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"The Family and the Integration of the
Handicapped Person in Childhood and Adolescence"
During recent years, the world’s attention has focused with increasing frequency on the frightening drama of child on child violence in North American schools. Just over a year ago, in my home state of Oregon, a 15 year old boy murdered his mother and father and then calmly went to school and proceeded to shoot down his classmates. It is a problem that is unique to the United States and for which everybody seems to have their favorite theory. Whatever the reason behind this epidemic of violence, one thing is very clear. We are failing many of our children and we and they are paying a terrible price for our failure.
I will address my comments today to one of the more curious problems that afflicts children in the United States, the behavioral syndrome known as Attention Deficit Disorder or ADD, and its more annoying sibling Attention Deficit Hyperactivity Disorder or ADHD. Let me issue a disclaimer right from the start and tell you that I am not an expert of ADD/ADHD and I make no claim to an authoritative voice on the subject. It is a highly controversial topic with very intelligent people staking out positions that are diametrically opposed and with millions of children caught in the middle. My purpose is to serve as a voice of concern, to issue a plea for caution. For my fellow North Americans, I suspect that my presentation will come as no surprise. Only by living in a cave during the past decade could you not be aware of the ADD problem in the United States. But for those of you from other parts of the world what I am going to present to you will, no doubt, be both troubling and frightening because, like school violence, ADD and ADHD are virtually unknown outside of the United States. I propose to you that there is a rather unnerving relationship between these attention disorders and the previously mentioned problem of school violence. Let my words be a warning to you.
In the United States, the labeling of children with the medical diagnosis Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder, and the use of medication to manage behavior has become something of a growth industry. Between 1990 and 1995 there was a fourfold increase in the number of children in the United States diagnosed with these conditions. During the same period, according to the US Drug Enforcement Administration there was a six-fold increase in the production of Ritalin, the stimulant drug of choice in the treatment of ADD and ADHD. In 1995 the International Narcotics Control Board reported that “10 to 12 per cent of all boys between the ages of 6 and 14 in the United States have been diagnosed as having ADD and are being treated with methylphenidate [Ritalin].” It is estimated that today there are more than 6 million children in the United States taking Ritalin with the number
predicted to surpass 8 million by next year. What is curious about all of this is that ADD, ADHD, and the use of Ritalin are practically unknown outside of the United States - at least for the moment. Indeed, the United States uses 90% of the world’s Ritalin supply - more than five times the rest of the world combined. Add to this the many children treated with other stimulant medications like Desoxyn, Dexedrine, and Adderal; with antidepressant medications like Prozac, Zoloft, Luvox and Paxil; with antipsychotic medications like Haldol and Thorazine; with tranquilizers and sedatives like Halcion, Valium, and Klonopin. The list goes on and on. According to psychiatrist Peter Breggin, one of the world’s leading authorities on ADD, “Children in the United States are being subjected to a massive experiment in pharmacological engineering the likes of which no society or nation has ever seen before.”
So what is ADD and why do so many North American children seem to have it? According to the modern psychiatric establishment, Attention Deficit Disorder is a genetically inherited neuro-biological disorder resulting in varying degrees of difficulty for the affected child to focus attention and control his or her level of activity which obviously has negative consequences for success in school and society. Attention Deficit Disorder first made its official appearance as a medical diagnosis in 1980 in the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
Despite the claim of ADD advocates that the disorder is genetic and biological, medical science has yet to find any definitive physical markers for the diagnosis of the condition. Blood tests, urine tests, EEG’s, brain scans - none of these things can tell a physician if a child has ADD. Perhaps one day there will be a test that can accurately determine if a child has this condition but for now diagnosis must be made on the basis of behavioral characteristics.
