- Email: [email protected]
CHILDREN TRAUMATIZED BY WAR
LETTERS
TO
THE
EDITOR
DISTRACTIBILITY AS A SYMPTOM OF ADHD
To the Editor: From time to time, I find that I make the diagnosis of attention-deficit/hyperactivity disorder in a child or adolescent where a colleague has not seen it. In discussions with my colleagues, more often than not, the difference of opinion concerns the cardinal symptom of distractibility. Distractibility is referred to in DSM-IVas criterion Alh: "is often easily distracted by extraneous stimuli." In DSMIV's general description of attention deficit disorder, we find the sentence, "Individuals with this disorder are easily distracted by irrelevant stimuli and frequently interrupt ongoing tasks to attend to trivial noises or events that are usually and easily ignored by others." I do not believe that DSM-IV's description of the distractibility of attention deficit disorder is accurate. Distractibility, often defined as the diverting of attention rapidly from one topic to another, is actually a normal phenomenon that is not only common, but necessary in healthy functioning. For example, while I am typing this sentence, I can momentarily glance at my clock, noting how much time I have left before I have to leave to pick up my son at school, and return to the typing of this sentence, hardly skipping a beat. Distractibility in attention deficit disorder differs from the normal in either of two ways: (1) The individual with attention deficit disorder, once distracted, may never return to the original topic, or if he does, it is too late. (2) The individual with attention deficit disorder may never get distracted in the first place. Using my example from above, with attention deficit disorder, (1) I might be diverted to the clock, get entranced by the flashing colon between the digits, and start humming a tune to the cadence of the flashing, forgetting what it was I was typing in the first place, or (2) I might get so engrossed in the typing that I'll fail to be distracted and leave my son stranded! We are all familiar with the child with attention deficit disorder who can sometimes play with Leggos for hours to the exclusion of everything else. Or the child who gets so intent on what he is playing during recess that he cannot hear the bell ring or the teacher calling. Or the child who is having a water-balloon fight with peers, and misses the subtle cues that the game is getting too rough and that it is time to
back off. He is the one who will get into trouble for doing what everyone else was doing just a moment before. I am hoping that some readers will find these observations regarding distractibility in attention deficit disorder useful. Michael A. Kalm, M.D. Salt Lake City, UT
Replyftom DSM-IV Work Group: In his letter Dr. Kalm draws attention to some of the interruptions that may occur during the course of attentive behavior. He argues that because responding briefly to distracting events is part of normally attentive behavior, criterion Al h of ADHD "is often easily distracted by extraneous stimuli" is inappropriate. We agree with Dr. Kalm's astute clinical observations. However, just because a behavior is normal does not mean that it cannot reach symptomatic levels. Indeed, exaggerations of normal behaviors, emotions, and cognitions are the rule in child psychopathology. Dr. Kalm describes the minutiae of behavior that would not normally be observed by a clinician or by the patient. DSM does not provide a framework for such detailed observations but rather documents the gross aberrations of behavior or feeling that emerge in the usual clinical context. David Shaffer, M.D. Ben Lahey, Ph.D. Rachel Klein, Ph.D.
