T h e  M u s i c C l u b

Son Vi Nguyen, M.D. Writings


Perry Como "And I Love You So"

   
 

MORAL DEVELOPMENT

REALITY AND MYTH

 

LETTER TO MOTHER

 

                                                    Compiled by Son Vi Nguyen, M.D.

 

 

Dear mother,

 

          I remember Wittgenstein saying that it is impossible to have propositions about ethics; thus, we must be silent about what really matters in human life and the only way we can speak about these topics is through the imprecise and emotive connotations of poetic metaphors. I really think that there is nothing more poetical than the moral development in me in its very first development inside you, amidst the fluid that was part of myself and indirectly of yourself. It was this warmth inside you, and all the emotions that you have about my growth that gave me the feeling of well being and the sense of good. It was then me, but also part of you, and really there was no difference between you and me. This wonderful symbiotic relation which made no distinction between me and the whole universe also gave me a sense of good. And if I can define development as changes of the structural laws of the organism, there must be an internal process that tends to bring me to a state of new equilibrium and stability. This equilibrium and constantly newly acquired stability made me feel secure and good.

 

          And then came the day when you gave me the right to breathe my own air, to see with my own eyes and to feel the outer world with my own senses. My relation with you was still a symbiotic one in which you and me made two but at the same time was only one, and then I heard people starting to assess and comment about my development. I was there, this little creature experiencing changes every moment of my life, but in spite of these changes, of this development, I knew that I was a reality as any other reality in this life, but this reality has been" seen in so many ways, and assessed so differently by what is known as schools of thoughts - and their approaches of considering the moral development in me are so antagonistic that they appear to be irreconcilable.

 

          First, there was this mechanistic concept about my moral development that made the ego in myself so uncomfortable that I would like to mention first in order to forget it as fast as I can.

 

          There are these assumptions at the foundation of the mechanistic approach. First, that the human mind is like a tabula rasa, a blank page, infinitely malleable and open, whose only contribution to its own change lies in its state of readiness and receptivity. Second, that the human mind is affected by elementary sensations in such a way that its overall state could be described perfectly by the sum of the units of stimulations.

 

          There is summation instead of structuralization. And finally, the mechanistic view postulates that the human mind changes in a more or less stable way by accumulating associations and systems of associations between elements. These associations take place under the influence of external conditions, the recurrent patterns, of events, reinforcements etc... The mechanistic mind, empty and receptive, is essentially passive. Like a camera, it imprints what is offered to its eye, and all that is offered is imprinted. And while the organism defines the environment, the environment defines the mind machine. Thus, understanding only means establishing casual connections: we know the mind when we know what produces it. The mechanistic view looks at development as a neat and continuous succession of changes, and as Berlyne (1965), and Mischel (1969) see it, although there could be associations and relations in the human mind, these relations just happen to be the way they are, like those existing between the stones of a heap. The mechanistic approach refuses to recognize anything special in development that would differentiate it from other changes. These changes in developmental process do differ from each other in duration, consistency, orderliness etc... but the differences depend simply on what is offered by the environment.

 

          Completely opposite to the mechanistic view is the organismic approach of moral development which recognizes in the mind a more active role able to select the environment and interpret what is selected. The mind doesn't imprint things passively as a movie camera where the order of the structures is just a matter of continuous succession of changes received as they are. But as Piaget sees it, there is selectivity and flexilibility, namely articulation and accommodation, in a very structured way where development occurs as a series of upheavals and discontinuities. Here development takes place in synchronization with and closely related to the cognitive development. This development consists of structural changes, any new structure constitutes a break from the old one. This is not the result of addition or subtraction, but at any time there is establishment of new principles governing the relations among the parts. In the same time, the selectivity by which the organism functions and the tendency always to integrate the available material, guarantee a fundamental activity between the successive organizations of a developmental sequence.

 

          You can imagine that I feel much more comfortable with this organismic approach to psychological development in general and to moral development in particular, because this approach recognizes the specificity and uniqueness of the individual and in the same time distinguishes the common ground that the human mind shares with one another.

 

          Without excluding one another, many different organismic concepts of moral development have been proposed going from  structuralism found in the French school represented by the anthropologist Levi Strauss, the philosopher-psychologist Foucault, the psychoanalyst Lacan and the philosopher Althusser, to cognitive developmental ism whose main proponents are Piaget, Wallon, Ball and Kohlbert or also to interpersonal psychology portrayed by Harry Stack Sullivan.

 

