THURSDAY, February 2, 2006

Session 4: Fundamental Needs of Children

Brock Eide, M.D., M.A. and Fernette Eide, M.D., Eide Neurolearning, Edmonds, Washington

Stanley Greenspan, M.D., Clinical Professor of Psychiatry, Behavioral Sciences and Pediatrics, George Washington University Medical School, Washington, D.C.

CHAIRMAN PELLEGRINO:  Thank you very much.  Thank you very much for coming back so promptly.  I know we have deprived you of your afternoon sustenance, and I hope your blood sugar isn't so low that your cortical cells aren't working.  They do take a lot of energy, don't they?  So I've been told. Our next speaker is Dr. Stanley Greenspan.  And I've informed him that we have not been reading curricula vitae in any detail.  So he will begin launching into the subject himself.

He is clinical professor of psychiatry and behavioral science and pediatrics at George Washington, right here in town.  And he is going to address us on some of the issues that we have been talking about.

Dr. Greenspan?

DR. GREENSPAN:  Yes.  It is a real pleasure and an honor to be able to be here with you today and part of this wonderful deliberation and thoughtful exploration.  I'm particularly pleased that children and mental health of children are on your agenda.

Just as a way of introducing my comments — then I have a brief video illustration to show you of a few of the points that we'll be making in the second part — I think many of the ethical issues need to be framed within a larger psychosocial or bio-psychosocial context.  And when we don't do that, we tend to get our backs up against the wall.

I think it's the same thing we're learning in terms of international relations. Unless we see the big picture, unless we see all the dynamic relationships between all of the factors, we sometimes embark on a policy initiative that needs to be revised in midstream.  And the same thing comes I think with ethical issues as well.  One concrete example, an issue that gets many headlines, is a medication for very young children, three and four-year-olds being put on Depakote or Risperdal or Ritalin or some of the SSRIs, like Prozac or Celexa.

Often the situation in context for something like that is a child who seems to be out of control and a parent who presents to the emergency room or to the physician with a desperate situation.  And obviously there is a need to deal with the crisis at the moment.

What used to happen, way back in the 1970s, is there would be a broader approach, then.  Even though you might deal with the crisis of the moment, you would have a broader approach to find out what is going on in the family, what is going on in that child's life to precipitate this sort of a crisis.

Now that is not happening as much.  And so the crisis becomes a perpetual crisis.  Often one medication doesn't work.  A second one gets added.  And then we have three and four-year-olds on polypharmacy.  And then it comes to the attention of the media and the press and the public and then becomes of concern to the President's Council, as it should, on Bioethics.

Then the solution gets focused on, well, should we use adult medications on very young children, rather than what is the broader psychosocial or bio-psychosocial dynamic framework that we need to be looking at, what has been eroded in our society in terms of the way in which families are taking responsibility for and we collectively as a society are giving support to families so that they can handle the vicissitudes of both healthy development and challenging development.  What sort of services do we have available that focuses on this broader bio-psychosocial context?

And when we look at that, we begin seeing a worrisome picture.  We see a picture of a service system where it's fragmented, where we're not providing that broad — we use the term "bio-psychosocial," but we don't practice bio-psychosocial.  And we have families that are being encouraged towards more narrow and simplistic ways of thinking about their kids' quick fixes.  And then we look for quick fix policy solutions, you know, rather than long-term solutions that will produce an adolescent and a young adult who will be a contributing member to society.

This is not just simply happening in poor populations or socially at-risk populations.  It is happening in the well-to-do.  Also, I can tell you as a child psychiatrist who in my research and in my practice, I see every socioeconomic group.  It's happening across the board.

I see as many what I call multi-problem, multi-risk families from the very wealthy and among the very powerful in Washington as I do among the very poor.  And, unfortunately, it's the same qualities in the families, even though some families have the means to do much better.  So that's the broader point I would like to emphasize for our discussion.

Within that context, you know, I just want to focus in on a few things that reflect some of our current knowledge that can be put to very good use.  And, again, I'm not sure if this is completely the purview of this Council, but I think it should be.  So if it's not, I'm hoping it can be embraced because as many voices that I think converge on these themes, the better.

Some of the issues, again, that grab the headlines, are we labeling children with mental health disorders, such as ADHD, which I know you were talking about just a few minutes ago, when they are simply showing normal variations?

Are we helping or hurting when young and younger children are put on psychiatric medications, the issue you just addressed, depression, anxiety, bad behavior?  You know, we're doing it for many things now.

Is increasing testing of school children encouraging rote memory skills, teaching to the test, and decreasing critical thinking skills or fueling better education? Big issue.  I think it's ethical as well as educational.  Is full-time day care for infants and toddlers and preschools helpful or harmful? Very big issue.

Back in the 1970s, only a small percentage of children were in out-of-home care.  Now, over half the nation's children are being reared in the first four years of life out of the home, very important issue because it's no longer just an option.  It's now in many circles a favored and recommended alternative to family environments.

In what way can early identification, intervention in mental health and developmental problems be harmful?  Again, these questions grab the headlines, but the answers identify the components of a children's mental health and education policy.

A children's mental health and education policy must begin with a definition of what we think of as healthy development.  It has to be a positive framework, promoting healthy development, and then seeing problems off of that.

Again, here we have become too symptom-based when we think about children.  So we identify the signs of autism or the signs of learning disabilities or the signs of ADHD, but we don't identify the context of a framework to adapt to a healthy development.  And we often miss the boat.  And that's where we make misdiagnoses and we have failed policies or failed interventions.

Recently we have formulated a road map for children's emotional and intellectual growth that can enable parents, educators, and policy-makers to create proper goals.

The elements of the road map are neither elusive nor complex and, in fact, are familiar to most parents.  And here, this is a road map that I have personally been involved with the research on, starting back in my days at running a center at the National Institutes of Mental Health and continuing to the present day.  And it's a road map that we have a lot of data and evidence for.

We recently tested it on 1,500 families... down to a simple questionnaire that can ask parents questions about this road map.  And it distinguished normal from problematic children.  It distinguished different groups of disorders and also validated the foundations for healthy development.

So this is now a well-validated road map.  And the interesting thing about it is the same milestones that predict social and emotional competency predict intellectual competency.

So we don't have to be thinking about what is going to make a child smart and what is going to make a child mentally healthy.  It's the same processes and the same early milestones.  So we can have a quick look and give parents information and give our pediatricians and give our day care workers information that will promote healthy intellectual and emotional growth.  And briefly they are the first capacity is helping a baby be calm and regulated and attentive to sights and sounds and smells, the sensations around them.  This starts in the first months of life.

Number two, forming that first relationship and then continuing to deepen it with great intimacy, early relationships and the ability to form that relationship is critical for all later skills.  And the babies who don't have it or children who don't develop it later because of access to a nurturing parent have lifelong difficulties, often winding up in delinquency and antisocial behavior if they're fortunate.  If they're less fortunate, they have mental retardation and possibly delinquency.

Third is the ability, still in the first year of life, simply for a baby to form purposeful two-way communication to interact with gestures, to point, to reach, to smile, to vocalize in a responsive way to the parent and the parent to be responsive back, to get what we call circles of communication back and forth, back and forth, signaling, very easy to observe, very easy to ask parents if the baby is doing it with them.  And that's the basis for learning to be logical, learning to be causal, learning to read emotional signals, learning to be a social creature, learning to adjust to rules eventually.  It's again a foundation for everything else.

The fourth we call shared social problem-solving, where toddlers are already becoming scientists.  They're taking mommy by the hand, walking her to the toy area, pointing to the toy they want, and then motioning "Pick me up."

Well, this is the beginning of pattern recognition.  This is the beginning of scientific thinking.  This is the beginning of figuring out "I've got to do step A, B, and C to get to step D."

Now, again, parents that facilitate this kind of problem-solving produce kids who are already problem-solvers before they talk.  And when they use words, they know what the words mean because they were already experienced in the world and they can already organize it in terms of patterns.  So when they label something, they know what it means.

Children who don't experience this, either because of environmental deprivation or biological challenges or combinations of both, again don't have that foundation for healthy educational growth or healthy emotional and social growth because this is necessary for reading someone's emotional signals as well as for learning to read and learning to do math and learning to write an essay.

The fifth milestone is the ability to use ideas, which includes language, obviously, meaningfully and creatively, not just rote.  You all see kids being shown off by their parents, labeling cars or chairs or using flash cards to learn to even spell as they are learning to talk.  And that kind of rote learning is the ticket to poor intellectual, emotional, and social growth.

On the other hand, meaningful use of ideas and creative use of ideas, as you see in imaginative play, you see when a child says, "Mommy, I want my juice now" and she says, "Why?" "Because I am hungry," that child is learning to use ideas meaningfully and functionally.  That's a person who will be able to be a problem-solver, not just repeat facts in a mindless way.

And the sixth milestone is the ability to connect ideas together logically and meaningfully, answer that why question, "Why do you want to go outside?" "Because I want to play."  "Well, why are you so mad today?" "Because Johnny stole my toy or took my toy."