It is instructive to look at the diagnostic criteria that psychiatrists use. According to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, a child is diagnosed with ADD or ADHD if he has 6 out of 9 symptoms in either of 2 categories - Inattention or Hyperactivity/Impulsivity. The listed behaviors are ranked in descending order of importance. Here are just the first three of each category:
Inattention(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
(b) often has difficulty sustaining attention in tasks or play activities.
(c) often does not seem to listen when spoken to directly.
Hyperactivity(a) often fidgets with hands or feet or squirms in seat.
(b) often leaves seat in classroom or in other situations in which remaining seated is expected.
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).
Impulsivity(g) often blurts out answers before questions have been completed(h) often has difficulty awaiting turn(i) often interrupts or intrudes on others (e.g., butts into conversations or games)
So, based on observation of a child’s behavioral symptoms, a diagnosis of ADD or ADHD is made and the child is then placed on medication. It is important to point out that this observation is often made not by the psychiatrist but by teachers, school psychologists, school nurses, pediatricians, and occasionally by parents. Many prescriptions for Ritalin are written by family doctors that have no training whatsoever in psychology or psychiatry! But the point is that if a child’s behavior fits the mold, it is deemed sufficient justification for him, or her to be placed on medication, most typically Ritalin.
Ritalin has in fact been around a long time. It was first synthesized in the mid-1940’s and received approval by the US Food and Drug Administration in December 1955. During the 1960’s it began to be used rather widely for the treatment of behavioral conditions in children. During the 1990’s its use has exploded. So what is the problem? With so many children taking Ritalin, with so many doctors prescribing it, with so many years of experience, surely it must be safe and effective. Well, not exactly. There are in fact many reasons for concern and caution.
One of the facts about Ritalin that virtually never receives publicity is that throughout its 40-year history it has always been recognized as addictive and subject to a high rate of abuse. The reason for this is quite simple. Ritalin is a psychostimulant amphetamine-like drug. In 1971 it was classified as a Schedule II drug by the World Health Organization, along with such other drugs as amphetamine, methamphetamine, cocaine, opium, morphine and the barbiturates. Ritalin was one of the first drugs to be placed under such international control. Later that same year it was classified as a Schedule II drug by the US Department of Justice. Schedule II is a classification reserved for those drugs that are considered the most addictive in medical use. As with all drugs, Ritalin comes with an official warning label regarding its use. The warnings deal with such things as use of the drug with young children, use for long periods of time, etc. Routinely physicians are ignoring these warnings. One warning that is particularly relevant is that “Stimulants are not intended for use in the child who exhibits symptoms secondary to environmental factors.” This means those factors like life at home, the school situation, diet, and so on are considered to be of great importance. And it says that if these factors play a primary role in the child’s symptoms then that use of Ritalin is inappropriate. These environmental considerations are rarely taken into account. Why? Because the underlying assumption in ADD/ADHD is that the problem lies within the wiring of the child’s brain and not in the environment so nobody ever looks there.
Another highly questionable aspect of this is the way in which Ritalin works. And lest there be any doubt let me make it clear that there are times when its action seems almost miraculous. Wild children can become tame and manageable. But how, and at what price?
One of the effects observed with some frequency is what is termed the “zombie effect”. Peter Jenson, of the National Institutes for Mental Health, makes the following amazing statement in his chapter on ADD in the Comprehensive Textbook of
Psychiatry, published in 1995. He says, “The amphetamine look, a pinched, somber expression, is harmless in itself but worrisome to parents, who can be assured.” He goes on, “The behavioral equivalent, the “zombie” constriction of affect and spontaneity, may respond to a reduction of dosage, but sometimes necessitates a change of drug.” He mentions this effect three times within this one chapter. I suggest to you that this is pretty serious stuff. Here is one of the leading proponents of ADD and the use of Ritalin in its treatment admitting in a textbook on psychiatry that this drug can turn children into docile robots but that this is no big cause for concern. I am reminded of the film from the 1960’s, “One Flew Over the Cuckoo’s Nest.”