CHILDREN TRAUMATIZED BY WAR
To the Editor: I recently returned from a trip to a war-ravaged area. There, I had the opportunity to work as a child psychiatrist. The clinic in which I worked was located in an extremely poverty-stricken area racked by violence from an ongoing war. Children and families were consistently confronted with the threat of physical harm either by gunshot or by physical assault. Gun-toting individuals ruled the streets and could appear without warning to shoot the most innocent
j. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:9, SEPTEMBER 1995
1119
LETTERS TO THE EDITOR
of victims anywhere at anytime. Threats of violence to both children and adults were ever-present from either family, friend, or foe. Attacks could either take place on the street or in the home by known or unknown persons. Even the family, usually considered a potential safe haven for victims in war-torn areas, was not safe. Parents were abandoning children for drug habits, often leaving them without food or shelter. By the grace of God, interested relatives or grandparents often took the responsibility to care for the young whose parents had since left or become incapacitated due to drugs. In other cases, children were subjected in their homes to rampant physical and sexual abuse repeatedly, even to the point of death. In other homes, rodents and roaches were so commonplace that children began to consider them family pets. Even before birth, children were being poisoned with hazardous substances such as lead, alcohol, and drugs. Many caring individuals attempted to assist those in this war-torn hell. There were different agencies, religious organizations, and volunteers who attempted to make a difference but were frustrated time and again by the overwhelming task of attending to the increasing numbers of those in need. Oftentimes, while providing service to this population, the staff had been threatened within the same community they were trying to help. What about the children and families in this area?Traumatized-yes. Fearful-yes. Angry and resentful-yes. Hopeless-yes. Surprisingly, though, many of the families I met persevered against all odds in an attempt to endure and survive in this situation. The resilience evident in the persona of these challenged individuals was inspiring. Often, I would think, "How many of us as seasoned professionals would survive if placed in an environment such as this?" Despite the frequent traumas to these families, in spite of the everpresent suicidal thoughts related to a communal hopelessness, the fighting and the victimization, there were glimmers of hope. At our clinic, a child would smile at a funny thought. Another would hug his or her parent after the parent made a loving comment about the child. Yet another would glow after having contributed something of value to a group of peers. Families would express gratitude to the clinic for helping them get through another day. These glimmers of hope provided inspiration and gave me strength to continue. Perhaps, I would think each day, we as clinicians are planting seeds that would one day cause our children and families to blossom. I will make another trip tomorrow morning to this wartorn area as I make my way to work-here in the United States of America. The name of the city is irrelevant, because many cities, if not all, have war-torn zones of their own. While I am in my car, I will turn on the national news and hear of war zones such as this one, only the areas that
1120
they will talk about will be far away. The newscaster will give the illusion that nothing like that exists in this great country of ours. I'll hear of troops being deployed from around the world to keep peace and to defend democracies I've never heard of; the government will enforce trade embargos against evil regimes and the President will lobby for federal budget extensions to fund programs supporting ailing governments. But what of our own war-torn zones? I'll hear of blame, finger-pointing, and corruption as the cause of these horrifying areas; I'll listen to solutions such as budget reform, more prisons, and cuts from this or that. All of these solutions will of course apply to some distant location, so that listeners will always have the implied option to move away if the situation begins to touch them personally. But how is it that the war-torn zones of this country are not considered a national emergency tantamount to a state of war that is threatening the lives of our very own citizens, many of them children and infants? What is to become of our fellow Americans' lives that are in a perpetual state of fear, unpredictability, and violence? How will our children grow up to be sensitive, reliable, and contributing members of society with the scars they will carry from an embattled existence? Tomorrow is here. I enter the clinic for my first morning appointment. Johnny, a child growing up in this battle zone, smiles. He is proud to tell of his accomplishment of behaving in accordance with his grandmother's rules. Grandmother, working step by step to set her grandchild's life in order after several years of abuse to him by his drugabusing mother, shares a technique that she has learned to help Johnny behave. Firmly, yet lovingly, she shares her expectations for her grandson. I watch as the two of them take pleasure in the successes that he is experiencing at school and on the newly joined sports team. I see before me what I think is a seed being planted on this battleground. The unsung heroes of this community, as evidenced by this grandmother, are sowing seeds while fighting the battle to reclaim their and their families' lives. They plant amidst a life-and-death struggle of trying to save their children from a life filled with violence, hatred, and hopelessness. Watching this seed being planted before me, I've once again received strength to return to this war-torn zone that my patients may never leave. The commitment shown by these unsung heroes in striving to make a better life amidst the struggle cannot help but inspire a renewed sense of commitment within me to be there to help in my role as a child psychiatrist. Stuart Varon, M.D.
Editors Note: The October issue of the Journal will feature several studies on the effects of urban violence on children and adolescents.