That's a child who can connect ideas together, figure things out, doesn't have to act out, doesn't have to behave impulsively, doesn't have great mood swings.  They can figure out their internal or their feelings, but, more importantly or equally importantly, they can also problem-solve in school, figure out why two plus two is four, figure out why the story has a meaning and what the author's intent was.

And then we have, which I won't go into in any detail, three levels of higher skills having to do with what we call multi-causal thinking, gray area, incomparative thinking, where you can see the subtleties and nuances between things, and then what we call reflective thinking, where the person can evaluate.  This doesn't come in until 9 to 12.

The person can evaluate their own behavior, their own thoughts, and their own products so they can evaluate their own essay and say, "This was a good essay.  I made my point," "This wasn't so good.  I didn't prove my point.  I wasn't happy with my performance." They can learn from mistakes.

And this is what you need to be a self-learner.  You need that ninth level, that reflective thinking, to really be a contributing member to society because without that, you don't have a real sense of what justice is, you don't have a real sense of abstract concepts of what freedom truly means.  And when we bring democracy not just at home when we want further democracy, when we further it in other countries, we have to promote these same milestones.

Unless we get growing children to this ninth level, they can't really embrace what Jefferson had in mind when he said the consent of the governed because that means investing in abstract institutions and abstract concepts, which requires mastery of all of these milestones.

Right now in the United States, I worry that less and less of the population is mastering all of these critical milestones.  And at a certain point, you do reach a tipping point, where there are not sufficient numbers to embrace what democracy really means and what freedom really means and what equal opportunity really means in the complex world.

On the other hand, if X percent have these capacities, then equal opportunity, freedom, justice, and all the things we stand for really have meaning.  So this does come back to the cornerstone of our world.

Now, as I mentioned, we have evidence.  And we have a simple questionnaire that takes parents about 15 minutes to fill out that can give the parents a quick picture of where their child is on these milestones.  It's now we just did the research with Psych Corp., our hard-core assessment, because they had the resources to test it out on 1,500 families and produce it as an instrument that's available to the general public.  It is just fresh.  Literally within the last few months did it come out.  That gives us tools to work with.

We also use these same questions in a survey with the National Center for Health Statistics of the Department of Health and Human Services on 15,000 families.  And it identified 30 percent of children who otherwise wouldn't have been identified on the traditional health survey.

The traditional health survey asked, "Does your child have a problem?  Does your child have a developmental disorder, emotional problem," et cetera?  The answer was no.

Then they were asked specific questions from the these questionnaires, like "Does your child relate warmly to you?  Does he respond to gestures with gestures back?"  And that picked up 30 percent additional children who required services, who weren't getting the services.  And a lot of these were obviously from underprivileged or poor households.   But it showed that we can do better in terms of early identification and preventive intervention.

Now, when we use a road map of healthy development, it provides the tools for us to do a few other things.  We can give parents this information and knowledge.  And I recommend a major initiative where we provide this good information to parents because we formulated an initiative called the Family First Initiative, where families are empowered with knowledge to be the first ones on the line.

When we talk about education, we have to realize that education begins in those first three to four years of life, when their brain is growing to two-thirds, three-quarters of its adult size.  And the parents are usually the key people educating children.

Again, the emotional and social growth and intellectual growth are one and the same at that early age, when the brain is growing so rapidly.  Now we have overwhelming evidence that the actual laying down of pathways in the brain, the structure of the brain is influenced by the environment.

It's not that the genes determine the writing of the brain and the environment provides slight modification.  Our genetic makeup provides us with a very fundamental only beginning blueprint.  And then Mother Nature was very wise in allowing the brain to grow depending on the environment so it could adapt to different environments.  But that makes the laying down of pathways dependent on experience.

And so we have lots of evidence from imaging studies as well as animal studies that the not only learning but actual brain structure is determined by what kind of experiences we provide for our children.  So we have to provide what we are calling a Family First Initiative, which is in the briefing notes that I sent around, where we really empower families to know enough that they can take charge.

And it has two components:  one, identifying healthy development so they can share and enjoy it with their children; two, the kinds of interactions that promote healthy development, not simplistic things, like having kids watch TV or high tech stuff but the kinds of playful interactions, like peek-a-boo games and back and forth signaling games and things that promote engagement and relating, you know, that have stood the test of time but that parents are being dissuaded from doing because of misinformation from a variety of sources.

So we have to get parents back to the basics of things that produce healthy children and give them the kinds of activities that really work for their babies and young children.

And, number three, we have to provide parents with the warning signs of when things are not going right, you know.  And that has to be done in a healthy framework so that it's not simply looking for "Is my child blinking too much or is my child a little too active?" but "Is my child failing to learn to be a shared social problem-solver?  Is he 15-16 months old and he can't show me what he wants, can't gesture it, you know, just gets frustrated and cries or just gets impulsive and starts hitting?"

So it's really the absence of the healthy milestone, not so much the presence of the problem that we want parents to focus on, because then we can help the parents to promote that healthy milestone, which is often the ticket to overcoming the problem behavior.

And we have to do a very active campaign with our early child care educators, day care, and nursery school educators, and pediatricians, who help parents, who are the front line, as well as our other health and mental health professionals, who don't get much training or background in the early years of life, who are mostly experienced — (en my colleagues in child psychiatry are mostly experienced with the kids over age five).  Rarely do they get a lot of work with the younger kids.

So I recommend a Family First Initiative for parents.  Also, a second initiative I'm recommending based on this is a prevention initiative.  We could probably reduce health care costs by 50 percent and improve our outcomes for future citizens having healthier thinkers and healthier copers with reducing divorce rates and reducing criminal behavior and reducing depression if we took a real prevention initiative beginning early in life.

We have the know-how now.  We really know what to do, but there's not a sufficient emphasis on prevention in our health policy and our education policy.  And we really need to change that around with what we now know.  We know how to build healthy foundations.

And, again, it's not the quick fix.  Take reading, for example, which is high on the current agenda.  Child A isn't reading simply because he hasn't had the practice.  He'll respond well to current programs with more emphasis on reading.

Child B isn't reading because he can't distinguish sounds very well.  So when he hears the "bah" and the "gah" and the "dah," you know, he doesn't separate those.  So he can't match the sound, then, to the visual image.  And he has a deeper problem.

We can identify that deeper problem by eight months of life because that child in the back and forth signaling won't be vocalizing as much because he's not decoding the sounds.

We can play games with that child where we expose the child to different sounds while the brain is growing.  By the time he gets to school, he can decode lots of sounds.  And he can then become easy to work with reading.

That won't be with a quick fix approach.  That will be with understanding the sequence leading to good reading skills in a broader developmental framework.  So we know that now.  We have agreement among experts on that line of development.  But we need a prevention policy to really do it.

And a third part of our initiative is there are a number of families that are very, very dysfunctional, where one generation produces another generation of people with multiple mental health problems and poor coping skills.

This is the 6 percent of the population that uses about 75 percent of the public services.  They're in emergency rooms.  They're in crisis centers.  They're using social services.  There's abuse.  There's neglect.  There's a heavy drug use and alcohol use.  There's heavy psychiatric illness in the adults.

We did an experiment in Prince George's County, Maryland with these families we call them.  We published a monograph called "Infants in Multi-Risk Families."  I did this when I was at National Institutes of Mental Health.  And we demonstrated we could possibly work successfully with these very at-risk families and turn around this multigenerational cycle, but this requires a heavy, heavy outlay of outreach services reaching out because you're not working with people who come in and ask for help.  So you have to have outreach for a very small percentage of families that really require it to interrupt this multigenerational cycle of poor coping.

Now, what I want do in just finishing up is show you this prevention approach that we have been doing.  We have been applying it to children with autistic spectrum disorders.  And we have been working with kids at early ages.  And we have been helping them build healthy foundations, mastering these milestones that I just reviewed for you of attention and engagement and emotional and two-way signaling and learning to think creatively.

I'm going to show you one little boy, who is about three and a half to four, who is at the early stages of work.  You will see him in just the first consultation session, and what happens, just as we get the parents working with these foundation pieces. Then you'll see a boy who is the teenager, who is talking politics, some of which you may agree with, some of which you may disagree with, but who was diagnosed with autism as a young child and was the product of a program that focused on healthy foundations, not on just changing behavior.  In other words, there are two philosophies in treating autism now, one that I represent, building healthy foundation; the other, just changing surface behaviors.

So I want to show you these briefly as just a little example of what we are talking about them concretizing.  If you would show the first videotape?

(Whereupon, a videotape was played.)

DR. GREENSPAN:  He had been diagnosed with autism.  And we were seeing him for a consultation.  He is kind of in his own world a little bit and doesn't respond to the parents' overtures.

So here you can see how he is not again relating to the mom, to his own mommy, or interacting with her or exchanging gestures or exchanging words but just focusing on the concrete objects.

Now he begins drifting off again.  Now we start working with him.  He's in control.  We're constantly enticing, luring him in so that he becomes more comfortable with controlling the warmth and the intimacy.