In 1995 the United States Drug Enforcement Agency published a table of Ritalin’s adverse effects. Here are a few - heart palpitations, tachycardia, increased blood pressure, excessive CNS stimulation, psychosis, insomnia, irritability, sadness, attacks of Tourette’s or other tic syndromes, anorexia weight loss, growth suppression. Remarkably, the DEA notes that irritability and sadness have been reported in up to 22% of children receiving stimulants. So it is important to recognize that Ritalin is not candy. Not used correctly, it is potentially a very dangerous drug.
So what is going on here? Why are we seeing so many children with behavioral problems? And what can we do to help our children besides medicate them?
In the first place, I think that it is important for us to recognize the profound changes that have taken place in American society during the past fifty years. When I was a child the person who spent the most time with a newborn infant and who stimulated and nourished that child was almost always mother. Dr. Dan Siegal has spoken eloquently to this conference about the critical importance of the “mutual gaze” between the primary caregiver and the infant for the child's future development. Mother and child almost always shared that gaze. Although there were women who worked outside the home, they were the exception. Motherhood was considered a noble pursuit. Without the benefit of advanced degrees in education and child development, relying strictly on their instincts and on the wisdom passed down through the generations, mothers raised their babies as they have done for millions of years. And by and large they did a pretty decent job of it! When I was a child, families were essentially intact and fathers were responsible. I returned home last week to celebrate Thanksgiving with my family and on the street where I grew up and learned about the world and my place in it there is not one family where the marriage ended in divorce. Not one of my childhood friends had to endure the trauma of the destruction of the family. When I was a child the world of children was a place of innocence and safety and play. I can not remember a moment of stress in my childhood until the day in the third grade when I had to bring home a bad report card from school. I was eight years old. When I was a child, parents recognized that part of their duty, although sometimes unpleasant, was to establish firm limits of behavior and to enforce them. Discipline was not a dirty word. Of course parents were not always perfect - lets face it we are all making it up as we go along, we make mistakes. My father was a strict disciplinarian but his firm hand was always delivered from a place of love and devotion. And while at the time I did not always appreciate his methods I knew with absolute certainty that I was loved. Now as a parent myself, while I may differ considerably in my approach to discipline, I have come to regard his efforts with a deep and abiding respect. When I was a child, the family sat down every day for a meal together. Real food, lovingly prepared, and shared together over conversation, laughter, and occasionally tears when one of the children refused to eat his spinach. When I was a child television was a curiosity. We did indeed have a television but it played no role in
my early childhood and was controlled as I grew up and television programming expanded to encompass more hours of the day.
Contrast that childhood with the childhood that an average American infant will experience today. To begin with the American family has self-destructed. Fifty percent of all marriages end in divorce and there is a shocking percentage of children who are born to unwed, single mothers. Motherhood, as a respectable thing for a woman to do with her life, is devalued and dismissed as old fashioned, a way for men to keep women subservient. Women are much more likely to be out in the workforce with full time jobs, than to be home with their children. Children are placed in childcare, often at 3 months of age, and that mutual gaze, which we now know is so critical, is shared mostly by strangers instead of by mother. Sixteen years ago, for about 6 months, I ran a day care program in an excellent Montessori school in one of the wealthiest counties in the United States. These were children of privilege. They had every material good imaginable yet many of them were desperately unhappy. These were toddlers and young children with big problems - problems that had their roots in disturbed families and a desperate need for parental attention, a need that could not be met because mother and dad were too busy making money and “self-actualizing”. Their favorite justification was that the important thing with children is the quality of time, not the quantity of time. This is pure and unadulterated psychobabble. It is nonsense. It is true that the quality of a child’s experience is important. But more than anything else what children want to know is that they are important and worthy of attention. A child will be just as happy sitting at home with mom contemplating each other's navels, as he will be visiting the local art museum. It demonstrates that mom cares! I can tell you that the experience ranks as one of the most distressing and disturbing of my life.
