritalin and can cause liver damage! Also (amazingly) promoted is the amphetamine, Dexidrine, used by German flyers in WW2 and lazy students before examinations. Obviously a poor practice! Strattera (azomexetine), a norepinephrine antagonist, is claimed as the “first non-stimulant for ADHD.”

Use of sedating anxiolytics – such as Valium (diazepam) and Buspar (azapirone) – is irresponsible. They impair memory and are habituating if not addictive. Barbiturates (mind-dulling depressants) sedate from cortex on down and may compromise an already under-functioning reticular substance, aggravating neuro-ADHD. If a doctor puts an SIH-child on a sedative or anxiolytic drug it should be a clear medical choice. In my opinion it’s a poor choice; there are just too many unnecessarily doped-up children around.

The Internet list of drugs for ‘ADHD’ goes on: Powerful anti-hypertensives such as Tenex (guanfacine) and Catapres (clonidine) have entered the race. The old-fashioned tricyclic antidepressants Tofranil and Desipramine have been resurrected! Prozac (fluoxetine), a serotonin re-uptake inhibitor, is also pushed. SRI variants, may work in SIH, but it seems excessive. Reports of suicide in young people support my long held doubts about their willy-nilly use.

TREATMENT QUANDARIES: Strategically placed people—teachers in particular—actively find and, in one way or another, refer hyperactive children to compliant family doctors who simply—prescibe. A cautionary vignette:

C6: I once saw a wildly hyperkinetic boy who was spiraling up and up. His doctor had started Ritalin and, egged on by the child’s teacher, stubbornly kept increasing the dose. It turned out that this was a pure SIH-child. By stopping the medicine and dealing incisively with both parents the boy literally wound down overnight. The teacher needed no extra convincing.

DOUBLE DIAGNOSIS—‘ADHD’ and SIH acting together—is not uncommon. Genuine neuro-ADHD may be complicated by the concurrent presence of single or several split fields. Consequent wildly exaggerated hyperkinesis poses a true treatment dilemma. Increasing the stimulant drug will aggravate the SIH component; decreasing it may exacerbate the organic ADHD. So, if hyperactivity breaks through in a child previously under good medical control, don’t automatically increase a once effective dosage to high levels simply hoping for the best. Do not start switching medications around. Do not add a sedative for the SIH on top of the ADHD stimulant. These children are best kept on a level dose of a proven stimulant while the newly active split social fields are sought out. The split fields are dissolved as described earlier, or the child, if in danger, is extracted from the noxious situation—hospitalized or taken into temporary protective care. The following life-and-death emergency makes it clear that mixed SIH-ADHD is nothing to trifle with:

C7: Timmy, 10, was hospitalized in a drunken stupor. Vomiting 20 times/hour, he weighed a cachectic 15.4 Kg. The pediatricians (attending and resident) had investigated everything and tried almost anything—tube-feedings, IVs, antinauseants, sedatives—to no avail. The boy on the verge of dying, ‘last resort’ psychiatric consultation was saught. Timmy was frantic: hyper, dilated pupils, hair pulled out in tufts, tied to the bed. He had been diagnosed ADHD—now off Ritalin.

Multi-level assessment brought out that a vicious family SF:RS was central to MSFs involving ward staff, nurses and doctors. The mother was found to be subversively orchestrating the mess. She was primarily at odds with the head nurse and caught ‘pleasantly’ tickling Timmy’s ear-canal with a Q-tip while suggesting he throw up. The original clinical diagram of years ago shows three quite distinct split fields (T = Timmy, P1&2 = pediatricians, N = nurse, M&F = mother/father).

The mother’s visits were diplomatically ended; she was seen in my office, ostensibly to keep her informed of the boy’s progress. Children’s Aid was discretely notified as back-up in case she try to pull Timmy out of hospital. All meds and heroics were stopped. Staff meetings to air differences and coordinate treatment activities were started. This simple approach turned things around. In a few weeks a calmed-down Timmy, back on Ritalin, his weight doubled, was smiling ear to ear.