This is all about engaging.  It's all about intimacy.  It's all about him feeling comfortable with intimacy.  And he has to feel in charge of that.  So we entice.  We move.  He wants to move away.  He moves away.

We entice him back.  But we let him be in charge of the body.  If he wants to kick the dolly away, "Oh, bad dolly.  You're kicking the dolly away."  Okay?  If he wants to feed daddy, "That's great."  Okay?  We're enticing.

We will sometimes take his little thing in his mouth and put it in our mouth to entice him because then he will come to us.  That's it, making sounds to each other.  Keep that up.  That's wonderful.  That's beautiful.

That's all for this tape.  Here you can see how we're building those early milestones that I was talking about.  We're building healthy foundations in this little guy, rather than just trying to change his behaviors.

Now you're going to see just for about 30 seconds a teenager who started off with a diagnosis of autism.  And I will let you judge for yourself how he is doing now as a teenager.  Again, his political views are his own.

(Whereupon, a videotape was played.)

DR. GREENSPAN:  We can stop now.  We can stop the tape now.  What I wanted you to see was his kind of logical analysis, whether you agree with his ideas or not.

So here you see a young man.  He's in one of the more demanding private high schools of Washington, had a lot of friends, played sports, gets good grades, going to be going to college very shortly, probably one of the better schools.

And he's like a bunch of kids.  We have a subgroup of kids, those that we work with, that's a fairly sizeable subgroup that are just like him now that we have followed for 10 to 15 years who are no longer receiving any services, who are fully on their own and no longer need any mental health care.

This surprised us.  We didn't think that even a subgroup of children — this is not true for all children with autistic spectrum disorders.  There are other children that make slower progress and other children that it is very difficult to make progress with.

But in this subgroup, which is a sizeable number, they surprised us in how well they did when we took this healthy foundation-building approach.

Now, just to kind of conclude my comments and then open it up for your questions, if we use our road map for healthy mental health and intellectual functioning coupled with a family-oriented and prevention and comprehensive outreach and treatment initiative, we can answer the questions raised earlier.

A picture of healthy development will enable the true identification of real problems.  They're not just symptoms.  They're the failure to meet these healthy milestones.

Medication that is being used more and more widely for younger and younger children reflects in this context the erosion of comprehensive child and family-oriented approaches in mental health care.  That's what is pushing the system in that direction and with the erosion of family support.

Increased testing, if not tied to respect for variation among children and from the importance of critical thinking skills and for innovative teaching and for education-parent partnerships can undermine, rather than facilitate, long-term academic development.  So testing is okay if it's tied to the broader other goals.

Full-time day care for very young children is counterproductive if parents are able to provide high-quality care themselves.  In other words, therapeutic day care for high-risk families seems to be helpful.  However, day care for children who have parents who can provide high-quality care seems to be counterproductive when we look at their development.

And there is new research showing higher stress hormones in the kids who are in day care for longer hours each day and also more problematic and aggressive behaviors by age four and five.  But we know that four babies for one care-giver, they can't get the help they need to master these early milestones well.

Early identification and intervention is only helpful if it focuses on positive growth and development that would be beneficial to all children.  So a road map in these types of initiatives are necessary if future generations will be able to cope and lead an ever growingly more complex society.

Thank you.

(Applause.)

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Greenspan.

Are there questions?  Dr. McHugh?

DR. MCHUGH:  Dr. Greenspan, I was very pleased to listen to you.  I have worked with you before and found it very interesting.

Questions I wanted to ask you relate to two sides of your presentation.  The first one and the one I absolutely agree with is that we are doing a very poor job in assessing our patients, children or adults, for that matter.  And we don't do what you referred to as a bio-psychosocial study, which I would say we don't do essentially a full workup.

And that's not because of the society, though, Dr. Greenspan.  That's because of American psychiatry, which has decided in its wisdom to employ a checklist diagnostic system that resembles, as I've said to this Council many times before, fundamentally a natural field guide, rather than a diagnostic system, or an understanding.

It's entirely different from ICD-10.  DSM-IV and ultimately DSM-V will be continuing this method, which, by using field marks, checking off like we check off the color of the wings of a bird or something, ultimately very quickly and with checklists leads to a diagnosis and a penny in the slot therapeutics in which we give a pill and a pill and a pill and see whether they — again, I wonder whether you would agree with me.

That's my first question, if you would agree with me that psychiatry has a lot to answer for, particularly if it's continuing this method and discouraging the full workup of patients.

It used to be, to use the expression of William Osler, that when you went to see a specialist or a consultant, the thing that the consultant did was do a rectal.  What has happened in psychiatry is that when you go to see a consultant, like me or you, what you do and what you get is a history, a full workup, a study, and a differential, rather than a checklist.  And I think it's not correct to complain that this is society's fault, although I think the health care delivery system now is going with us in psychiatry, letting it happen.

So that's the first question I want you to address.  The second thing is I am interested in your method of studying and seeing patients and appreciating how they go in relationship to these goals or elements in the developmental process.  And it resembles, of course, other developmental processes but now in a more bio-psychobehavioral approach.

What I wanted to know from you because it wasn't quite clear was whether when you found somebody who was slow in failing in one of those developments.  What you then did because it could be that this is a very appropriate scale for picking up troubles, but does it diagnose troubles as well?

Again, this falls back on our field right now, where we have claimed that scales and systems like the diagnostic interview schedule, the so-called DIS, we thought that it was carrying diagnosis.

It turned out to be very good at recognizing disorder in the sense that a person was disordered, but it didn't recognize the diagnosis of that disorder.  It worked something more like the sedimentation rate than it did like a diagnostic instrument.  Where does your scale fall in that relationship?

And then, thirdly, you offer us some optimism in the treatment of autistic spectrum disorder.  Is that optimism based on controlled trials and things of that sort or is it still at the level of your knowledge as an expert dealing with patients of this sort?  So those three questions, sir.

DR. GREENSPAN:  Yes.  Thank you.  Those are excellent questions.  They really all converge on, I think, the same kind of answer.  I think you and I are very much on the same wavelength.  In fact, we quoted you recently in making the argument that you just made in an article we did for a broader diagnostic system because you had done an article for I think the AMA journal a little while back.  And we found that very, very helpful.  So we're on the same wavelength.

Basically, I think American psychiatry made a turn in the road a number of years ago when they gave up complexity for reductionism and attempted to use the symptom approach, sort of the term that you term aptly the field approach, to get greater reliability and hopefully more science, but the reality is it turned out not to yield even that.  And it is misleading because it doesn't look at the whole person, doesn't look at the complexity of human functioning.

And when you look at clinicians in practice, reliabilities are tragically low.  So it didn't even accomplish the limited goal that it had.  And now it's kind of facing that folly.

We recently brought together, just as a side note, — I think you'll find this of interest — all the organizations concerned with psychodynamic approaches, which tends to have a broader model focused in on the psychosocial part of the bio-psychosocial.  And we are about to publish in about three or four weeks, but there was an article in the New York Times about this effort, this Psychodynamic Diagnostic Manual, the PDM.

And that's an attempt to move in this direction.  I hope you'll like that when you see it.  But it's a broad-based approach looking at personality and looking at profile of mental functioning and looking at symptoms as well but symptoms from the point of view of the patients, full experience of those symptoms, the subjective level, not just the tip of the iceberg.

So I am very much in agreement with you.  I think psychiatry took a turn in the road.  I think, unfortunately, the population has been moving in reductionistic ways, too, because of other forces in society and managed care and other things.

So I think a lot of things are converging fostering reductionistic approaches.  And I think it needs to be reversed because it's going to be hazardous for the future.

The second question about our own identification of these milestones, yes, that's simply — and I agree with you — the first step of kind of identifying a road map for healthy development that allows us to know which children need a further workup.

So it's not supposed to be a diagnostic tool.  It's not even supposed to be a screening tool.  It's supposed to be kind of a help and observation, saying, you know, what have we learned in the last 20 years that will help us observe infants and young children a little more effectively?  And can we turn these into a series of questions you can ask, that a parent can ask, so that they're not just looking at it as a baby crawling?

See, historically parents were looking at it as "Is my baby crawling?  Is my baby saying first words?"  And that's not enough.  We find that these landmarks "Is my baby engaging with me?  Is my baby interacting?  Is my baby problem-solving?" yields much more fruit.

And then you move to the second step, which is exactly what you're saying, a full diagnostic work-up involving the family, involving the history, involving the infants' biology.

And then when we develop our intervention programs for children with autism, it's a full bio-psychosocial model of intervention.  I mean, I don't have time to go into it here, but there are a number of — those who would like information about it, there's a book I wrote called The Child With Special Needs.  And there's another book that will be coming out in about a month called Engaging Autism that describes our developmentally based bio-psychosocial approach, which we call the DIR model, where we work with the child's development, individual biological differences and family relationships, as well as therapeutic and educational relationships in a very complex dynamic framework.