Today one of the principal educators of children is the television. TV programmers have even created programs aimed at newborn babies and infants. The tube has become teacher, mother, and baby-sitter all rolled into one. Television is so ubiquitous in our culture that we tend to just take it as a given without even thinking about it. But I promise you it is a very serious thing. In 1977 advertising expert Jerry Mander wrote a book, “Four Arguments for the Elimination of Television.” It is a book that will change forever the way you think about television. One thing that we know with certainty is that TV has undeniable effects on the function of the brain. TV is hypnotic - it induces alpha brain rhythms in the brain and puts the watcher into a trance. The light transmitted by the TV is not natural light. We now know that the brain is programmed to respond to natural sunlight and that its function can be greatly altered by overexposure to artificial light and underexposure to natural light. Additionally, the experience of watching TV is what Mander calls a “mediated” experience and it is no substitute for real experience. Seeing a program about the Amazon River may be quite interesting but it is not the same thing as actually visiting the Amazon River. You can’t smell the smells, feel the heat and humidity, breathe the air, see the vibrant shades of green, hear the cracking of twigs underfoot and the screeching of monkeys overhead. TV, in effect, detaches the viewer from real sensory experience. When children sit in front of the television for hours on end their brains are certainly being wired but not in any way that is conducive to good development and function.
Discipline today is an outmoded concept. Parents will do anything to avoid being labeled strict. Parents want to be their child’s friend. They want their children to like them. They fear what effect they might have on their child’s self esteem if they set limits.
And finally, today our children live in a toxic world. The food they eat, the water they
drink, the air they breathe, all of these things has a potential effect on the function of the brain. American children eat a notoriously poor diet filled with sugar and artificial chemicals. Dr. Kenneth Krischer, noted specialist in environmental medicine, touched on this subject yesterday. His work with children who have neurological problems, in particular children diagnosed with autism and ADHD, is producing extraordinary results. I can tell you from our experiences that many of the kids we work with have problems of attention and behavior that are rooted in sensitivities to elements in the physiological environment.
Our children pay a big price for these failures and we as a society as well. Just recently a few articles on this subject attracted my attention. On November 26, 1999 an article was published in the Philadelphia Inquirer entitled “Military see a revolving door of enlistees with psychiatric ills.” The article describes the alarming percentage of young recruits who are discharged because of psychiatric histories for problems ranging from depression to ADD. Any young person who has ever been under psychiatric care, including ADD, or treated with medication like Ritalin is automatically ineligible for military service.
Also, recently a web site newspaper published for college students ran a frightening story on the widespread use and abuse of Ritalin on college campuses in the United States. It is widely available and cheap. What is alarming is that students are using it for the stimulant effect as they used to use coffee but without the recognition of all of the potential adverse effects that I mentioned previously.
So what can be done? Let me summarize my thoughts on this. The simple truth is that optimum brain function is a prerequisite to successful function in life and therefore necessary for the achievement of one's potential. All human abilities result from the development and organization of the human brain. This includes the ability to focus attention on the task at hand. A person will reach a level of intellectual, physical, and social development to the exact extent to which the brain is developed and organized. Brain development and organization is a dynamic process that starts shortly after conception and continues throughout childhood, adolescence, and adulthood. None of us is functioning at full capacity. Not one of us has reached our full potential. Each one of us can learn more and function better. We should always be aspiring to the achievement of higher levels of ability because that is our gift. The extraordinary human brain makes that possible.