          Having known with you the wonderful experience of the object relation that, as Erick Fromm in Escape from Freedom sees it, has come to free me from my environment and give me the feeling of security through the concept of object permanence. I feel myself cherishing Sullivan's interpersonal view about ego and moral development. Sullivan assessed that moral development in its first beginning can be seen in the infant's earliest self-concept which is split into three elements: The good-me is whatever leads to or is associated with mild or moderate anxiety and the not-me is associated with sudden access of overwhelming anxiety which cannot be integrated by the infant as a learning experience, the not-me is the equivalent of Freud's "traumatic events" which are subsequently repressed into the unconscious. The infant's first. experiences of good and bad are related to his own experience in the relations with his mother, as the infant distinguishes only good-mother from bad-mother, this . notion of good and bad can be considered as the first basis for moral development, because for the young infant all good ones are the same person, and all bad ones are the same person. As the child experiences feelings through his senses, he integrated the good-me and the bad-me into my body as opposed to the environment. Language helps from the personification of the good mother and bad mother into my mother who is no longer interchangeable with surrogates, the child begins to distinguish him from others and from the environment. He recognizes what is good or bad for himself, and what is good and bad in others. Getting out of his symbiotic growth with the earth, the child's interpersonal learning of this period is based on human models that Sullivan called dramatizations. His moral understanding and behavior is constructed by acting like, sounding like his parents. In this play, a lot of fantasy is involved; but as the child enters the juvenile era, there is an increasingly clear distinction between reality and fantasy by means of "consensual validations" by which Sullivan means the importance of others in consolidating one's perception of reality. As the child matures, the role of mother in moral development declines in favor of peers. Popularity and approval are motives with ostracism the corresponding sanctions. This juvenile era sees the favorable formation of an orientation in living that represents long term goals and values. Sullivan also discusses the consequences brought by the difficulties that the child experiences in his developmental process which is reflected in what Sullivan called "malevolent transformations". These malevolent transformations constitute or bring about a practical arrest of development, a concept very close to Freud's fixation theories.

 

          Piaget had an important contribution to the study of moral development although most of his ideas about the subject were found directly in one volume called "The Moral Judgment of the Child". Many critics had been voiced against Piaget because of his lack of age related study and his little interest in individual differences as such.

 

          In fact, Piaget explored the moral judgment of children by asking them what a lie is, and why it is bad; which of several misdemeanors is worst and why; which of several punishments is fairest and why, and where the rules of the game of marbles acquire the sanction.

 

          Piaget sees moral judgment in terms of polarity with heteronomous morality at one extreme and autonomous morality at the other. However, there is also a prior stage called anomy.

 

          From the beginning, the infant has no conception of rules, he simply follows his own wishes. As his motor development progresses, allowing him to have more control over his movements, he plays with toys such as marbles according to repetitive motor schemes, largely dictated by the nature of the materials. These motor schemes are the forerunners of rituals, thus of rules.

 

          Imitation of the parents or older children takes place as the child grows a little older. In games, the child does not understand that the aim is to win, his point of view is egocentric, where everything is interpreted in terms of his own interest. Physical and moral laws are not differentiated. Things are as they should be and as powerful persons like father decree that they shall be. What is bad is what is punished. At first, punishment for misdeeds seems not so much exacted by individuals as immanent in things; later, it appears as arbitrary revenge, which gives way to the notion of expiation. Since the child does not see anything wrong about speaking his fantasies aloud, he cannot comprehend what a lie is, except that it is spoken and punished; hence a lie is at first just a "naughty word".

 

          This heteronomous morality rises from unilateral respect of the child for his parents and is enforced by constraints. The child regards the rules of the game as sacred and given for all time or decreed by adults. A change of rules would be a transgression. The very exteriority of the rules, however, means that he does not obey them dependably. Responsibility for accidents and transgressions is "objective" that is, the greater the palpable damage, the greater the fault, regardless of interest. A big exaggeration is a worse lie than a little exaggeration, even though it deceives no one. Thus, what matters is not consequences but what is real to the child.

 

          Piaget also used the term of "moral realism" to describe the thinking of this stage, meaning that morality is thought of as subsisting outside of and independently of the child's own mind. Its three features are that the good is defined entirely by obedience, that the letter rather than the spirit of the law must be observed, and that actions are evaluated not in terms of motives, but "objectively" in terms of exact conformity to rules. Here, the egocentrism implies a confusion of the subjective with the objective and the moral development proceeds by intellectual constraint by adults.

 

          As the child grows older, he has more interaction with other children. The game of marbles is particularly valuable for judging the child's development, since boys of about twelve or thirteen years are the oldest players. By this game, one can recognize the development of the premises for social contract, the children understand that they can change rules by mutual consent, that the rules vary with time and place. There is from the mutual agreement an interiorization of the rules. Between children of the same age, there arises mutual respect, as opposed to unilateral respect, and thus, reciprocity and cooperation which are the essence of autonomous morality. The paradoxical result is that the child becomes dependably faithful to the rules when he no longer believes they are sacred and uninsurable.

 

          At the stage of autonomous morality, the child believes in subjective responsibility, that is, the intent behind the transgression is what makes it reprehensible. A lie is wrong because it deceives, a mistake committed inadvertently is hardly reprehensible since it deceives no one. Retributive justice gives way to distributive justice. Punishment is not motivated by the need of expiation, rather, it restores reciprocity. Older children choose less harsh punishments than younger ones and opt for no punishment beyond disapproval or mere explanations of why something is wrong. It is interesting to observe the final stage of the game of marbles. Some of the oldest children, in their conception of distributive justice, go beyond equality to equity; that is, rather than treating everyone strictly the same, one should make allowances for special circumstances. Piaget believes that reciprocity, which is the basis for autonomous morality, is more compatible with equilibrium than is unilateral respect for authority, and it is the need to communicate which lends to formulation of reasons, thus, it is the moral and social mode which account for the child's intellectual advance. Piaget points out that the function of rules is about a year ahead of the consciousness of rules. From these concepts, it seems that Piaget wants to prove the moral superiority of children to adults. There is a lower kind of morality, heteronomy, based on the authority and constraint and higher kind of morality, autonomy, based on cooperation and reciprocity. Piaget considered that the inequality of a yes must give rise initially to heteronomous morality, but parents and teachers, by demanding obedience and conformity and sometimes even punishing cooperation between children, discourage normal progress toward autonomy which is the appropriate form of morality in adults in a democracy. Piaget wrote: "If one thinks of the systematic resistance offered by pupils to the authoritarian method, and the admirably ingenuity employed by children the world over to evade disciplinarian constraint, one cannot help regarding as defective a system, which allows so much effort to be wasted instead of using it in cooperation". Piaget also believes that even under the most benign regime, children will go through the heteronomous stage before achieving the autonomous one. Moral realism reflects the small child's intellectual realism, that is, his tendency to see things in concrete and simplified form.