WHO CAN DO SIH TREATMENT? Answer: any good clinician – once oriented to the reality of SIH. Until now the existence, nature, and esoteric jargon of SIH have undoubtedly been unknown to most readers. It is hoped that both teachers and consulting physicians exposed to this article will now have a rationale for accurate diagnosis and correct treatment. Those identifying SIH could spread the word and all school pricipals can hold community conferences. In the interest of their little wards, school authorities might encourage special educators and school nurses to seek and personally develop the necessary clinical skills for dealing directly with SF:RS-MSFSIH families. Teachers should teach not treat. School psychologists probably will continue, one-on-one, to test and de/recondition. And doctors will prescribe, hopefully correctly. Everyone might remember: Treatment without diagnosis is incompetence. Diagnosis without treatment is neglect.

THREE KEY STUDIES

Years ago, as others stepped up their researches into the biochemical and genetic factors underpinning psychological problems, I turned my attention to discovering/deciphering corresponding social-family mechanisms.xiii The workings of a variety of dysfunctional family triangles were teased out. Two preliminary studies led up to my definitive research on SIH. Designed to examine coincidence of hyperactivity with the SF:RS-MSF mechanism, it took place piecemeal over a span of 30 broken-up years starting in the late 1960’s. At its inception I had no idea the study would last so long.xiv (Private office research is daunting. It took 26 active years to gather less than half as much data as earlier in just two years at the city clinic. I attempted to set up an ongoing matched and blind protocol, but over the long haul it was not feasible. There was no control group of hyper children not connected with some sort of community meeting.) It bears emphasis that during the active years of the study I maintained a general medical family practice to which I applied psychiatry. So the numbers are consistent with what a family doctor might expect to see—which, in turn, corresponds with general incidence-prevalence.

Data: On average, between 4 and 10 hyperactive children were seen each year for a total of 150 over a 30-year, partly broken up, time span. In that entire period only six were diagnosed with genuine neuro-ADHD—all of which were responsive to Ritalin ® (or generic methylphenidate). One child had squirmy rheumatic restlessness. All the other hyperactive children, 143, were found to be relayers in split field families. About two thirds of this group, 90, were also at the nexus of multiple split field triangles involving school, court, child welfare, etc. (Twirling little autistic children were excluded from the study as were head-banging, pacing, mentally retarded children. Unfortunately discounted, referred children wrongly on Ritalin were mostly SIH cases. One notable small girl had very profound hyperactivity secondary to cerebral complications of rheumatic fever.)

Differential outcomes: Symptoms were alleviated in 95% of instances that used two modalities of intervention—family Rx and conferencing. Where a community conference was not possible (rarely), but incisive family therapy with a focus on MSFs was, the success rate dropped to between 75-85%. Thus the significance of SIH was verified.

A BIT OF SOCIAL EPIDEMIOLOGY

According to the Internet Pediatric Database, the prevalence (all existing cases) of ADHD (defined loosely) is 2.5% of children, with an incidence (new case occurrence) of 1-6% of school age children.xv The truth is shown in the above graph: neuro-ADHD (grey) accounts for less than 5% of all hyperactivity. Stated another way, there are 25 SIH cases for one of organic neuro-ADHD. The latter is grossly over-diagnosed. In SIH boys and girls are affected equally; in true neuro-ADHD the gender ratio is 3-4 boys for 1 girl. There is afoot an upsurge of this newly discovered type of hyperactivity. Formal epidemiological studies of SIH remain to be done. Coincidentally, the incidence of each, SIH and divorce, has been rising step by step in parallel – a true epidemic of both. I am less concerned with statistics than getting across observations and associated ideas. These are related to fundamental principles underlying social complexity and form, cybernetic feedback loops within a communication model, at three system-levels: the individual child, its family, and all appropriate wider social systems. Statistical evidence is tied into effecting family and social changes that correct hyperactivity. In science discovery and description should move toward search, research and measurement. This study admittedly has its numerical shortcomings, but it has heuristic value.

THE CRUX OF THE MATTER

There is an upsurge of this newly-discovered type of hyperactivity, SIH, afoot in Canada and the USA. What deeper trends could be behind it? To reach an answer we’ll meld together my own ideas about SIH with a seminal statement by the great Canadian philosopher, Marshal McLuhan, and the astute analysis of an American child psychiatrist, William Glasser. McLuhan, of ‘medium is the message’ fame, observed a radical reversal of two important personal priorities beginning around mid-twentieth century. He encapsulated this change in these seminal words: ROLE now precedes GOAL.