]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:9, SEPTEMBER 1995
TO
THE
EDITOR
DISTRACTIBILITY AS A SYMPTOM OF ADHD
To the Editor: From time to time, I find that I make the diagnosis of attention-deficit/hyperactivity disorder in a child or adolescent where a colleague has not seen it. In discussions with my colleagues, more often than not, the difference of opinion concerns the cardinal symptom of distractibility. Distractibility is referred to in DSM-IVas criterion Alh: "is often easily distracted by extraneous stimuli." In DSMIV's general description of attention deficit disorder, we find the sentence, "Individuals with this disorder are easily distracted by irrelevant stimuli and frequently interrupt ongoing tasks to attend to trivial noises or events that are usually and easily ignored by others." I do not believe that DSM-IV's description of the distractibility of attention deficit disorder is accurate. Distractibility, often defined as the diverting of attention rapidly from one topic to another, is actually a normal phenomenon that is not only common, but necessary in healthy functioning. For example, while I am typing this sentence, I can momentarily glance at my clock, noting how much time I have left before I have to leave to pick up my son at school, and return to the typing of this sentence, hardly skipping a beat. Distractibility in attention deficit disorder differs from the normal in either of two ways: (1) The individual with attention deficit disorder, once distracted, may never return to the original topic, or if he does, it is too late. (2) The individual with attention deficit disorder may never get distracted in the first place. Using my example from above, with attention deficit disorder, (1) I might be diverted to the clock, get entranced by the flashing colon between the digits, and start humming a tune to the cadence of the flashing, forgetting what it was I was typing in the first place, or (2) I might get so engrossed in the typing that I'll fail to be distracted and leave my son stranded! We are all familiar with the child with attention deficit disorder who can sometimes play with Leggos for hours to the exclusion of everything else. Or the child who gets so intent on what he is playing during recess that he cannot hear the bell ring or the teacher calling. Or the child who is having a water-balloon fight with peers, and misses the subtle cues that the game is getting too rough and that it is time to
back off. He is the one who will get into trouble for doing what everyone else was doing just a moment before. I am hoping that some readers will find these observations regarding distractibility in attention deficit disorder useful. Michael A. Kalm, M.D. Salt Lake City, UT
Replyftom DSM-IV Work Group: In his letter Dr. Kalm draws attention to some of the interruptions that may occur during the course of attentive behavior. He argues that because responding briefly to distracting events is part of normally attentive behavior, criterion Al h of ADHD "is often easily distracted by extraneous stimuli" is inappropriate. We agree with Dr. Kalm's astute clinical observations. However, just because a behavior is normal does not mean that it cannot reach symptomatic levels. Indeed, exaggerations of normal behaviors, emotions, and cognitions are the rule in child psychopathology. Dr. Kalm describes the minutiae of behavior that would not normally be observed by a clinician or by the patient. DSM does not provide a framework for such detailed observations but rather documents the gross aberrations of behavior or feeling that emerge in the usual clinical context. David Shaffer, M.D. Ben Lahey, Ph.D. Rachel Klein, Ph.D.