 

          It will be hard to deny the value of Piaget's contribution to the understanding of moral development in the child, but his views had been also subjected to discussions and critics because of some contradictions that these views contain in themselves, particularly with regard to the concept of Piaget assessing that these cognitive capacities of the child limit him at first to moral realism.

 

          In fact, N.J. Bull objects to Piaget's view of heteronomy as a hindrance to development of autonomy. Bull believes that heteronomy is a necessary predecessor of autonomy. Bull insists that autonomy is grounded on heteronomy rather than on reciprocity.

 

          Bull's methods of investigation do not differ very much from Piaget's. He divides moral development into four stages: Anomy, Heteronomy, Socionomy and Autonomy and there are types of people who remain at each stage into adult life, and each stage persists as a pattern of moral judgement .after it is outgrown, thus, Bull's conception is a true developmental characterology.

 

          Secondary to Bull, Anomy is a premoral stage in which behavior is instinctive with pleasure and pains as sanctions. Bull refers to Kant to define heteronomy as morality imposed from outside and autonomy as morality freely accepted, thus arising within. Heteronomy develops to Socionomy. Socionomy is external, internal morality, it covers the era when moral judgments are shaped by relations with others especially peers. There is a beginning of a sense of obligations and responsibility. Self-respect and guilt begins to replace fear as a motive for moral conduct. Public opinion becomes an authority, dread of social isolation, sympathy and altruism become the main concern. This stage corresponds to Piaget's reciprocity.

 

          During the last two decades, Kohlberg had a very precious contribution to the study of moral development. He was influenced by the ideas of Baldwin, McDougall and Mead and even Piaget whom he seems to be often critical. Kohlberg considers the child's moral judgments evolving as a function of cognitive and emotional restructuring in a foreordained sequence. Kohlberg's chief instrument has been incomplete stories presenting classical moral dilemmas. Kohlberg's emphasis about wrongness is slighted from the content of moral judgment to its form. What evolves and becomes increasingly moral with age is not the specific actions condemned or approved, but the child reasons, his structuring of the situations.

 

          In designing his concepts about the stages of moral development, Kohlberg received a strong influence from McDougall who sketched the moral behavior as proceeding through the four following stages:

 

          1. The stage of instructive behavior modified only by the influence of the pains and pleasures that are incidentally experienced in the course of instinctive activities.

 

          2. The stage in which the operations of the instinctive impulses are modified by the influence of rewards and punishments administered more or less systematically by the social environment.

 

          3. The stage in which conduct is controlled by the anticipation of social praise and blame.

 

          4. The highest stage, in which conduct is regulated by an ideal of conduct that enables a man to act in the way that seems to him right regardless of the praise or blame of his immediate social environment.

 

          Starting from McDougall's stages of moral development namely: 1/ the premoral level, 2/ the level of conventional role conformity, 3/ the level of self-accepted moral principles, Kohlberg discerns within each of these levels two types. These six types of moral orientation represent Kohlberg's stages of moral development.

 

          *Type 1: Punishment and obedience orientation, there is no concept of duty or morality except in terms of concrete rules enforced by external constraints. Punishment is conceived as personal retaliations. People of high status or authority are not bound by rules. Authority is seen in terms of age, size and power. Respect for authority simply means obedience. There is no concern for the welfare of these beyond avoiding taboos acts. The value of human life may be confused with the value of physical possessions, or it may be based on status or physical attributes of the person.

 

          *Type 2: Naive instrumental behavior, rules are followed in order to obtain rewards and favors. There is a beginning of reciprocity. Rights are based on ownership; there is no concern for how exercise of one's rights may interfere with rights of others. Punishment is not needed if physical restitution or other undoing has occurred.

 

          *Type 3: Good-boy morality of maintaining good relations with and approval of others. There is a genuine sympathy and liking for others and concern for maintaining loyalty, deviations from rules are permitted for the sake of loyalty. Moral reciprocity is based on gratitude rather than a one-to-one exchange. Authorities are idealized.

 

          *Type 4: Authority-maintaining morality - one conforms to avoid censure by authority and resultant guilt. The law demands invariant obedience because it is the basis of the social order which maintains distributive justice. Exceptions to moral and legal rules are not justified on the basis of status but may be justified by the situations. Punishment is seen as expiations, paying one's debt to society, it makes the culprit feels remorse. Persons at this level deny the possibility of moral conflict and do not feel responsible for the effects of their behavior beyond their defined role responsibilities. Life is seen as sacred in terms of its place in a categorical moral or religious order of rights and duties.

 

          *Type 5: Morality of contract and democratically accepted laws, one conforms to maintain the respect of an impartial spectator judging in terms of the community welfare. Laws command obedience because. they are. the product of democratic process. Distributive justice is conceived in terms of equality of opportunity rather than of outcome. Respect for authority is based on the qualities necessary to be chosen rather than on status as such. Punishment serves rehabilitation, there are universal human rights.