There always have been goals, selfless or selfish, related to survival and there always have been personal, self-enhancing roles. Only rich and powerful people could afford to equally indulge the latter. The helpless could but hope. The striking statement, goal now precedes role, means that a traditional emphasis on responsible planning and directing of one’s actions outwardly, with concurrent concern for others, now takes second place to an inward preoccupation with recognition by others of one’s own uniquely personal worth. Role now preceeds goal. And this means for just about everbody!

Glasser, author of The Identity Society, tied McLuhan’s reversal of personal priorities, beginning after two world wars and the great depression, into two long-emerging social trends and an epochal technical revolution: 1) rising levels of affluence and buying power, 2) progress in human rights (and hopes) for women and children as well as minorities; and 3) television, which portrays an overflowing fantasy-land of wonderful things and beautiful people.xvi

TV advertising displays the likes of a shapely, sparsely dressed girl sitting on the hood of a car. The image says, “Buy me (this car) and you’ll be somebody!” Or, in school, get a pat on the back first, then study. From a 2011 viewpoint, television still promises instant role gratification … without real social effort. Social-technological trends have moved ahead apace to include personal computers and the endless internet. Results still can be dramatically translated into before and after scenarios in which the old goal of relatively selfless but sheer survival continues to give way to a self-centered, me-first role, in a materialistic world. Now, how does all of this clever theorizing tie into the immediate clinical problem of hyperactivity? In five ways:

1. There is a burgeoning of divorce. In the old survival-security and goal-oriented society people got married and stayed married. It was safer. It was a goal in life. In our modern identity society, confirmation as a valuable person, as ‘someone,’ is an almost insatiable craving. If a partner feels unappreciated, or poorly stroked (as described by Eric Berne), even merely unhappy, it is seen as okay to keep an eye out for someone new who might combine all the marital talents of a small village, and depart for greener fields. Impossible! but believable. Thus, people easily split up and divorce rates spiral ever up. And as we earlier saw, separated parents are a perfect setup for split social fields and SF:RS hyperactivity. Compounding it even more, many children are farmed out to multiple recreated families – with new fathers, new mothers, new siblings. These families of divorce are ideal opportunities for the emergence and maintenance of yet more split social fields. It is my strong impression that the incidence rate of each, divorce and child hyperactivity, has been rising step by step in parallel – a true epidemic of both.

2. Nowadays, intact nuclear families are probably much more democratically laissez-faire than were their counterparts of half a century and more ago. Children are often allowed and feel free to cross the generational barrier with relative impunity. In times past, families were less child-centered and it would hardly be conceivable to allow, let alone enable, any child to mix into parental affairs, and be relayers. Also, children themselves ‘knew their own place’ and were less likely to get in the middle. Certainly some did, and SF:RS’s must have existed in small numbers. Also before, most people chose a partner from the same social-cultural background. There were few child rearing differences between them to argue or simmer about – or to exploit. Parents certainly had their silent differences, probably much more hidden than now, but, for the most part, they wouldn’t enjoin a child to convey their complaints to the other. Now, as we know, many do. Taken together, we can tentatively conclude that in intact families there has been an overall, absolute (but likely moderate) increase in SF:RS hyperactivity.

3. Single parent families are on the upswing, either by initial choice or through separation and divorce. At least for the latter, separation and divorce, everything said in the first point above applies. Even in the former, where a mother (or father) wants no committed part of the opposite sex, there may be an alienated boy/girl friend lurking in the wings, so the same applies. In short, single parent families are not immune to SF:RS’s. They are just harder to get at and treat.

4. In our present day entitlement type of world respect for many societal institutions has gone way down. Professionals too are less highly regarded. So, if there is a difference, say, between a parent and a teacher it is easier for the child to become a relayer of hostile messages. Back when I was in grade-school most parents were solid allies of teachers. If I got into mischief at school the chances were about 100% that I’d catch the dickens even more back home. The long and short of it: there was little chance for the sprouting of a noxious split field between parents and teacher with a child swept up in it. Now it happens all the time over many issues. Another point: Before, performance took precedence in school; reward for effort was considered a fillip. Just like for dad, it was a ‘day’s pay for a day’s work’. Few kids expected a pat on the back first. Children were expected to study hard and pass. Otherwise, no easy ‘A’ for effort. Things have changed. Another point yet: While respect for institutions has diminished, unhappy involuntary involvement has increased. I think there are more children from more families being ‘helped’ by more agencies now than ever before. The sheer numbers increase the chances of more split fields – multiple split fields – and induced MSF hyperactivity.

