THURSDAY, February 2, 2006
Session 4: Fundamental Needs of Children
Brock Eide, M.D., M.A. and Fernette Eide, M.D., Eide Neurolearning,
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
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
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
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
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
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
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
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
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
— and 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'
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 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
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.
CHAIRMAN PELLEGRINO: Thank you very much, Dr.
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
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
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
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
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
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
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
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
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
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.
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.
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
CHAIRMAN PELLEGRINO: Full agreement with that.
DR. FERNETTE EIDE: You're so kind. Thank
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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 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,
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
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
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
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
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
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
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
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
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 eliminate all adversity
from our children's lives, we should seek to create ways of
raising them in which challenges and struggles result in growth
and development, not frustration, misbehavior, diagnoses, and drugs.
CHAIRMAN PELLEGRINO: Thank you, Dr. Eide and
CHAIRMAN PELLEGRINO: Are there questions? Dr.
DR. MCHUGH: Can I just make
one point? Obviously I'm not going to repeat what I said before.
You are beating on an open door with me. And until we change the
general direction of the American Psychiatric Association so that
in 2011, we don't have DSM-V, son of DSM-IV, son of DSM-III
— if that happens, it will be a disaster for American medicine
and for all the people. Okay? You should be screaming about it.
I'm screaming about it. And we'll all scream.
But I can tell you it's not likely to make any difference
because institutional psychiatry at the moment has this in its bit.
Bob Spitzer and everybody else says the following. This is the
central dogma of contemporary psychiatry. We do not know the cause
of any psychiatric disorders. Okay? That's the central dogma.
And it is amazing to hear it read out that way and produce this
imitation of Roger Tory Peterson.
Now, the second point I want to make, though, to you is that everything
you said today is wonderful to hear, but I heard it and everybody
heard it a long time ago. In what way are you different from Itard;
Seguin; Gallaudet; and, of course, the wonderful Maria Montessori,
who said all the things that you have said, not in quite the task
that you said it in but said it in exactly the same way, the incremental
learning, the differentiation amongst children, the children learning
at their own rate, all of that? Don't you agree with me or
DR. BROCK EIDE: Well, I think there's a
few things to say on that. Number one, I think the neuroscience
is starting to catch up with the —
DR. MCHUGH: With Montessori.
DR. BROCK EIDE: — with the political perception,
DR. MCHUGH: She was wonderful.
DR. BROCK EIDE: You know, and empiricism and
basic research are basically the two hands that go together that
need to accomplish any subject. Hopefully the impetus from showing
where some of the research is heading can help to move that along
in a policy perspective.
I think, you know, another way that the setting is somewhat different
now is that we're unquestionably in the midst of a crisis in
education that is universally recognized and that is not going anywhere
I think that, you know, we made the little comment about the No
Child Left Behind policy. Some good things have come out of it.
I mean, it certainly made a lot of extra work for us, but it's
also helped to really strip away any pretense that there is no crisis
DR. MCHUGH: I see.
DR. BROCK EIDE: And it has put a sense of urgency,
I think, on, you know, the state educational associations and the
teachers that we talk to. They're starting to feel under the
And I think that we're going to be able to see a willingness
to try more variations within the public school system than we have
seen before. So I think that is different.
DR. FERNETTE EIDE: I think that the internet
also has affected things. We get a lot of parents who are really
combing the internet looking for answers. And, in fact, there have
been a number of papers sort of actually ruing the fact that parents
are trying to end the drugs as soon as they can after they have
been on it.
And I think there is a lot of interest and there are a lot of
people who are also really fascinated by the neurobiology and the
fact that functional imaging gives us a much better view in terms
of what is happening with learning disabilities as well as why kids'
brains are so different from adult brains.
So I think all of these kinds of things are swirling influences
that can lead to a discussion on a deeper level.
DR. MCHUGH: Well, I will be
happy with the deeper level. But the practices are all the same,
as I said, from Itard through Seguin to Gallaudet to Montessori.
They are not different.
DR. FERNETTE EIDE: Well, I will tell you one
DR. MCHUGH: And I want to know
in what way. But I might be missing something.
DR. FERNETTE EIDE: Yes.
DR. MCHUGH: I mean, I love
DR. FERNETTE EIDE: Yes, yes.
DR. MCHUGH: I've got my
friend here, who tells me it's the greatest. But I want the
psychology to do the thing.
DR. FERNETTE EIDE: We have been telling stories
here today. I have noticed that. So let me tell you a story.
DR. MCHUGH: Okay.
DR. FERNETTE EIDE: All right. Well, there was
an epiphinal case for me, actually, when I was asked to see in the
hospital a woman with juvenile diabetes and clearly an intelligent
woman. It was one of these kind of hopeless things. She's
complaining of memory problems, probably nothing we can do.