 

          *Type 6: Morality of individual principles of conscience, one conforms to avoid self condemnation. Duty is an inner compulsion of conscience. Moral principles are universal axioms from which concrete rules can be derived. Reciprocity is based not on contract, but on the need to maintain personal trust as a condition for an ideal society. The sacredness of human life represents a universal value of respect for the individual.

 

Dear Mother,

 

          I am sitting here, in the dawn with its beauty and the hope that any beginning is bringing to man, writing to you about all the concepts of moral development that so many prominent authors have tried to shed light on in order to give man the hope that he is having a strong grip of the stone of wisdom. I want to be optimistic; the more man understands the principles of morality, the more secure the world we are living in is. But didn't you tell me also that the happiness of man lies not in the process of moral development, but on the end-product of this development, on how man understands and believes in the principles of Right and Wrong and is willing to live up to them.

 

          But mother, don't you think that man has not thought enough about morality and the value of his conscience. And how about Immanuel Kant, Alexander Bain, Stuart Mill and Herbert Spencer, Dewey, Tuffs and many others more?! Are these names not enough to insure that man has in his possession the real "code of ethics" that lights his way up and bringing him to glory.

 

          Glory! - Oh! forgive me mother; now I remember the way you looked at me when I was talking the other day about man's glory. I still hear your voice: "My son, man's glory is still an illusion, the advance in technology makes man too proud, and this is the sickness! Where man sees as his glory is only his morbid pride, his narcissistic pretension; that pretension which lessens man and denies him of his own value. Man will only find the way to glory the day he recognizes not only the value in him, but also the value in others, because let me tell you one thing my son, there is a rule of morality that makes morality truly ethical, that is consistency. Consistency which makes things in this world congruent, truthful and reliable. Consistency which denies the right of the deceitful and the hypocrite. Consistency which makes this world a better place to live because there will be more place for faith and love. And, yes my son, you still hear and see many contradictions in life. You hear the world over praising love; and yet, we are still living in a world of violence and hatred; you hear echoing everywhere the words of God that everyone is born equal, and yet in many parts of the world the belief is still kept alive that the value of a man is predetermined by the color of his skin and not by his intrinsic human nature. And in some other parts of the world, freedom is mentioned as a prime value and yet to preserve freedom they say that you have to surrender your own freedom. And you hear about fairness as being one of the value in a civilized society, and yet the law of the stronger is still the rule. Don't you tell me that I am teaching you the loser’s view and how to be a pessimist. No my son, I am just telling you about the reality of life, about not making a myth a reality. Morality is still a myth not because it has not been conceived, but just because man has not learnt how to help it through its difficult labor, so it has never been delivered. Morality is not a reality, but it does exist. It exists from the time the creature called Man began to be a fact of Nature, bringing with him the ultimate value of life. Its existence never came to reality just because man has failed to live up to his own value, that is why, as paradoxical as it may appears, morality is a myth in a reality and a reality in a myth! And one thing I want you to remember my son, is to never surrender your faith. Those who believe in happiness will have happiness, those who still believe in moral value, will never lose their own value."


 

 

Thank you mother for giving me hope in this life. Thank you for making me understand that all the contradictions and inconsistencies are facts of life, Sisyphean works which have their own value because they demonstrate that man still has energy to work for a change. Thank you! the many people who have so much toiled, suffered and even given their life to make our world a better place to be, to make this flame of hope still burning. Thank you for keeping this prophecy of William Faulkner alive that ultimately "not only man will survive, but he will prevail".

 

Fall, 1982, redacted Winter 2008

 

Dr. Son Vi Nguyen is

former Assistant Professor of Psychiatry at:

 

-         The University of Texas School of Medicine at Houston

-         Texas Tech University

-         The Texas College of Osteopathic Medicine

 

 
 

CHILDREN'S STORIES: Meanings And Applications

 

                                                                                                                           by Son vi Nguyen, M.D.

 

                                                  We are inclined to put a sharp limit between

                                                  fantasy and reality,  but the fact is that often 
                                                               our life is a living dream where reality and

                                                   fantasy are involved in an endless waltz...

                                                                                                                                                          S.V.N.

 

Ladies and Gentlemen,

 

I have always believed that stories that we happen to hear in our childhood do not die with time. Not only they don't die away, but constitute a powerful dynamic force that has the capacity to influence      our life                    either at a conscious or unconscious level. I guess that some of you have heard about the story of Barry Clifford who recently discovered the treasure of the Whidah, the flagship of the notorious buccaneer Sam Bellamy which sank in 1717 within sight of the beach at Cape Cod. Let's leave it to Barry Clifford to explain how he happens to think of the famous pirate's treasure and make its hunting a lifetime dream: "My uncle Bill Carr, a master storyteller, first told me of the Whidah one night when I was about 8. The story never faded. I started exploring the ocean bottom when I was very young... I pretended I was a time-traveler wandering the liquid space. Letting my mind wander back through history, I would dream of shipwrecks I'd discover. Most old Cape Cod families have their own version of Captain Bellamy's exploits and the whereabouts of his treasure. From candlelit taverns where would-be sailors planned their expedition to the bedroom of my 6-year-old son, Brandon, the legend of the Whidah has been listened to with wide-eyed wonder. Separating the fact from the folklore became my challenge... In the fall of 1982, 30 years after Uncle Bill told me my bedtime story, I sat on the edge of Uncle's Bill bed. This time it was my turn to tell him a pirate's story. He knew I'd found her. His eyes sparkled like a child's in anticipation. Uncle Bill died later that night. I'm sure he dreamed of treasure."