5. Today, there is more recognition – ‘case-finding’ – of what is thought to be ADHD. But it is most likely spurious. When I was a child (in the 1930’s) there were three great gangling, twitching, 14 year old boys held back in my grade 4 class. One of these, in retrospect, was definitely hyperkinetic – with unrecognized, probably true ADHD. But the problem then was virtually unheard of. In the 1960’s a whole school might have had only one true ADHD child, if that. (ADHD then was termed ‘minimal brain damage.’) There might have been just one or so SF:RS-MSF child in a classroom, generally unrecognized as such. Now, SIH which is wrongly diagnosed as ADHD seems rampant. I doubt – I know! – that the absolute incidence of pure neurological ADHD has increased all that much if at all over the intervening years. SF:RS-MSF hyperactivity (SIH) has.

SUMMARY

Problems: Increased case-finding by teachers understandably fails to separate out distinct varieties of distracted, hyperactive children who may arrive at the sometimes poorly informed doctor’s office – indiscriminately lumped together. Current treatment is driven by drug manufacturers capitalizing upon the misconceptions of parents, teachers and doctors – all. Thus, true neurological ADHD is over-diagnosed and non-organic hyperactivity (SIH) incorrectly treated with drugs.

A Discovery: In light of a new causative source, the biphasic SF:RS-MSF mechanism that constitutes SIH, the burgeoning concerns posed by hyperactivity and distractedness can be reevaluated. Not coincidentally, the rising incidence of SIH parallels a rising divorce rate in our modern laissez-faire society. Not all divorces are bad, but some badly affect children. SIH, much more prevalent than neuro-ADHD, accounts for most child hyperactivity. It does not need medication. In fact, stimulant Rx is contraindicated. Haphazard treatment stems from an absence of theoretical perspective and proper diagnostic tools to differentiate types of hyperactivity.

The Remedy: When teachers and doctors learn to recognize SIH – its phased, 2-step SF:RS-MSF mechanism is easy to see; it’s right before our eyes – then the unhappy scenario of children wrongly on drugs may change. Distinction is possible between bona fide neuro-ADHD, which is properly treated medically, and SIH, which is not. Thus, the vast majority of child hyperactivity (and concurrent school issues) can be handled without resort to drugs. That is, secondary prevention of school failure and bad conduct associated with SIH is effected through effective social management and almost surgically incisive family Rx.

WFH April 2011

iHogg, William. The Split Field Relayer System as a Factor in the Etiology of Anxiety (A matched study of 48 cases), Psychiatry (Journal for the Study of Interpersonal Processes), Vol. 35, No. 2 (1972).

iiIn the wordy disciplines of psychology and sociology succinct mechanism-diagrams not only are a visual bridge between verbal and mathematical-scientific descriptions but also are sophisticated process explanations in and of themselves. In psycho-social clinical work, as we’ll see, concrete problems almost inevitably give way to even more abstract etiologies that involve dilemmas and/or disputes.

iiiHogg, W.F. & J. E. Northman Ph.D. The Resonating Parental Bind (RPB) in Delinquency, Family Therapy (1979).

ivAnthony, E. J. Psychiatric Disorders of Childhood, in Freedman and Kaplan, Comprehensive Textbook of Psychiatry. Williams & Wilkins (1967). Note: My references are mostly ‘ancient’ as the modern literature is understandably devoid of the SIH concept.

vJenkins, R. L. Classification of Behavior Problems of Children. Amer. Psychiat. Jr. (1969).

viIt is useful to bear in mind that easily distracted children with short attention span may be surmised as having a learning disorder (eg., dyslexia) and unnecessarily subjected to an expensive battery of psychological tests. In the end the correct diagnosis may turn out to be SF:RS anxiety with minimal hyperactivity.