To answer your third question, we have been getting much better results than before.  And the answer is somewhere in between.  It's not just impressionistic and clinical experience of experts, but it's not at the clinical trial phase.

No approach to autism actually has had good clinical trial comparative studies yet.  The Academy of Sciences issued a very good report a few years back on educating children with autism, where they cited our approach and other competing approaches, such as behavioral approaches, and pointed out, as many of us have been, that we need comparative clinical trial studies between the competing approaches right now, because there's a whole group that is developmentally based, which I kind of represent, and then another group that is more behavioral and symptom-based, represented by behavioral approaches.

And we need comparative clinical trial studies, but we do have a number of studies, small studies with control groups showing efficacious results.  We also have a study of 200 children with autism, of which I showed you the tapes of some of the kids who participated in that review of 200 cases.  And we have percentages for the rates of improvement that go way beyond the expected rate.  So we had 58 percent that were like that teenager you saw in our study of 200 children.

Now, this was not a representative population, but they did start out with all degrees of severity.  But it wasn't a brand new group from the community.  So I can't generalize that in the community, we can do this with 58 percent, but I am convinced that there is a sizeable subgroup that can have much better outcomes than we're seeing.  But I need to show that in a clinical trial study.

So we're somewhat I think in between.  I'm looking for — we have a clinical trial study planned.  And hopefully we'll undertake in the next year, year and a half.  We're getting the funding and the organizational support needed for it because, as you can imagine, it's a very expensive undertaking and not easy to implement.

So I am basically in general agreement with the thrust of your comments and would second them and think we need to do a lot of work to shift the momentum that we're seeing in psychiatry but also in general society away from the quick fix and away from the short reductionistic approaches towards back to understanding human complexity.

PROF. HURLBUT:  I have two questions.  First, when I watched those parents, they seemed like pretty earnest parents.  And if you say that the normal development takes place in an interactive environment, that kind of attunement and entrainment that goes on to establish that sense of pathic communion or whatever it is, intersubjectivity, it struck me that those parents would have been quite diligent in that.

Actually, now, a few weeks ago, a paper came out showing fMRI studies of kids with autism and deficiencies in certain areas associated with Rizzolatti's mirror cells.

DR. GREENSPAN:  Right.

PROF. HURLBUT:  And what I am wondering is, well, maybe a little reflection broadly on, is that just another form of reductionism?  And why didn't that child relate to his parents?  Is it that they needed to do different kinds of strategies, they had to reach out a little further than normal?  What was going wrong there?

DR. GREENSPAN:  Well, basically autism is fundamentally a biological disorder, where the children's biology is different, making it much harder for these ordinary parental processes, even among gifted parents — and these parents were very gifted.  You saw how quickly they shifted what they were doing with a little bit of coaching.  So it shows you how gifted they were.  And the parents of these teenagers were quite gifted.  And that's why he did so well, in part.

Autism is fundamentally a biological disorder, not a disorder of parenting.  And so the children do process information differently.  For example, children at risk for autism early in life, we see some of them are over-reactive to things like touch and sounds.  Some are under-reactive.  Some have low muscle tone.  Some can't distinguish sounds easily.  Some get confused by visual input.  They can't see patterns.

The mirror imaging work is interesting because we do see problems with early imitation, you know, where the neurons that supposedly help with imitation, these mirror neurons, are supposed to be activated.

The problem with the research on the mirror neurons, just as a quick side note, is that where it's an example of reductionistic thinking, when you read the research and read the reports of the research in the media and read it in the scientific community, there's an assumption because these mirror neurons are part of the physical structure of the brain and partially under genetic control, that, therefore, this is a fixed, genetically mediated biological deficit, which will be lifelong and unchangeable.

I will bet dollars to doughnuts, give odds to anyone around the table who would like to take me up on this bet that if we do research and show — use the approach that we have developed for the children with ASD, where we help parents understand the unique biology of the child and then we tailor the learning interactions to the biology of the child.  So a child, for example, who has got problems with visual pattern recognition or auditory sound recognition, we provide extra experience but in a fun way for that child while we're mastering the milestones.

So we meet the child where he is.  If he's not engaged, we don't try to teach him words.  We work on engagement.  But we do it in the context of the child's unique biology.  So we're extra soothing for the over-reactive child.  We're extra energizing for the under-reactive child.  For the sensory-craving child, who is impulsive and all over the place, we provide extra structure.  For the child, again, who doesn't decode visual input, we're slower on the visual providing more auditory support or vice versa.

So we really tailor to the child's biology.  That's not intuitive.  It's very rare, we find, that parents can do that on their own.  Occasionally some parents have figured it out just by reading some of the materials.

But this is a relatively new approach represented by a group of us who are not just using a fixed curriculum but tailoring the approach to the child.  So there are biological differences and we tailor.

What I would predict hypothetically, again, from a hypothetical bet, is that if we looked at the mirror neurons for kids who were deficient and then provide them an environment that had this very tailored approach, we would see their mirror neurons, their ability to imitate, grow.

And if we had another group that was given a more conventional intervention for autism, let's say more of a behavioral approach, just training, memory, and rote behaviors, not working on the fundamentals, we would not see changes in their brain structure.

In fact, we're doing just such studies now at York University in Canada, where we have a big research grant, where we're studying the brain as we're doing our intervention programs, to see what happens inside the central nervous system, as we provide the opportunity for children to master these milestones.

So I think that research on mirror neurons and other neurobiological research is very exciting and very important except there's often the assumption that it's fixed and can't be altered by the environment.  And that is an unproven assumption and a mistaken assumption I think and a pessimistic one.

PROF. HURLBUT:  You know, as I looked at that, the other thing that struck me was you can imagine those parents getting pretty frustrated and then kind of flooding over and causing things to get worse.  And I thought as I was watching that how often that must actually be happening, both within the home and within school settings.

And it strikes me that from your description, there is such a range of pathologies and normal chronologies as well as styles of learning and so forth.

Are we doing a violence to our society by our standardized education?  Are we somehow missing the point in stigmatizing and marginalizing certain people as failures?

I mean, Mike Merzenich is a very interesting guy to talk to about dyslexia in his programs to technologically in a way overcome this strange barrier to neurodevelopment.  He has a program called Fast Forward, where he uses computers to retrain the hearing discernment so that they can then hear the language they weren't hearing before.

What strikes me is — and he will tell you that a great many of the people in prison are actually suffering from dyslexia.  And you can imagine that we may have stigmatized them very early and just essentially promoted their failure with our standardized system.

Would you comment on that?  And also, in addition the kind of thing Mike Merzenich is studying, what kind of technological things can this Committee have on its radar for what interventions might be done to improve the range of approaches that are causing some of these problems?

DR. GREENSPAN:  Yes.  I think, number one, the answer is yes, 100 percent.  We are causing more harm than good with our standardized approaches.  Most children vary considerably from other children in the way they learn.  They react differently.  We have shown this now very well.

Even normal children have different patterns of reactivity to sound and sight.  They process sounds and sights differently.  Basically they have different strengths and different weaknesses, which most parents know about their own kids.

And there is a cycle of failure when a child enters school with processing problems, not the first kind of child who just needs extra practice reading but the second child who can't decode the sound and that is why he is not reading.

So, even with extra help in school, he is frustrated.  He is not getting it because he is missing the fundamentals.  And we have approaches that work on the fundamentals, that work on auditory discrimination first before we expect them to learn to read that are very successful, by the way.

Then we have evidence for their success.  So it's not as though we couldn't be helping them, but it requires better diagnosis and individualizing the educational system.

When we don't do that and the child experiences failure and also has families that are under stress, then there is a high likelihood of school dropout.  Then there is a high likelihood of delinquency.  Then there is a high likelihood of winding up in the criminal justice system.  And the rest is sad commentary.

We can intervene at many points in that developmental trajectory.  One of the points educationally is to teach that child the proper sequence to reading and then also have better school-parent partnerships so we pick up the stress at home.  And even if we can't help that family sufficiently because their problems are so grave, we can provide more support at school for that child so that there is a mentor program associated with the school so there is some adult that the child can do well with.

We have learned that even kids from the most high-risk environments who are given other adults to relate to may become the policeman, rather than the criminal, you know, may have a different identification and a different adaptation.

So the answer is a resounding yes.  We are doing a terrible job with our current system.  And we're creating problems.  And it's the wrong philosophy.  It has to be an individual variation, individual different philosophy, not a one size fits all philosophy.

And your second question?  Just remind me again a bit.  I got so focused on the first one.

PROF. HURLBUT:  Are there other technological things we should be alerted to?

DR. GREENSPAN:  Yes.  I think  what we need to be most alert to is that we now have the understanding.  It's not based on high technology.  I mean, Fast Forward is a good example.  I'm very familiar with it.  It's a way of helping kids processing.  But it also has its negative side because it increases screen time.

And a lot of these kids need more human-to-human interaction.  There are other ways to get the same processing improvements in human-to-human interaction, where we get two for one.  So depending on the child, I may recommend it for some kids and not for other kids, again, individual difference model.