 

The story of Barry Clifford tells us many things about Children's and folk stories which used to share the same origin:

 

              1/ One of the popular mode of transmission of the stories are by word of mouth.

2/ The stories are frequently told at bedtime in a family environment, from parents to children.   It  seems  that  both   parties want to carry the fantasy into their dreams.

 

3/ Carried on by oral tradition, the same story may exist under different versions, each reflecting certain aspirations of the storyteller, or of his time.

Children’s Stories/Page 2

 

4/ The stories always content mixed elements of reality, and fiction, but instead of carrying the subject away from reality, the fantasy part enriches and gives more power to the sense of reality.

5/ The sharing of the stories often is an occasion to close the gap between generations.

 

Though my experience in the field is still very limited, but the more I learn about the meanings of traditional stories, particularly of children's stories - which is the subject of this discussion - and their functional implications, the more I find them extremely interesting and useful.

 

History and Anthropological studies have proven that children's stories and folk tales are a key to understanding a people, their way of life, their sense of values, their love of beauty, their dreams and aspirations.

 

The children's literature of the 17th and 18th century in England and America reflects a profound influence of Puritanism. John Bunyan's Pilgrim's Progress published in 1678 was an eloquent example of the use of children's literature for educational purposes, it was an allegory of man's conflict between good and evil. The aspirations of people of low social status to gain parity with their master are found in Charles Perrault's tales Sleeping Beauty or Cinderella. The wish to explore new lands at a period when colonial expansionism was booming was expressed in Gulliver's Travels written by Jonhattan Swift and published in 1726. Daniel Defoe's Robinson Crusoe written at a time when voyages by sea to the remote and sometimes unknown lands were becoming more common seems to me as an expression of hope for survival should the worst catastrophe ever happens.

 

Robin Hood is not only the picture of a buoyant young man robbing for the poor, it's a message about social injustice, that social unfairness is so bad that sometimes the act of robbery could find a justification. This theme is so deeply enrooted in the people that the story has been kept very alive throughout the ages and has been retaken several times by different authors, among them The Merry Adventures of Robin Hood published in 1883 by Howard Pyle, and during  the last presidential  election campaign, the formula "reversed Robin Hood" has once again entered the lexicon of political debates. The Legend of King Arthur and his Knights of The Round Table is another example of the people's aspirations for political justice. It seems to me that it is one of the early and primitive foundations of the democratic institution in the West. At a time when the king used   to   be   regarded  as some sort of deity,   King Arthur's sitting symbolically as an equal partner to his knights around a round table discussing   the   affairs of   the state   represents indeed a new

 

Children’s Stories/Page 3

 

political vision. The story brings the image of the king and the problems he has to face at the level of the most common of men. He wasn't neither the strongest nor the wisest; the mighty magician Merlin and the knights were there to help him. Though religion and magic run through the story, King Arthur's Court at Camelot represented a social scene at the most human dimension. As a monarch, the king was not able to keep the love of his wife Guinevere who has lost her heart to the passionate Sir Lancelot. There was the courteous Sir Gawaine; the brave Sir Percival; the traitor Sir Modred, the noble Sir Bedivere, Sir Tristam, the knight of many skills and the noblest of the knights Sir Galahad who found the Holy Grail. The story went on at a time when the political dream was still not fulfilled, that explained the legend of the King's return some day from Avalon.

It is interesting to note that, children's stories, though designed for the young ones, are originated and transmitted mostly by adults. It is then not surprising to realize that children's stories often are an aesthetic product of this society as conceived by the adults, mirroring their values and offering a projective screen that illuminates their wish fulfillment fantasies. As the example of King Arthur's legend eloquently demonstrates it, often the stories are used to satisfy the desires of the adults to transcend their mundane world. This is where the most beautiful dreams find their fulfillment, where one gets rich overnight, a peasant's daughter marries a prince... It is also here that political, philosophical, ideological concepts find their ways to expression which would otherwise be impossible. It is through juvenile literature that the revolutionary vision of the child had been propagated by Jean Jacques Rousseau through his book Emile published in 1762. The child was no more considered as a mere adult in miniature, but as an entity with his own rights and who needs to be looked at under his own light. The idea was picked up by many other authors, among them the writer Thomas Day, the mystic poet William Blake and accounted for the advancement of Children's literature  in the 19th and 20th century. It is a fact that many children's stories writers seem to create the stories for themselves or as a means to send a message of their own. Hans Christian Andersen, one of the world's most illustrious writers of fairy tales for children is an eloquent example, his "distance" from the children is a well known fact. In 1875, admirers in his country wanted to honor him by having his statue placed at Kongens Have, a park in Copenhagen. The sculptor August Saabye brought him a sketch which showed him seated in a chair reading, surrounded by a crowd of eager children, here is Andersen's angry reaction as related by the writer himself: "My blood was boiling, and I spoke clearly and unambiguously, saying, “None of the sculptors knew me, nothing in their attempts indicated that they had seen or realized the characteristic thing about me, - that I could never read aloud   if  anyone   was  sitting  behind   me,   and    even  less if  I

 

Children’ Stories/Page 4

had children sitting on my lap or on my back, or young Copenhagen boys leaning up against me, and that it was only a manner of speaking when I was referred to as the ‘children's writer'. "