We must recognize that all children are somewhere on what I call a "continuum of human development". You and I are on that continuum as well. The continuum ranges from no organization at one end, resulting in virtually no function (as in a person in a coma), to complete organization at the other end resulting in an ideal level of physical, intellectual, and social ability. Each one of us in this room lies somewhere between those two extremes. So, what I am saying is that the child who has ADD actually has much in common with me. He has a level of ability commensurate with his degree of neurological organization. As do I. Several things determine neurological organization in a child: genetic makeup, the quality of the neurological environment, the developmental opportunities, the physiological environment, and whether or not the brain is compromised by brain injury. We must remember that everything in the environment and every developmental opportunity has a direct effect on the development and organization of the brain. The child’s brain does not judge whether a stimulus or opportunity is good or bad. It simply takes it in and is molded by the experience. But the human brain follows the laws of nature and one of nature’s
immutable laws is that you reap what you sow. Whether one believes in the diagnosis of ADD or not, there can be no denying the fact that more and more children are coming into school with more and more difficulties. There simply is no question but that many in today's generation of children are functionally different from that of forty years ago. And if you look at the differences in the way children are raised I think it is easy to see why. Confinement in a playpen or walker is not the same as the freedom of crawling or creeping on the floor. Spending the day at the local day-care facility is not the same as spending the day at home with mom. Sitting in front of the television for hours on end watching children play on Barney or Sesame Street is not the same as actually playing. I know that people will say that times have changed, that now mothers have to work etc., etc. but we are fools if we think that we can change the nature of the child’s upbringing and still end up with the same child. Each of these situations has a neurological effect. They are the experiences that literally wire the brain. We must wake up to the fact that the child's place on the continuum of human development is largely in our hands. For many of the children diagnosed with attention problems the answers are staring us right in the face if we only have eyes to see them. And even if it is found that some children have a genetic predisposition to attention problems we must be very careful to remember that biology is not destiny.
I believe that many of the problems surrounding the ADD controversy stem from the fact that for so long psychiatry has been divided into two armed camps, the geneticists and the environmentalists, with the geneticists firmly in charge at the moment. But as Dr. Siegel so correctly pointed out to us the other day, genetics is a starting point, it is a springboard not a prison cell. Genetics must interact with environment and therein lies the possibility for a more compassionate response to the pain that some of our children experience. There is no need to look for a magic bullet to cure ADD. The magic is already in the brain of every child and in the loving bond that exists between all responsible, devoted and loving parents and their children - what I like to call the anthropological reality of the family bond. Parents must reclaim their rightful responsibility to parent and we professionals must help them to do that. Parenthood must be recognized and respected for the glorious gift, responsibility, and sacred trust that it is.
Finally I would like to conclude by quoting an editorial published in the San Francisco Chronicle last year by a medical doctor named Lawrence Diller who himself has frequently prescribed Ritalin in his practice. In the title of the editorial he asks “Would Tom Sawyer Have Been Prescribed Ritalin?” He goes on to explain his experience with the diagnosis ADD and the drug Ritalin and expresses concern about what he sees as an alarming trend to label any deviance from an arbitrary standard of behavior as an illness. And he points out that many of our most famous thinkers and leaders - people like Benjamin Franklin, Thomas Edison, Albert Einstein, Winston Churchill - would today be labeled ADD and would probably be treated with Ritalin. He finishes with the following lament - “there is an intolerance of temperamental diversity in our country that views modern-day Tom Sawyers as nothing but genetic detritus. Human diversity in the past has contributed to the richness of our culture and civilization. I worry about a society where there’s no place for an unmedicated Tom. He is so many of our sons and daughters.” I share Dr. Diller’s concern and urge all who are charged with responsibility for the development of children, parents and professionals, to recognize that children are a gift that must be treated with reverence. Our future depends on it.
CURRICULUM VITAE NUNO MARIA REIS DE MATOS SILVA Setembro de 2002 Pessoais 2 Habilitações Académicas Actividade Profissional em Arquitectura Por conta de outros. 3.1.1 No atelier do Arq. Michel Nazarenko. Em Limoges, França. 3.1.2 No atelier dos Arq. os João de Almeida e Pedro Ferreira Pinto. 3.1.3 Com o Arq. Manuel Vicente. 1974/1982 3.1.4 Com o A
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