So the technology that we need to be advocating is our new knowledge base.  We now have the knowledge base about what constitutes healthy development.  We have the knowledge base for early detection of children who were not mastering these healthy milestones.  And we know better what kinds of experiences, some involving technology, some involving human interaction and family support.  And we need a comprehensive, you know, family-oriented, broad-based approach.

There is a book I will send around that we just wrote called The First Idea:  How Symbols, Language, and Intelligence Evolved from our Primate Ancestors to Modern Humans.  And based on your questions, I was going to send it before I came to the Committee, but now based on the way the questions are going, I'll definitely send it after having had a chance to meet some of you and hear your questions because I think you'll find it interesting.  It addresses just these questions and issues you're raising.

DR. KASS:  Very quickly.  I would be willing to pass if you want to move on, but, first of all, I very much welcome this approach, which begins with an attempt to give an account of healthy child development.

However, I am struck by the certain absence from this account.  It looks like an account of child development that would get your kids into good schools and keep them out of the hands of psychiatrists, where what is missing is something like the development of habits and questions of character and impulse control, how to deal with your fears, how to practice self.control, and just simple things like toilet training, eating with implements, not interrupting, showing respect for your elders, putting your clothes in the hamper, certain kinds of elementary things.

And it seems to me that if a concern is probably triggered through autism and things of that sort, I understand exactly why the article goes the way it does.  On the other hand, there are some parts of child rearing which are like teaching young birds to fly and other parts of child rearing are like breaking a wild horse.

And the question of vanity, pride, and self-esteem are at the center of this.  On the one hand, you want children to feel self-esteem.  On the other hand, you don't want them to become little egomaniacs and think they're as large as the whole world.

And I would think that an account of mental health and normal child development would have those characterological things because very often it's the absence of that kind of self-command — I'm not talking about high virtue but minimal virtue — that gets in the way of people actually being able to learn.

DR. GREENSPAN:  Absolutely.  I'm glad you asked this question.  The approach we take to that — let me give you an example just by talking about moral development — thinking about it in a complex dynamic way or what I would call an over-reductionistic way.

An over-reductionistic way would be, unfortunately, the metaphor of breaking the wild stallion.  I think that's reductionistic.  You know, you've got to discipline the kid more.  You've got to scare them a little bit and teach them to be a good citizen.

I think that often doesn't work.  It produces a fearful person.  It produces often a non.thinking person, often produces a person if they have values, if they're very concrete, they often break the values.  They're the person who when you're watching him does the right thing.  But as soon as they're off in their own place, they do the wrong things.

On the other hand, if moral development is based on the healthy model of development, it starts with forming that relationship with others because you have to care about others to be a moral person, to be empathetic.  You have to invest in relationships.

You have to be able to read the emotional signals of others, two-way communication, to understand what another person is feeling, to be a moral and ethical and empathetic person.  And you have to be able to be a complex problem-solver where you read patterns so you understand other people's behaviors as well as your own and how your own behavior is influencing theirs as part of pattern recognition.

Then you have to be able to use ideas to express your feelings and also express to yourself the feelings of others.  And you have to be able to connect those ideas together logically.

Then you have to become a gray area thinker because if you're an all or nothing thinker, you'll say it's either my way or the highway.  But if you're a gray area thinker, you'll say, "Well, we've got to share.  We've got to compromise.  You know, sometimes I get my way.  Sometimes he gets his way."

And you become a reflective thinker if you're fortunate.  From an empathetic and moral point of view, that means you can understand your feelings in relationship to other people's feelings and also regulate your behavior accordingly.

Now, does limit setting play a role in that trajectory?  Absolutely.  Will kids test the limits?  Will they need punishment sometimes?  Absolutely.  Will they need firm boundaries?  Absolutely.

I have written 38 books.  And you will see that in every book I have written:  the importance of the firm boundaries, firm discipline.  But it has to be gentle, supportive, and in a thinking-based approach, where the child understands the reasons for it.

So it's not easy to do.  It's not easy to produce a highly empathetic, moral person of high character.  And I agree with the thrust of your comment that it does require the discipline in the boundary-setting part of it, but it requires it in the context of the thinking-based individual who is sold on the human race and who cares deeply about other people.  We have to have both.

And what happens if we get into polarized discussions, where there is the kind of laissez-faire attitude, "Just let the kids become narcissistic and unbridled," on the one hand, or the over-disciplined approach, "Let's scare the shit out of them" but not give them the nurturing that they need.

And neither approach works.  One produces a fearful or antisocial person.  The other produces a narcissistic person.  So I think neither one works in isolation.  I think both.

So the thrust of your comments I agree with.

DR. ROWLEY: I was going to just ask you about the wider acceptance of some of these views in other either school systems or medical/child care settings, though I realize that we're more than out of time.  Maybe you could comment briefly.

DR. GREENSPAN:  I think what we are doing is we're trying to educate colleagues in schools, in child care settings, day care, also parents, but we're fighting a very powerful trend in our culture in the other direction.  There is a very powerful trend in education towards rote memory approaches, not thinking-based approaches.

There is a powerful trend for families, even when they can provide high-quality care, to farm out the care to day care and, as you heard, even in the psychiatric community, you know, a tendency to look at symptoms.

So there was momentum in this direction in the 1960s and early '70s towards more dynamic what I would say frameworks.  And there has been a regressive movement in the last 30 years or so.  And I think it's very important to counter that now with a progressive movement towards understanding the complexity of human development.

So we can modify the philosophy-guiding, education-guiding, child care-guiding-related approaches.  And I think a Council such as this in terms of setting a broad tone, having a statement about what constitutes human functioning, and all the elements that have to be taken into account, and focusing on the theme you were saying related to individual variation, I think having some sort of official support for our concept of humanity so we don't — if we're moving dangerously towards an automaton computer-based picture of the human brain — I'll just say one more thing, I know we're out of time.

I talk with my neuroscience colleagues, many of them distinguished.  But even in that time, like the mirror neuron research.  It's a very modular view of the brain.  We've got this area of the brain that's happiness.  That's controlled by this gene.  We've got this area of the brain that's pride and avarice.  It's controlled by this gene.

I mean, that's just not true.  It's not proven.  It's a scary science fiction image of a computer, not a human being.  Human beings function in an integrative whole.  And all the parts of the brain interrelate to one another.  But we're dangerously moving in that direction.

That's why we pop pills for every ailment from frustration to bad behavior and why we're putting kids on medication younger and younger.  So if you want to attack the problem from the core, we've got to do it with the definition of what constitutes healthy human functioning and how that has to modify our education, mental health, and child care approaches.

CHAIRMAN PELLEGRINO:  Thank you very much.

DR. GREENSPAN:  Thank you.

(Applause.)

CHAIRMAN PELLEGRINO:  There is never enough time.

DR. GREENSPAN:  Yes.  Well, thank you all.  And it's a pleasure to be talking with you.

CHAIRMAN PELLEGRINO:  Really appreciate it.  Thank you.

DR. GREENSPAN:  Thank you.

CHAIRMAN PELLEGRINO:  I think we will move right to our —

DR. FERNETTE EIDE:  If you need to stretch your legs, go right ahead.

PROF. MEILAENDER:  Before they start, could I just sort of make a comment/question?  I am just afraid that they are going to try to rush through what they have.  And I think we should agree right now that we're staying longer than we planned to.

CHAIRMAN PELLEGRINO:  Yes.  I will do that.

PROF. MEILAENDER:  I don't want them to try to say in 15 minutes what they were going to take a half an hour to say or something like that.  I'm content to stay.

CHAIRMAN PELLEGRINO:  Full agreement with that.

DR. FERNETTE EIDE:  You're so kind.  Thank you.

PROF. MEILAENDER:  Most people don't think that.

DR. FERNETTE EIDE:  We will try to make it really good.  Yes.  We will try to make it really good.  Otherwise we'll get out the hook.  Okay.

Well, thank you very much, Dr. Pellegrino and members of the Council, for the honor of inviting us here.  Given our background and our clinical focus, our comments today will deal with the needs of school-aged children, particularly in regard to how we as a society choose to understand and treat their learning behavioral difficulties.  I think it's a nice dovetail with what Dr. Greenspan just spoke about.

When we first began working with children with learning and behavioral difficulties, we were struck by a paradox that existed in this field.  Although we found many different professional groups willing to diagnose and treat such children, general and developmental pediatricians, pediatric psychiatrists, psychologists, neuropsychologists, educational specialists, and even a few neurologists, we found a surprising degree of uniformity in the approaches that they employed.

Each specialty relied almost exclusively on behavioral approaches to diagnosing and managing children's learning and behavior problems on observing and categorizing children's behaviors, rather than identifying the causes of those behaviors in the child's unique neurological wiring and life experience.  In practice, this meant a reliance on the DSM.  And it's exclusively behavioral criteria.