CHILDREN TRAUMATIZED BY WAR
To the Editor: I recently returned from a trip to a war-ravaged area. There, I had the opportunity to work as a child psychiatrist. The clinic in which I worked was located in an extremely poverty-stricken area racked by violence from an ongoing war. Children and families were consistently confronted with the threat of physical harm either by gunshot or by physical assault. Gun-toting individuals ruled the streets and could appear without warning to shoot the most innocent
j. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:9, SEPTEMBER 1995
1119
LETTERS TO THE EDITOR
of victims anywhere at anytime. Threats of violence to both children and adults were ever-present from either family, friend, or foe. Attacks could either take place on the street or in the home by known or unknown persons. Even the family, usually considered a potential safe haven for victims in war-torn areas, was not safe. Parents were abandoning children for drug habits, often leaving them without food or shelter. By the grace of God, interested relatives or grandparents often took the responsibility to care for the young whose parents had since left or become incapacitated due to drugs. In other cases, children were subjected in their homes to rampant physical and sexual abuse repeatedly, even to the point of death. In other homes, rodents and roaches were so commonplace that children began to consider them family pets. Even before birth, children were being poisoned with hazardous substances such as lead, alcohol, and drugs. Many caring individuals attempted to assist those in this war-torn hell. There were different agencies, religious organizations, and volunteers who attempted to make a difference but were frustrated time and again by the overwhelming task of attending to the increasing numbers of those in need. Oftentimes, while providing service to this population, the staff had been threatened within the same community they were trying to help. What about the children and families in this area?Traumatized-yes. Fearful-yes. Angry and resentful-yes. Hopeless-yes. Surprisingly, though, many of the families I met persevered against all odds in an attempt to endure and survive in this situation. The resilience evident in the persona of these challenged individuals was inspiring. Often, I would think, "How many of us as seasoned professionals would survive if placed in an environment such as this?" Despite the frequent traumas to these families, in spite of the everpresent suicidal thoughts related to a communal hopelessness, the fighting and the victimization, there were glimmers of hope. At our clinic, a child would smile at a funny thought. Another would hug his or her parent after the parent made a loving comment about the child. Yet another would glow after having contributed something of value to a group of peers. Families would express gratitude to the clinic for helping them get through another day. These glimmers of hope provided inspiration and gave me strength to continue. Perhaps, I would think each day, we as clinicians are planting seeds that would one day cause our children and families to blossom. I will make another trip tomorrow morning to this wartorn area as I make my way to work-here in the United States of America. The name of the city is irrelevant, because many cities, if not all, have war-torn zones of their own. While I am in my car, I will turn on the national news and hear of war zones such as this one, only the areas that
1120
they will talk about will be far away. The newscaster will give the illusion that nothing like that exists in this great country of ours. I'll hear of troops being deployed from around the world to keep peace and to defend democracies I've never heard of; the government will enforce trade embargos against evil regimes and the President will lobby for federal budget extensions to fund programs supporting ailing governments. But what of our own war-torn zones? I'll hear of blame, finger-pointing, and corruption as the cause of these horrifying areas; I'll listen to solutions such as budget reform, more prisons, and cuts from this or that. All of these solutions will of course apply to some distant location, so that listeners will always have the implied option to move away if the situation begins to touch them personally. But how is it that the war-torn zones of this country are not considered a national emergency tantamount to a state of war that is threatening the lives of our very own citizens, many of them children and infants? What is to become of our fellow Americans' lives that are in a perpetual state of fear, unpredictability, and violence? How will our children grow up to be sensitive, reliable, and contributing members of society with the scars they will carry from an embattled existence? Tomorrow is here. I enter the clinic for my first morning appointment. Johnny, a child growing up in this battle zone, smiles. He is proud to tell of his accomplishment of behaving in accordance with his grandmother's rules. Grandmother, working step by step to set her grandchild's life in order after several years of abuse to him by his drugabusing mother, shares a technique that she has learned to help Johnny behave. Firmly, yet lovingly, she shares her expectations for her grandson. I watch as the two of them take pleasure in the successes that he is experiencing at school and on the newly joined sports team. I see before me what I think is a seed being planted on this battleground. The unsung heroes of this community, as evidenced by this grandmother, are sowing seeds while fighting the battle to reclaim their and their families' lives. They plant amidst a life-and-death struggle of trying to save their children from a life filled with violence, hatred, and hopelessness. Watching this seed being planted before me, I've once again received strength to return to this war-torn zone that my patients may never leave. The commitment shown by these unsung heroes in striving to make a better life amidst the struggle cannot help but inspire a renewed sense of commitment within me to be there to help in my role as a child psychiatrist. Stuart Varon, M.D.
Editors Note: The October issue of the Journal will feature several studies on the effects of urban violence on children and adolescents.
]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:9, SEPTEMBER 1995