 

On a psychoanalytical standpoint, children's stories are viewed not functionally, but behavioristically. Elements of the story, namely myths, fantasy, humor and characters express hidden layers of unconscious wishes and fears. Sigmund Freud himself drew extensively upon folk sources and fairy tales in such works as: The Interpretation of Dreams (1899), Jokes and Their Relation to The Unconscious (1905) and Totem and Taboo (1913). The stories are assessed symbolically in terms of their psychosexual interpretation and their meanings with respect to the resolution of the Oedipus complex. In "Little Riding Hood", the young virgin was identified by the red cap which is considered as a menstrual symbol, her being devoured means that she had been seduced by the wolf who disguises himself as the grand- mother, an Oedipal figure. In Jack and The Beanstalk, the stalk is interpreted as a phallic symbol, and Jack's chopping it down is regarded as a masturbatory fantasy. The fairy tale Rumpelstilskin reported by the brothers Grimm relates the story of a gnome who has the power to transform straw into gold. Thanks to this alchemical ability, the gnome has a chance to save the life of a young girl whose father has lied to the king that his daughter was gifted with the same ability. The little man helps the girl three times, all during night time, the first time in exchange of a necklace, the second time in return for the girl's ring, and the third time with the girl's promise that she will give him her first-born child after she becomes Queen. The girl subsequently marries the king and bears a child whom the gnome threatened to appropriate unless she is able to tell his correct name - Rumpelstiltskin - which ultimately she does. The dwarf was so frustrated that he tears himself in two. In their brilliant paper, Rinsley and Bergmann (1983) point out that the character Rumpelstiltskin        incarnates the stunted, sexless pre-oedipal male and his gold-spinning is a child playing with his own feces, a masturbatory precursor. The dwarf also symbolizes the phallic-symbiotic mother from whom the daughter can never separate and individuate. Heuscher (1963) saw him as the symbol of the girl's harsh, sadistic superego from which she cannot free herself. Ultimately, the girl succeeds at the expense of all other characters in the story, Rinsley and Bergmann go on to conclude that the tale is an account of the "great and baleful power that lies behind the facade of the innocent, virginal girl who achieves the trappings of womanhood at the expense of those around her and who are indeed parties to her effort". The psychoanalytic interpretations of children's stories can go on and on, particularly with the work of Sigmund Freud, Carl Jung, Bruno Bettelheim, to name just the most prominent.

 

          We have just made a quick review of the meanings of children's stories at the

Children’ Stories/Page 5

 

adult's level and in terms of their functional orientation and psychodynamic implications. Now let us consider their meanings with respect to the children for whom these stories are originally intended. Obviously, what make children's stories exciting are their elements of fantasy and a wide variety of unusual situations, and there had been concerns that this fantasy world of giants, witches, plots and intrigues may not serve the best interests of the child. This concern doesn't seem to be well founded. I believe that fantasy is one of the safest defense mechanism against frustration if it is limited in time, scope and not overused. Studies have shown that fantasy is a common mental activity in the child, this has been discussed by many authors. Sigmund Freud describes a form of primitive hallucination that precedes fantasy. According to Freud, the primary response of the newborn when desired food does not materialize is to hallucinate the experience of the feeding, thus evoking the memory of a past pleasant experience. Melanie Klein and Isaacs (1959) believe that at the unconscious level, the primary and original psychic activity is the "unconscious fantasy" which serves then as exclusive means to express .all needs and impulses. According to Isaacs (1959), the unconscious fantasy affects the body first and carries both libidinal and destructive impulses against the object. Fantasy is developed into a defense mechanism and as a means for satisfying needs and dealing with anxiety initiated by destructive impulses. The same author postulates that hallucinatory satisfaction of the desire, along with primary identification, introjection and projection are the foundation of fantasy; in another word, fantasies are mental representations of instinctive impulses. To borrow the ideas of M. Klein, we can say that fantasy is at the root of object and moral development. Klein also believes that the concept of object is determined by physical needs, impulses and fantasies, thus fantasies support the representation of the needs. The child's object can be internal or external to his own body. It is internal when it is introjected to satisfy the needs of the child and external when it concerns the person or object the child depends on. The introjected fantasy object is experienced by the child as "good" or "bad" depending on whether his oral needs are gratified or frustrated. From this perspective, this primary fantasy becomes the seeds from which the superego is going to develop into the moral system of the child. M. Klein also developed the concept of partial object which represents a bodily part and will ultimately appear in hallucinations or fantasy. These partial objects come to be perceived as good or bad and can be introjected in the form of an idiosyncratic sensation which acts as an internal reality. Apparently, the child develops his sense of reality by going through fantasy and reality situations at the same time, with both physical and emotional experiences. This mixture of reality and fantasy elements is found in most children's stories. In the very early time, the storyteller has learnt that even with a children's audience, there is a need for certain degree of realism even in the most fictional tale.    It   seems that   while   letting his imagination wander into the

 

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fantasy realm, the child still needs to have one foot on the ground; obviously the infant who hallucinates or fantasizes his gratifying object still has the ultimate need to get the real milk.