As a neurologist, this pattern of assessment went very much against my grain.  I was trained never to rely exclusively on behaviors for diagnosis because behaviors, like limps or clumsy fingers, can have many different causes, as can problems with reading or paying attention.  Instead, we're taught to work backward from behaviors to locate specific causes in the nervous system because effectively directing treatment requires correctly identifying the sources of dysfunction.

The DSM, by contrast, bases diagnoses and treatments exclusively on visible behaviors and ignores their causes.  The distinction between behavioral and causal approaches is important because the decision to adopt one approach or the other has profound consequences for how we understand and treat children with behavioral and learning challenges and for how we organize our educational, health care, and even parenting practices.

Consider, for example, how this decision affects our approach to children who demonstrate the behaviors in the DSM's ADHD diagnostic scale and are having difficulty paying attention in school.

This is a very large group of children.  According to the American Academy of Pediatrics, 8.10 percent or up to 14 percent of boys will meet the criteria for ADHD.

Now, given the Council's previous works, we believe you're largely familiar with the DSM's approach.  So we're going to focus here on the implications of adopting a causal or neurological approach to children with attention problems with reference to how such an approach can serve as a model for approaching children's learning and behavioral problems in general.

A causal approach would begin with the premise that children can show ADHD-type behaviors for many reasons.  Most children who struggle in school frequently show some of these behaviors and will meet the criteria.

Studies have also show that nearly all children stop paying attention when they're confused and become unmotivated when they can't succeed.  Confused and unmotivated children are often inattentive and restless.  And it's important to distinguish causes from effects.

When we examine children who show ADHD-type behaviors, we often see a variety of causes for these behaviors, rather than a single global problem with attention.  Many have undiagnosed reading and handwriting problems or brain-based visual or auditory processing deficits.  There are sensory-motor processing problems that can make handling the barrage of information in a busy school environment, including social signals, difficult.

Also, we find children with strong or uneven learning preferences whose performances might vary dramatically depending upon the learning environment.  There are also highly intellectually gifted children who may be simply bored with an insufficiently challenging routine.

Understanding why a particular child is struggling with attention involves more than simply documenting behaviors.  It requires completely assessing physical, medical, neurological, cognitive, behavioral, emotional, educational, and psychological aspects of a child's development to see where breakdowns in a child's attentional or behavioral control mechanisms are occurring.

Although many practice guidelines, like the American Academy of Pediatrics', advise considering such factors when making behavioral diagnoses, they provide little guidance on how they should influence the diagnosis.  And because they are not included in the DSM, researchers have documented that they are seldom considered by practitioners when diagnosing ADHD.  Yet, these factors play a crucial role in determining a child's problems with attention and behavior and must be identified if the right steps are to be taken.

School or day care for younger children plays an enormously important role in children's neurological and behavioral development because most children spend so much time there.

For many children, schools are sources of enormous stress.  Stresses may arise from interactions with peers involving struggles for acceptance or esteem, or even physical threats or bullying, or also with teachers, who are enormously important figures, especially during the elementary years.  Stresses may also arise from the learning process itself.

Academic pressures have intensified in recent years due to the standards movement.  While valuable in pointing out the problems with our current educational system, the No Child Left Behind Program has, with an almost Orwellian irony, raised the specter of grade retention and failure for millions of children.

One recent survey of third graders preparing to take a new state-mandated test found that 80 percent ranked their stress levels as "high" or "very high."  When asked about their greatest fear, the most frequent response was, "I'm worried that my friends will think I'm stupid if I fail."

Unfortunately, for all too many children, this fear isn't idle.  Enormous numbers are struggling to meet basic academic standards in areas like reading, writing, math, and language.  Many have neurologically based disorders of cognition and learning.

Up to ten percent of children have dyslexia, 18 percent with untreated visual problems, 13 percent partial hearing loss, 5 to 10 percent with central auditory processing disorders, 5 to 10 percent language disorders, and 6 percent with motor coordination problems that impair vital functions like writing.

Unfortunately, current federal guidelines permit only 3 percent of a school's students to opt out of standardized assessments because of disability.  So many students with learning problems are under increasing pressure to meet performance standards.

Most learning or behavioral difficulties arise from one of two types of problems.  The first is a problem with one of the basic neurological functions that underlie reading, writing, counting, and these other basic academic functions.  These neurological problems, which occur in areas like perception, motor coordination, memory, attention, or pattern processing, are often very difficult to diagnose because they frequently don't present in ways that suggest their true nature.  Yet, these difficulties are relatively common in school-aged children, and are often mislabeled as deficits in attention or in autism spectrum disorders.

Correct diagnosis is crucial because, as we'll discuss later, these problems can often be treated successfully using therapies that take advantage of nervous system plasticity to repair the underlying deficit and eliminate the resulting ADHD-type behaviors.  We will be talking about some of the technological things as well.

The second type of problem is caused or greatly exacerbated by instruction that is poorly suited to the way that particular children are wired to learn.

While most of us learn better in some ways than others, for some children these differences are profound and are essential to take into account when designing their education.

These children could learn very well in the right setting, but they struggle in particular classrooms because information is presented to them in forms they are not well-suited to take in or process.  They are asked to express themselves in ways that hinder them from fully communicating their ideas.

Frequently, these children have difficulty taking in information through auditory-verbal, or lecture-based, instruction or expressing information through writing by hand.

Because our educational system overwhelmingly stresses these forms of communication, children with these primarily visual, spatial, hands-on, or novelty or experience-based learning styles or difficulties with written expression can suffer needless problems with learning and attention.

Some children also differ markedly in the rate and depth at which they prefer to take in information.  Some are intellectual pythons, who prefer extended periods to digest a single topic.  Others are learners like sparrows, who need frequent short bursts of learning interrupted by frequent breaks.

While all students must achieve certain basic competencies in core subjects, they do not all need to pursue them in the same ways or through the same routes.  What they really need is a form of education that's right for the children who learn the way they do.

In most cases, these learning differences don't need to become disabling unless we let them.  Many children who struggle in school do not have cognitive impairments or abnormalities in any absolute sense but simply differences in learning style, many of which actually render them well-suited for various adult occupations.

So we wanted to give you some examples from our clinical practice.  Because our clinic is located just north of Seattle, we see many children who are the kids of software designers and engineers who work for companies like Microsoft and Boeing.

Often the supposed learning disorders that have made these children poorly suited for auditory-verbal learning environments in their schools are manifestations of the same visual and spatial reasoning styles that have made their parents professionally successful and creative.  Their learning and behavioral problems simply result from the conflict between learning style and their school's teaching style.

Such conflicts can be avoided by providing children with as many routes to learning as there are different types of learners and thinkers.  Our adult society thrives on the differences between learning and thinking styles, interests, and work habits that produce teachers and soldiers, engineers and plumbers, lawyers and graphic artists, doctors and cosmetologists.  Yet, our schools treat this diversity as a problem to be solved.

The cost of failing to meet the needs of children with either of these two types of problems is enormous, both in human suffering and in squandered talent.

When children find themselves in environments where learning is demanded but not facilitated, they all too often end up in a cycle of despair.  They struggle, fall behind their classmates, become anxious and ashamed of their difficulties, and even of themselves.  They may even have begun to wish they had never been born, like our patient who told her mother that she wanted Santa to bring her death for Christmas or the boy whose mother found in his backpack a note he had written to himself saying he deserved to die for being so stupid.

For children like these, learning challenges aren't just a question of grades or achievement.  They strike at the very heart of a child's self.image and for some can quite literally be a matter of life and death.

Too often they receive a variety of diagnoses, like ADHD, oppositional defiant disorder, depression, conduct disorder, bipolar disorder, and a variety of drugs, often three to four in a single child, to control behavior.

Is this the best we can do?  The answer is unquestionably no.  To help these children develop into competent and confident adults, we must identify the true causes of their behavioral and learning problems and equip their parents, teachers, and the students themselves to address these causes directly, rather than simply medicating troublesome behaviors.

To meet their fundamental needs for learning and development, we need to shift our focus beyond mere behavior, toward what modern neuroscience is telling us about the different ways that different children learn and process information and the ways in which their minds can be developed through targeted experience.

By using these insights, we can ensure that each child is able to master the skills that he or she needs not only to survive their education but to thrive in the demanding world of the future, where simply behaving by the rules will not guarantee success.

DR. BROCK EIDE:  To reach these goals, we must first remove the barriers to progress that have been raised by the behavioral and medication-dependent approach in at least four areas.

First, in the area of research, in the field of attention, for example, although the ADHD model has laid claim to scientific consensus, it has continued to receive criticism both from inside and outside the research and clinical communities.  Supporters of the behavioral approach have responded with a vigorous defense of the validity of the ADHD diagnosis and the efficacy and safety of stimulant treatment in a manner that has inhibited research into the heterogeneity of attention problems, enforced the notion that all children with attention problems suffer from the same general disorder of attention, and impeded research into treatments.