viiToolan long ago described acting-out as a ‘behavioral equivalent’ of depression. The reader may ask: Do SF:RS-MSF triangles produce just anxiety-hyperactivity? Why not aggressive rage? Well, triangles are malleable during their early, open phase and may display indicators of more than one basic emotion—fear, anger, happiness, sadness, disgust. If paradoxical metamessages are present a triangle becomes fixed and specific in its emotional-behavioral outcome: primary fear turns into anxious hyperactivity whereas anger in teens may escalate to acting-out.

viiiBakwin & Bakwin. Behavior Disorders in Children, Saunders.

ixHaley, Jay. Problem Solving Therapy, Harper and Row, New York (1978).

xThe astute physician, in addition to SIH and neurological ADHD, will consider such esoteric possibilities as anemia, rickets and scurvy, intestinal pin worms, rheumatic fever, diffuse brain trauma, post-encephalitic effects of influenzal meningitis… Brain-inflammation simply cannot be missed and treated as ‘ADHD’ with potentially lethal stimulants! Rheumatic fever is successfully cured with RAP: rest, aspirin, penicillin—not Ritalin. One child’s life saved is the best argument for a properly executed differential diagnosis.

xiJohnson, L. A. et al. What is the most effective treatment for ADHD in Children? Jr. Fam. Pract. Feb. 2005. Note: This paper was picked randomly off an Internet site devoted to posting quality ‘ADHD’ research. It surveys primary care professionals, concluding, “Stimulant drugs have a therapeutic edge over (vague) behavioral and family approaches.” In this biased article no criteria for the consistent diagnosis of ‘ADHD’ are cited.

xiiInternet searches done by high school senior, Patrick Hogg, 17.

xiiiThe Next Fifty Years (Science in the first half of the 21st Century), Edited by John Brockman, Random House, NY (2002). Note: This misguided book is cited as an example of retrospective 20-20 vision projected into a very Utopian future. The wild assumption is made that all genetic knowledge underlying child development, psychopathology, and social behaviour is or will soon be complete, and no future research (of any kind) in these fields will be valid without a prior genetic screen. If only such were so! In a fanciful spasm and burp of reductionist hubris, biology and genetics checkmates psychology and social studies. If only such were so simple. In short, social-psychological research, especially with a view to elucidating mechanisms, must continue apace.

xivThe original research, lasting two years in the mid-60’s, was done at the Children’s Service, Public Health Dept., Hamilton. The facility served all schools, agencies, hospitals, etc. There were 391 disturbed children overall and 48 matched anxiety cases. 70% of all children assessed as anxious were found to be relayers in families with split social fields. Dissolution of the split field quickly alleviated anxiety in 76.6% of the study group. (This rate climbed toward 85% as skills improved.) Controls had a predictable success rate of 66.6%. The hyperactive aspect of some of the SF:RS-triangle was a serendipitous finding which rested fallow over the years except for three update presentations: 1) Relevance of the Family in Medicine, a tape by Communications in Learning, Inc.; 2) a symposium on The Family in Health, Disease and Disorder, Roswell Park Cancer Institute, Buffalo (1978); and 3) a talking-paper, same year, at the American Association for the Advancement of Science annual meeting in Washington. The 2nd study came out of a community conferencing project in the mid-60’s designed to determine if information exchanges and coordination of effort between ‘divisive’ agencies would reduce police incidents with delinquents. Lt. Jim Paterson head of the police juvenile division and Mr. Sid Blum of the Social Planning/Research Council were critical to this phase of discovering SIH. 50 carefully matched, multi-problem families participated. All services dealing with these families met weekly at my clinic. Study group children had a significantly reduced incidence of police occurrences. I noted, then, 25 hyperactive children from the study families dramatically improved following their family’s conference. This seemed a curiosity only, at the time not published. But it set my brain to turning on the beneficial effect of community conferencing on MSFs and (later) SIH.

xvInternet Paediatric Database: ‘ADHD’ incidence stats as of Dec. 2003; last update 5/28/94!

xviGlasser, William. Reality Therapy in Child and Marital Counselling, 1973 (seminal) audiotape from the Audio-Digest Foundation, Vol. 2, No. 17. Los Angeles, CA. 