 

It is amazing to note that in spite of this reality­ fantasy duality, the child is often able to distinguish which part is fiction and which part is reality. Not only the rich material of the fairy tale doesn't confuse him, but he can really benefit from it. The child can stretch his imagination to a larger world which he can enjoy in fantasy, and still be able to learn a wide spectrum of situations which can happen in real life. He is quick to realize that in our time it would be hard to live a life as Robin Hood did and yet, people with the same personality and aspirations could still be found. The child can also use fantasy to explore their own feelings the same way that they explore their physical space. Millar (1974) believes that some children may use fantasy to try to make sense out of something they have encountered and that is puzzling and that children with a rich fantasy life are more able to sit still and wait in boring situations. Piaget proposes that the child assimilates new experiences into his cognitive framework by exploring, perusing, repeating and classifying events, verbal expressions and their own belief. Thus, the child's make-belief is a clue to the way they experience the world. Sometimes, fantasy could be a source of anxiety for the children because of their inability to control its content and development, but fortunately, frequently, the child can create and direct his imaginations particularly during the day time. A typical example of such imaginative activity is the experience of the make-belief friend who appears most of the time as friendly and helpful. Manosevitz (1973) believes that such imaginary companion is a helpful developmental experience, because with this companion, the child can practice and develop social and language skills which may otherwise develop more slowly. If we believe these to be true, then it is easy to recognize that the world of children's stories, with   their wide array of people and situations, offers the child with a very rich learning experience. Nowhere else, our world is presented under such plurality   where. There is no ends to human dreams and no limits to human tragedy, but the child always learns the ultimate optimistic message that  life is struggle and Right will prevail over Wrong. It is where the true nature of Man is observed through the magnifying glass of realism and one realizes that people need to be judged by their actions instead of their deceiving garb. The world offered by children's tales also abounds in good people who could serve as model for identification and provide with basic morality norms. American kids learn a good lesson about honesty through the legend of young Georges Washington who said to his father that "I cannot tell a lie, it was me who chopped the cherry tree". Through the stories, children also learn more about people and the world in which they live because many tales are generated to explain    the    physical   world    and   its   inhabitants.  They could also be used to

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safeguard    people's    identity     and     their      cultural      beliefs     as   in      the

example of the popular tale of the Ojibwa Indians who live in northern Michigan. The story explains that thunderstorms exist   only   in   the    neighborhood   of   Lake Michigan  because the Ojibwa Indian's protective deities were thunder spirits. Here, I want to emphasize on the importance of Animal stories. From the Babylonian animal tales, the fables of Aesop often adapted to children's stories, or Rudyard Kipling's "Jungle Books" (1894-1895) and "Just So Stories" to Joel Chandler Harris' Uncle Remus, we have beautiful illustrations of the relation of man and animal, of animals as man's friends. The stories bring to the child a broader view of our ecologic system with a continuum between the homo-sapiens and other living creatures in this planet where every element plays an important role in this harmonic and delicate balance of life. Since a particular story is characterized by its basic pattern and by narrative motifs, rather than by its verbal form, it passes language boundaries without difficulty, thus it is able to keep the child in touch with other cultures and other people and their symbol since almost every country has produced its own variety of helpful and harmful creatures such as the Dragon guardian of great treasures, giant birds carrying men off in their claws, evil witches, helpful genies, giants ect... Tragic situations developing into happy ending teach the child about the basic human dilemma worked out through the process of persevering struggle. Cinderella whose mother dies at her birth is at the mercy of her wicket stepmother, but she behaves morally and with good cheer and is rewarded in the end by a prince and happy life.

 

Whether painted in realism as in the case of Mark Twain's masterpieces "The Adventure of Tom Sawyer" (1871) and "The Adventure of Huckleberry Finn" (1884) or wrapped either in poetry, humor or imagination as reflected in Stevenson's "Child's Garden of Verses", Hillarie Belloc's "The Bad Child's Book of Beast (1896) or Walter De la Mare's "Songs of Childhood" (1902), children's stories offer the most precious function of juvenile literature which is the glorification of childhood and the child's world in its most beautiful and emotional dimension. Juvenile literature also introduces in its realm one factor which I think is one of man's most mature defense mechanism: humor. In fact, S. Freud (1916) has pointed out that the pleasure we take in humor is based on its ability to relieve us of psychic strain. The "Rhymes for The Nursery" (1806) which includes "Twinkle, Twinkle, Little Star" by the Taylor sisters Ann and Mary and the "Book of Nonsense" (1846) by Edward Lear will still be sources of joy and relief for many young generations to come. Love is not forgotten either in children's literature. Young girls of our time who read Ramona (1884) by Helen Hunt or the series by Sarah Chauncey Woolsey "What Kathy Did" will still discover with pleasure the warm and serene emotions of Cupid's world.

 

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An   important     contribution   to the   understanding of the meanings and

importance of children's stories is found in Bruno Bettelheim's superb book published in 1977 "The uses of Enchantment: The Meanings and Importance of Fairy Tales". Regarding   the concern about the possible negative impact of fairy tales,    Bettelheim contends that fairy tales are not only harmless, but offer great positive values. The wide variety of situations where fantasy and reality are both reflected enriches the child's experience and provides substance for his own fantasy. Bettelheim believes that the most delicate and important task in raising children is to help them find a meaning in life. And the deepest meanings in life are rooted in moral behavior. Fairy tales, with their simplistic and representative form, their formulistic expressions such as "once upon a time", their frequent repetitions and their basic realism, in spite of the enchantment, have proven to be very effective tools in presenting the child with a wide variety of daily life problems at a level that        can          reach  them  and    stimulate their        interest. Moral didactics are made less boring through the exciting vehicle of fantasy. Bettelheim also points out that children do not identify themselves exclusively with the hero, but also with wicket stepmothers and evil traitors. Each may represent one side of a child's nature. When the hero wins over the bad guys, the child understands that it is possible for him to overcome his bad feelings of anger or selfishness. Thus, out of fantasy, the child develops more strength to deal with the difficult issues of his own life.