For example, despite decades of heavy stimulant use, there has still never been a good long-term study of their safety and efficacy.  The only large study so far into risk factors for persistence of ADHD from childhood into adulthood by Kessler, et al., which we had included in your briefing book, found that after controlling for symptom severity before intervention, the single factor most predictive of persistence was treatment for ADHD as a child.  Treated children had an almost five-fold greater risk of persistence.

Given the virtual absence of data regarding long-term consequences of therapy, the growing practice of treating children with stimulants, antidepressants, and even antipsychotics continues as a vast untracked experiment in clinical neuropharmacology on an absolutely unprecedented scale.

A second area where this behavioral paradigm has inhibited progress is in clinical diagnosis and treatment.  Unsurprisingly, schools and day cares are the leading catalysts for diagnosis.

With ADHD, in nearly 60 percent of cases, teachers are the first to suggest the diagnosis, though many teachers over-identify children at risk.  In one study of teacher perceptions, 72 percent of teachers identified over 5 percent of students as having ADHD, and fully one-third identified between 16 and 30 percent.  Importantly, those rates of identification increased with class size.

Placing teachers in the role of diagnosticians creates a difficult dynamic, in which parents often feel pressured to pursue formal diagnosis and initiate drugs.  If pills make children more compliant, yet parents refuse to use them, hard feelings can ensue.

In our clinic, we've heard from many parents who have been told by teachers or other school officials that a refusal to place their child on stimulants would result in harm, both to the child's education and to the classroom environment.

Although legal protections have prevented the most overt forms of coercion, teachers still hold considerable authority and function as gatekeepers to success through their abilities to assign work, provide grades, and recommend retention.

Problems with diagnosis and treatment are also seen in physicians' offices.  Studies have shown that in over half of cases where primary care doctors make the diagnosis of ADHD, they do so without following established guidelines or formally assessing the child's attention.

One community-based study of children receiving stimulants found that over 40 percent had no documented diagnosis of ADHD.  Another study found that in roughly one-quarter of visits in which a psychotropic medicine was prescribed, there was no associated mental health diagnosis in the patient's chart.

To be fair, primary practitioners face a difficult situation.  Most are not trained in alternative approaches to attention problems, and many feel short of other options.  Meanwhile, they are expected to do something to solve the child's problem within the confines of a ten-minute appointment.

Similar problems can also occur in the area of autism and autism spectrum disorders.  One paper included in your briefing packet showed how Department of Education statistics for autism were compromised by variations in state definitions for autism.

Oregon, for example, lists autism criteria as simply, "Impairments in social interaction."  So defined, autism is little more than oddism, and any child who differs from peers can be so labeled.  Predictably, Oregon has had the highest rates of autism in the country, two to three times the national average, since statistics were first kept in the early 1990s.

Now, this is not in any way meant to cast aspersions on the diagnosis of autism, which is a legitimate pathophysiologic entity, but it is meant to point out how diagnoses made primarily on the basis of behaviors often undergo a process of diagnostic mission creep, in which after establishing a beachhead in an area of true impairment, they are extended by analogy to include a much greater range of behaviors of far less severity until they shade imperceptibly into normal.

An additional source of difficulty arises when pressures faced by schools and physicians combine to create incentives to label children with behavioral diagnoses.

The IDEA and its recent amendment have effectively tied school services and insurance payments to a limited set of funnel diagnoses, like ADHD and autism.

Disabilities in reading, math, language, and writing are lumped together under the heading "specific learning disability."  And amazingly in many districts these so-called academic disabilities will not qualify a child for an individualized educational plan while so-called medical diagnoses, like autism and ADHD, will.

Two results follow.  First, there is often pressure to diagnose a child with ADHD or autism simply to access needed services or accommodations for a learning problem.

We had two cases just like this just last week.  One mother of a fourth grade girl with classic dyslexic reading difficulties and handwriting difficulties was told by the district that they didn't recognize dyslexia as a disability, but if she could get her daughter diagnosed with ADHD, she could have access to the same services.  This is a ridiculous way of handling diagnoses and children.

The second unwelcome result is that teachers receive lopsided and incomplete training on the nature of children's learning challenges because their education is geared to the current system.

Autism and ADHD receive star building, while more common disorders, like dyslexia or handwriting impairments, often receive little explicit coverage.  Consequently, teachers often tell us that they have little idea how to adjust their educational strategies when a student struggles other than to refer him or her to a learning specialist.

Unfortunately, many learning specialists and school psychologists also receive little training in brain-based cognition and neurodevelopment and often follow general, rather than individualized, approaches to helping struggling children.

All of these factors combine to funnel growing numbers of children into behavioral diagnoses and onto psychotropic drugs.  Between 1994 and 2001, psychotropic drug prescriptions soared for teenagers by 250 percent.  By 2001, one in every ten office visits by teenage boys led to a prescription for a psychotropic drug.

In his testimony before this Committee, Dr. Steven Hyman speculated that much of this explosion has been driven by inadequately trained primary care practitioners who aren't following guidelines for treatment.

While this unquestionably contributes, if it were the major driver, we would expect to see many children who had been placed on medicines by primary practitioners taken off them by psychiatrists and behavioral pediatricians.

But we very rarely see this.  Instead, specialists typically switch or even add medicines.  Although primary care practitioners may sign the majority of prescriptions, they appear to us to be reflecting the practices of the specialist practitioners they are referring to.

It's difficult to see how this problem can be resolved simply through continuing medical education when over half of the CME in the US is funded by drug companies.

A third place where behavioral dominance is inhibiting progress is in the area of the moral development of children.  The article in your briefing books from the New York Times on psychotropic self-medication in young adults entitled "Young, Assured, and Playing Pharmacist to Friends" is obviously not a formal study, but it does offer some important insights into the kinds of habits that can be engendered in children who grow up taking behavior and mood-altering drugs.

One young adult, for example, was quoted as saying "I feel like I have been programmed to think, 'If I feel like this, then I should take this pill.'"  Notice both the passivity and the sense of mechanism in the phrase "have been programmed."  These feelings mark the transfer of causal efficacy from will to pill, where the role of the will is reduced to the agent that picks the mood and selects the drug to reach it.

This is a considerable decline in the will's domain and a reminder that other things may be lost when control of troubling behaviors or moods is pursued through chemical shortcuts.

Drugs don't teach self-awareness, self-restraint, the ability to delay gratification, persistence, resiliency, or any of the other skills that children need to control their own behavior.  Yet, developing these traits is one of the crucial missions of childhood.

We should take these challenges very seriously if our goal is to help children develop into competent and productive adults and not simply to control their behavior.

This brings us to the fourth and final area in which the dominance of the behavioral paradigm has inhibited progress, and that's in relationships of adults with children.

Behavioral labels can dramatically affect how adults perceive and behave toward children by purporting to describe limitations in their abilities, feelings, personal will or agency, and moral capacity.

We've had many parents tell us how teachers or therapists after casually diagnosing autism have made sweeping pronouncements about their child's cognitive and emotional limitations, like the speech therapist who told one mother that her son's apparent maternal attachment to her was not true affection because he had Asperger's syndrome or the many teachers who ascribe the intense, advanced, and often specialized interests of highly gifted children to the perseveration of autism or the hyperfocus of ADHD, rather than seeing them as healthy manifestations of high intelligence.

Diagnostic labels can also diminish a sense of adult responsibility for helping children with behavioral problems.  They may convince parents that their children can't control or prevent their misbehaviors, which only feeds into the cycle of bad behavior.

For example, we failed to convince one highly educated and professionally successful couple that their son, who had been diagnosed with ADHD and Asperger's syndrome, needed to be disciplined for repeatedly trying to shut his younger sister's head in a door, rather than simply to have his meds adjusted.  Such a view limits both children's and adult's responsibilities.

If the behaviors are the result of a disease and the pills make the behaviors go away, then the scope of adult responsibility shrinks to providing the right drugs, rather than disciplining, training, or modifying the home or educational environment.

Teacher's, too, often find it easier to attribute inattentive or hyperactive behaviors to ADHD than to look for learning challenges that require special educational modifications.

Although we can't show a causal link, it's worth noting that there's been a dramatic and well-documented decline over the last several decades in educational intervention research while psychotropic use has skyrocketed.

Finally, the diagnostic and treatment practices that have arisen as a consequence of this behavioral model both raise and obscure important questions regarding the extent to which adult approaches to children with behavioral and learning problems are really beneficial to the children themselves and to what extent they are simply convenient for others.

One of medicine's most basic ethical principles is that interventions can usually be justified only when they primarily benefit the patient.  How does such a consideration affect, for example, the use of stimulants in ADHD?

In the case of children whose behaviors are so severe that they have difficulty functioning in any environment, a group most experts would place between two and three percent, the benefits of treatment are easier to cite:  improved relationships, fewer risky behaviors, et cetera.

Treatment with stimulants can sometimes produce dramatic effects in these children, though even in this group, it is worth noting that behavioral modifications can also be effective and there are also significant subpopulations of children in this group with a history of head trauma or prenatal exposure to drugs for whom medications are not at all effective.