Statistical update

Statistics update (MedScape pediatrics July 30, 2008): Miranda Hitti in WebMD Health (July 24, 2008) writes, “The CDC today reported that about 5% of US children … have been diagnosed with ADHD according to their parents.” The 5% figure derives from telephone interviews (04-06, reported in Sept. 2007) at Cincinnatti Children’s Hospital by University of Cincinnatti College of Medicine in which parents of almost 23,000 children (aged 6-17) were asked if an MD or other health professional had diagnosed their child with ADHD or ADD. (The CDC didn’t check children’s medical records to confirm parents’ reported diagnosis.) The CDC also reports a 3% average annual increase in childhood ADHD from 1997-2006, that children with ADHD were more likely than other kids to have chronic health conditions and that the true number of all ADHD-children may be much higher than 5%. The CDC acknowledges that social-economic factors and access to health care affect chances of an ‘official’ ADHD diagnosis.

Notes

Why is this article a Knol?

I think the concept of SIH is interesting. Its practical reality, however, is seminally important, for far too many children are wrongly receiving powerful medicines for what might be called pseudo-ADHD (i.e., until SIH is more widely known). Some time ago I thought my research work should get out to professionals dealing with children: family doctors and pediatricians, public health nurses, social welfare workers, and above all, teachers. So, ten or so years back, I submitted the article to a major pediatric journal. It was turned down out of hand “because you discourage the use of drug Rx … and pharmaceutical advertisements sponsor/support our publication … we must rely on them.” (This article of course does not discourage medicines used correctly!) Subsequently, two general medical journals essentially said the same thing. Then I tried a major educational journal and was delighted to be accepted. But, a couple of months later was told that “we only publish pedagogic principles.” The editor of a top psychology journal declared that their journal was for PhDs not MDs. A social work journal was equally parochial. But I never give up on what I think is a good thing, so when Google came out with Knol, I jumped at the chance to at long last have this work read. Maybe some people will apply it. Maybe others will formally try to verify or reject it. And, maybe, a few parents will eventually get the message too, on behalf of their non-neurological ADHD children. /wfh


[1] In the wordy disciplines of psychology and sociology succinct mechanism-diagrams not only are a visual bridge between verbal and mathematical-scientific descriptions but also are sophisticated process explanations in and of themselves. In psycho-social clinical work concrete problems almost inevitably give way to even more abstract etiologies that involve dilemmas and/or disputes.

[2] Toolan long ago described acting-out as a ‘behavioral equivalent’ of depression. The reader may ask: Do SF:RS-MSF triangles produce just anxiety-hyperactivity? Why not aggressive rage? Or reactive depression? Well, all triangles are malleable during their early, incipient, open phase and may display indicators of more than one basic emotion—fear, anger, happiness, sadness, disgust. If paradoxical metamessages are present a triangle becomes fixed and specific in its emotional-behavioral outcome: primary fear turns into anxious hyperactivity whereas anger in teens may escalate to acting-out.

[3] Differential diagnosis: The astute physician, in addition to SIH and neurological ADHD, will consider such esoteric possibilities as anemia, rickets and scurvy, intestinal pin worms, rheumatic fever, diffuse brain trauma, post-encephalitic effects of influenzal meningitis… Brain-inflammation simply cannot be missed and treated as ‘ADHD’ with potentially lethal stimulants! As a crucial case in point, Rheumatic fever is successfully cured with what I call RAP: rest, aspirin, penicillin—not Ritalin. One child’s life saved is the best argument for a properly executed differential diagnosis.