When I went to see her, it looked hopeless because she did the
digit span. The notorious thing for neurologists is, can we escape
diagnosis and adios? That is what we are trying to do.
DR. MCHUGH: That's right,
DR. FERNETTE EIDE: But the interesting thing
for me was that she said she could only remember, actually, two
digits. She couldn't remember two digits in reverse. She could
remember two digits forward.
And she said, you know, "My daughter starts talking to me,
and I cannot even keep in the conversation. Once she starts talking,
I can't remember the beginning of the conversation. It looks
And then I thought, well, this is an interesting situation. I
wonder if this would help. She was a juvenile diabetic. And she
had become blind. But I saw all this fascinating work about visual
imagery. So she had acquired blindness. She was not congenitally.
DR. MCHUGH: Yes.
DR. FERNETTE EIDE: So I said, "Well, I'm
going to give you the digits. And now visualize them in your head.
It's a much more diffuse network, actually, than actually just
And so I said, "Well, now try to do it." She could
keep six in her mind with visualization. I thought, you know, "What
have we been doing all this time?" You know, why don't
you have a situation where you actually see someone who is aware
of how the brain is constructed and you say you have a block and
then you problem-solve and try to figure out around it?
We have a lot of psychometric exams where you have a standardized
battery. You can't go any other way. We've taking a lot
of the tools, for instance, like Mel Levine, where he gives you
a lot more flexibility when you administrate the tools.
So if we see a kid who has a block, a real bad block in anything,
we try very hard to find a way around it. And that's a different
approach to taking neurodiagnostics. And our hope is that, actually,
it becomes much more popular because it's using all this latest
research but, really, for a much better purpose.
And I think that, really, it certainly transformed our way of
thinking about things. And there's much more tools than you
CHAIRMAN PELLEGRINO: Meilaender and Foster.
PROF. MEILAENDER: Thank you
very much. This was very helpful and interesting to me.
I just want to make two comments. These are not really questions.
And so you don't have to feel compelled to reply to them. They
are also not criticisms. So you won't have an urgency of replying
But just for our own work, I wanted to note two things that struck
me while you were talking. One was a place where you were talking
about that New York Times article that you had included in the briefing
book. And you had the sentence about "These feelings mark
the transfer of causal efficacy from will to pill."
That clearly relates to our discussions about dignity. I mean,
that dignity is not just a theoretical discussion, in fact. If
you're right, then there's something wrong with what Patricia
Churchland was up to this morning, not in her presentation, which
had nothing to do with it, actually, but in the paper that she had
And so there are connections, actually, between what you are talking
about and those larger theoretical questions that we're taking
up in a sort of different area of our work.
The other thing, as I found myself listening to you, I was thinking,
"Yes, but we can't correct the profession of psychiatry.
We can't." And I started feeling sorry for teachers who
would be asked to try to accomplish this. I mean, it's not
a job I would want to undertake. And I'm not sure that we can
correct that either.
Another phrase you had with respect to just the medications that
these children are receiving, you spoke of a vast, untracked experiment
in clinical neuropharmacology. Bioethics, one of the things it
deals with is research, experimentation, and the ethics that ought
to govern it.
And if there's really a vast, untracked experiment going on,
then that is a legitimate bioethical concern that it seems to me
if we're thinking about sort of where does this big project
that we're sort of rummaging around in come to focus in various
ways is one possible place where it comes to focus.
CHAIRMAN PELLEGRINO: Yes?
DR. SCHAUB: I know that is late. I've got
one very quick question. How much would sex-specific education
help with this? In other words, we may not be able to move our
educational system towards completely individualized education,
but if there are some real differences in the way boys learn as
compared to the way girls learn, would that help?
DR. BROCK EIDE: Yes. What you basically have
with the two populations of boys and girls, I mean, within each,
you're going to have a range of learning style. So you will
have some boys that are predominantly auditory learners. But they
will be a much smaller group than you will see among the girls.
So you have different populations that differ a lot from each other
but are more homogenous within the group.
So each group has a splay, but it's a smaller splay than the
total population when you combine them together. So it would be
a big step in the right direction all the way throughout the educational
scale but especially during the early years.
CHAIRMAN PELLEGRINO: Any other questions?
PROF. GEORGE: Just to be clear, it would be single
sex education? sex-specific education is the it that would be —
DR. BROCK EIDE: That's right.
PROF. GEORGE: — good to have available
all the way through?
DR. BROCK EIDE: That's right. That's
DR. FERNETTE EIDE: For options.
CHAIRMAN PELLEGRINO: Other questions?
CHAIRMAN PELLEGRINO: Thank you very much.
DR. FERNETTE EIDE: Thank you.
(Whereupon, the foregoing matter was concluded
at 5:47 p.m.)