In the much larger group of children whose functional deficits are less severe, the benefits of stimulants are less clear.  One benefit frequently sought is improved academic performance.

Most parents and teachers believe that stimulants can make children better learners.  However, data supporting long-term academic benefit is extremely thin.

In the MTA trial, scores on achievement tests were virtually unchanged by stimulants.  The sole demonstrable benefit, a one-point rise in a reading achievement test, is comparable to a one-point rise in IQ.

Although stimulants often do make it easier for children to stick with and finish assignments, they don't make them better readers, mathematicians, or historians.  Stimulants help children conform better to the schedules and activities they're assigned but not to perform better in the sense of measurable long-term gains in learning.

For many parents and teachers who have grown weary of scolding, cajoling, and wrestling, this can seem like a big victory, but the question is, a victory for whom?

The other key factor in determining the risk/benefit ratio is risk.  And for the reasons we've mentioned above, this factor can't clearly be established at present.

In all but the most severely affected children, the benefits accrue largely to others while the potential risks and the clear short-term side effects accrue entirely to the child.

In such a setting, "Do no harm" should be given more weight than it is.  At the very least the medical community should be more open in providing parents with a complete and accurate assessment of the realistic benefits and the uncertain risks these drugs may cause.

Although chemical states in the brain do influence behaviors and moods and drugs can influence these chemical states, it's also true, as we have heard from Dr. Greenspan, that non-medicinal interventions can also alter brain chemistry and behavior in desirable ways.

Unlike medicines, which largely work only as long as taken, changes induced by new habits, new ways of thinking, and new ways of behaving really do become part of a child's neurological and behavioral fabric and are generalizable to many activities.

This brings us back to the question of the fundamental needs of children.  One overwhelming need is an approach to education and development that works with, rather than simply on, their developing nervous systems.

In contrast to the behavioral approach, whose disconnect with causation leaves it dependent upon the promise of better living through chemistry, a more neurologically based approach holds out the promise of better chemistry through living; that is, better neurological development and function through targeted experience or experience-directed neuroplasticity.

The brain possesses a remarkable capacity to rewire itself in response to experience.  By carefully targeting inputs through teaching, therapy, or play, existing brain pathways can be trained to function more smoothly, old blocks can be bypassed and new learning pathways can be developed.

By breaking down complex behaviors, like reading, listening, or paying attention, into component functions, then training those functions through targeted experience, researchers have dramatically improved function in the complex activities.

For example, Klingberg and colleagues in Sweden have significantly improved working memory and reduced ADHD-type behaviors in children diagnosed with ADHD using a computer-based training program.  And in children with reading difficulties who are often diagnosed with ADHD because of difficulties listening or concentrating on visual materials, researchers like Harold Solan at the State University of New York and Michael Merzenich at UCSF have shown that children can improve their reading skills by intervention that improve visual attention and auditory discrimination.

Work like this should lead us to abandon the view that children with learning and behavioral challenges are simply deficient in various brain functions or chemicals and see them, instead, as needing new experiences that can help them learn and function in new ways.

What we are arguing for is an approach we call "positive neurology," in analogy to the positive psychology movement that has shifted this field's emphasis from the relief of mental illness toward pursuit of mental health.

A similar trend in neurology, which aimed beyond cataloging weaknesses to developing strengths through targeted therapy, could revolutionize our approach to struggling children.

A child's brain is remarkably resource-full because of its plasticity and its diversity of systems.  That's why most children with learning and behavior problems can be greatly helped by reshaping their experience, both in the sense of general environment and in the therapeutic sense of targeted experience, to optimize performance and develop new capacities.

Our obligation to children is not simply to stimulate or sedate them so they can conform to the demands of a system that is not well.suited to their learning and their developmental needs but to create a system that better promotes development.

To accomplish this, our schools and our society's parents must develop a more neurologically informed understanding of the diversity of childhood development.  While all children must acquire certain necessary skills and essential knowledge, the experiences they need to acquire them will differ from child to child, both in nature and in the rate and manner of delivery.

Children differ markedly in the ways and rates at which they develop.  And a given child's development may differ greatly in different areas.  That's why attempts to educate all children in the same ways and at the same rates result in so many learning and attention problems.

There's no reason to assume that all children should make identical progress in all subjects using identical approaches, nor is there any reason why a child should be prevented from making additional progress in one area, like math, because he is not moving as fast in another, like reading.  Yet, these are standard assumptions in most of our schools.

Failing to take neurodevelopmental variations into account in designing schools means many children suffer needlessly because they're developing in ways or at rates that are poorly suited to a one-size-fits-all education.

It's as if our schools had adopted a factory farming model, where cacti and orchids were treated just like potatoes.  No one would try to raise plants with this model, and it works no better with children.

Younger boys are particularly likely to be disadvantaged because auditory processing and motor delays are much more common in males and often present as difficulties in attention.

One-third of five and six-year-olds cannot process a sentence longer than nine words.  So all that's retained from "When you need to go to the restroom, raise your hand and wait until I call on you," is "When you need to go to the restroom."  It's easy to see why such children can appear impulsive or inattentive.

Likewise, children with sensory-motor delays who require frequent movement to stay attentive may suffer learning and behavior problems when classroom schedules require lengthy seated work.

Schools must recognize that children develop at different rates and in different ways.  Rather than trying to modify them to fit arbitrary educational frameworks, we should design our systems to promote healthy neurocognitive development for children with all sorts of learning and processing styles.

There is no one right educational approach for all children.  And trying to design our systems as if there were will inevitably cause difficulties.

One key area in which a more neurologically appropriate understanding is needed is in the concept of basic skills.  When we ask educators, "What are basic academic skills?" most cite memorizing the alphabet, learning letter sounds, counting, performing simple calculations, and mastering penmanship.

In reality, these academic skills require complex mixtures of many underlying functions.  Before children can master ABC or 123, they must first master even more basic neurological skills, like auditory discrimination; speech-in-noise perception; visual perception; sensory motor skills; memory and language skills; and attention-related skills, like mental focus, motivation, and impulse control.

Normally, these skills are developed through interactions with parents, siblings, and peers, but for some children, like those Dr. Greenspan talked about, often who have impairments in sensory inputs or in the connections that integrate brain functions, routine play may be too confusing to stimulate optimal development.

These children must have their needs specifically assessed so lagging functions can be developed through the use of targeted experience or therapy.  For most children, this will involve the use of highly structured play activities, where incoming patterns are simplified for easier processing and repetition is used to enhance retention and increase the possibility of new associations.

In the future, older children, in particular, will benefit tremendously from a continuing breakdown of the artificial barriers that divide play, education, development, and therapy.

Both schools and therapy centers would benefit from an increasing use of technologies that allow sensory inputs to be precisely and repeatedly delivered, feedback to be immediate and direct, and progress to be monitored, not only by therapists and teachers but also by the children themselves.

This is one area where government can play a vital role by bringing together experts in education, neurocognitive development, and the software and video game industries to discuss ways in which healthy neurocognitive development can be promoted through educational, therapeutic, and entertainment programs.

We are already beginning to see games that were developed purely for play that can be used therapeutically to improve mental focus, impulse inhibition, and motor control in ways that generalize to academic skills, like the popular Dance, Dance Revolution, where children imitate movements on a screen by dancing on a pad that registers their movements.

By intentionally promoting needed skills, companies like Electronic Arts, Nintendo, Microsoft, and Sony could promote skills in behavioral control undreamed of by Pfizer and Merck.

Another way to promote healthier neurocognitive and behavioral development is by providing a greater degree of individualization in the learning experience.  Basic neurological and academic skills can be acquired in many ways.  And ideally each child's instruction should be tailored to make use of his or her optimal learning style.

The key to individualization is providing incremental challenges that are adjusted continually through ongoing assessment.  Research on motivation has shown a crucial relationship between success in learning tasks and continued motivation.  When children fail to achieve a critical ratio of success, motivation plummets, and they simply stop trying.

Children are often diagnosed with attention problems when they give up on tasks where they believe they can't succeed, like reading, writing, or math.

After repeatedly facing challenges that demand unmakeable, rather than incremental, leaps in their exercise of skill, they simply lose heart and give up.  But even thoroughly discouraged children can be rejuvenated by success.

We often see children who have given up in school work hard on demanding remediative therapies once they've seen how small successes build in a step-wise fashion.  Success breeds success by developing a taste for mastery.

Research has shown that mental focus increases dramatically in children who have been diagnosed with ADHD when they're given meetable challenges and deteriorates both when the challenges are unmeetable or crucially not challenging enough.  The desire to achieve mastery is natural.  Apathy is learned.

In summary, children need educational and clinical approaches that work to support their neurocognitive development in ways that develop their strengths and minimize their weaknesses, not approaches that attempt to stretch and trim them to fit artificial and arbitrary frameworks.

The development of a child's mind is a kind of unfolding or flowering that we can't wholesale create but which we can nurture into fullest bloom.  The metaphor is the garden, not the factory farm and certainly not the neurochemist's laboratory.

While we neither could nor should seek to eliminat