[4] The original research, lasting two years in the mid-60’s, was done at the Children’s Service, Public Health Dept., Hamilton. The facility served all schools, agencies, hospitals, etc. There were 391 disturbed children overall and 48 matched anxiety cases. 70% of all children assessed as anxious were found to be relayers in families with split social fields. Dissolution of the split field quickly alleviated anxiety in 76.6% of the study group. (This rate climbed towards 85% as skills improved.) Controls had a predictable success rate of 66.6%. The hyperactive aspect of some of the SF:RS-triangle was a serendipitous finding which rested fallow over the years except for three update presentations: 1) Relevance of the Family in Medicine, a tape by Communications in Learning, Inc.; 2) a symposium on The Family in Health, Disease and Disorder, Roswell Park Cancer Institute, Buffalo (1978); and 3) a talking-paper, same year, at the American Association for the Advancement of Science annual meeting in Washington. The 2nd study came out of a community conferencing project in the mid-60’s designed to determine if information exchanges and coordination of effort between ‘divisive’ agencies would reduce police incidents with delinquents. Lt. Jim Paterson head of the police juvenile division and Mr. Sid Bloom of the Social Planning Council were critical to this phase of discovering SIH. 50 carefully matched, multi-problem families participated. All services dealing with these families met weekly at my clinic. Study group children had a significantly reduced incidence of police occurrences. I noted, then, 25 hyperactive children from the study families dramatically improved following their family’s conference. This seemed a curiosity only, at the time not published. But it set my brain to turning on the beneficial effect of community conferencing on MSFs and (later) SIH.

[5] Private office research is daunting. It took 26 active years to gather less than half as much data as earlier in just two years at the city clinic. I attempted to set up an ongoing matched and blind protocol, but over the long haul it was not feasible. There was, sadly, no control group of hyper children not connected with some sort of community meeting.

[6] Twirling little autistic children were excluded from the study as were head-banging, pacing, mentally retarded children. Unfortunately discounted, referred children wrongly on Ritalin were mostly SIH cases. One notable small girl had very profound hyperactivity secondary to cerebral complications of rheumatic fever.

[7] I am less concerned with statistics than getting across observations and associated ideas. These are related to fundamental principles underlying social complexity and form—cybernetic feedback loops within a communication model—at three system-levels: the individual child, its family, and all appropriate wider social systems. Statistical evidence is tied into effecting family and social changes that correct hyperactivity. In science discovery and description should move toward search, research and measurement. This study admittedly has its numerical shortcomings, but it has heuristic value.

 

References


[i] Hogg, William. The Split Field Relayer System as a Factor in the Etiology of Anxiety (A matched study of 48 cases), Psychiatry (Jr. for Interpersonal Processes), Vol. 35, No. 2 (1972).

[ii] Hogg, W.F. & J. E. Northman Ph.D. The Resonating Parental Bind (RPB) in Delinquency, Family Therapy (1979).

[iii] Anthony, E. J. Psychiatric Disorders of Childhood, in Freedman and Kaplan, Comprehensive Textbook of Psychiatry. Williams & Wilkins (1967). Note: My references are mostly ‘ancient’ as the modern literature is devoid of the SIH concept.

[iv] Jenkins, R. L. Classification of Behavior Problems of Children. Amer. Psychiat. Jr. (1969).

[v] Bakwin & Bakwin. Behavior Disorders in Children, Saunders.

[vi] Haley, Jay. Problem Solving Therapy, Harper and Row, New York (1978).

[vii] Johnson, L. A. et al. What is the most effective treatment for ADHD in Children? Jr. Fam. Pract. Feb. 2005. Note: This paper was picked randomly off an Internet site devoted to posting quality ‘ADHD’ research. It surveys primary care professionals, concluding, “Stimulant drugs have a therapeutic edge over (vague) behavioral and family approaches.” In this biased article no criteria for the consistent diagnosis of ‘ADHD’ are cited.

[viii] Internet searches done by high school senior, Patrick Hogg, 17.

[ix] Ibid references 1 & 4 above.

[x] The Next Fifty Years (Science in the first half of the 21st Century), Edited by John Brockman, Random House, NY (2002). Note: This misguided book is cited as an example of retrospective 20-20 vision projected into a very utopian future. The wild assumption is made that all genetic knowledge underlying child development, psychopathology, and social behavior is or will soon be complete, and no future research (of any kind) in these fields will be valid without a prior genetic screen. If only such were so! In a fanciful spasm and burp of reductionist hubris, biology and genetics checkmates psychology and social studies. If only such were so simple. In short, social-psychological research, especially with a view to elucidating mechanisms, must continue apace.

[xi] Internet Pediatric Database: ‘ADHD’ incidence stats as of Dec. 2003; last update 5/28/94!

[xii] Glasser, William. Reality Therapy in Child and Marital Counseling, 1973 (seminal) audiotape from the Audio-Digest Foundation, Vol. 2, No. 17. Los Angeles, CA.