 

Ladies and Gentlemen,

 

At this point, I hope that we can agree that children's stories constitute an important part of the educational menu available to the child which can be reflected in multiple applications. Through the richness of the world that they depict and the creative fantasy that they evoke, it is hard to refute their cognitive, emotional and developmental influence on the child. But the problem is that how this menu is conceived, prepared and conveyed to the target subject. Not all stories, not all fairy tales, not all forms of fantasies are beneficial to the child. Since he is not a down-scaled adult, stories designed for the young could not and must not be an oversimplified theme of the adult drama. If we believe in the developmental theories proposed       by      S. Freud and particularly by Piaget, then we should understand that the development of personality is a maturational process, with continuous, predetermined and interrelated sequences, where the success of a previous stage is crucial to the completion of the coming stage which sets the premise for the subsequent stage, then we can understand that the children's stories under any form must be conceived and conveyed to the child according to his own degree of maturation. The argument that society has become more complex, so the child must be more prematurely exposed to adult's problems doesn't make sense,  

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it   is just like saying that the 12 month old baby must be able to   climb   a staircase   because  the house happens to have two levels! This is where adults' debates and struggle about terminology must not interfere. Please keep these big words of Liberalism and Conservatism off the serene and naive world of the child! Realism or fairies need not be a subject for worries.   The wonderful realism of Mark Twain’s Adventures of Huckleberry Finn (1884) and the enchantment of the brothers Grimm's "Fairy Tales" are both beneficial and enjoyable to the child. It is interesting to note that in the course of history, the realistic and imaginative   trends seem to take turn in dominating the juvenile literature. Even the Soviet Unions who claim themselves as the last bastion of materialism are not immune to these up and down trends. Though the orientation during the 30's, 40's and 50's seems to be in favor of realism, many rhetoricians and main writers of the regime have recognized some beneficial use of fantasy for educational and even propaganda purposes, among them was Maxim Gorky who used fairy tales to encourage the child to become "the knight of the spirit" and who called for creative fantasy for children's stories which make out of the human being instead of a  willess creature or an indifferent workman.

 

There is a growing concern that with this predominantly mercantile economic system, Children's literature and other forms of juvenile recreation and entertainment are going to be commercialized. I am afraid that this fear has long been overdue, because, indeed we are now faced with serious problems. With the advancement of all forms of modern technologies and a wide variety of communication means available and affordable to the individual family, children's stories are going beyond the oral and even literary level to embrace all forms of activities. Stories now could be told not only by word of mouth, picture ­books, and comics but also through TV shows and movies and even electronic games where the imagination of the child is reduced to the orality of Pac Man or the killing of Indians! This wide array of gadgetry is more than enough to confuse the young mind so vulnerable to external insult. Although books remain an important means to convey stories to the child, they have been increasingly subjected to political and religious debates along with other educational subjects under such rubric so much alienated to the child as "separation of church and state", "secular humanism" etc...And obviously books seem to have lost ground to other means of communication, particularly Television. We don't have anything against TV, on the contrary, we recognize it as a very effective educational tool, but unfortunately the quality of many TV programs which are within reach of the children, indeed are good reasons for worries. Moreover, there is another aspect: TV seems to be more of an   impersonal means to communicate than books. Children can find in a book its title, its author's name; the book can accompany the child in bed,    around the

 

 

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house, and stay there in the family for years like a friend.

 

          With the TV set, the communication start with the click of a switch. The kind of program depends upon the time and the day of the week. My 4 year old daughter used to say: "I want to watch TV" or a little better "I want to watch Cartoons" instead of naming a particular program or hero. But as said earlier, what is worrisome about TV is their quality. The invasion of the young mind by TV is not only reflected by long hours spent in front of the fluorescent screen at the prejudice of many other academic and physical activities, but also by other characteristics inherent to many TV programs of today. These include:

1/ The high degree of graphic violence and carnal sexuality which influence the child by means of negative modeling and behavior modification. Many TV programs have little concern for educational purposes; there is now much less emphasis on human values and moral responsibility than before. The good guy doesn't vanquish the evil villain any more but instead, violence, physical strength and shrewdness seem to take over. The teen-ager is encouraged to look for what used to be "adults' experiences" for  hedonistic enjoyment. Sexual encounters, contraception, even abortion are not the domain taboo to the 13 year old pubescent anymore.

 

2/ Because of increasing loss of control of the parents over their kids, more children now are watching programs originally created for adults. The direct consequences are that the children are absorbing materials that are too much for them to conceive and integrate: violent sexuality, adultery, divorce, abortion, incest, homosexuality and violent crimes etc... Many people argue that it is better to know than to be ignorant, they pretend that presenting people with ultra-realistic materials help them familiarize with factual truth and acquire more experience to deal with the troubled reality of life. But the fact is that when these materials reach the children, they leave them with no answers. I believe that partial knowledge in a creature who is not ready to acquire this half piece of information is even worse than sheer ignorance! What is interesting is that when the kids are in trouble, these same people are quick to point out the sole responsibility of the parents who have become somewhat the scapegoat. We don't mean that the parents are completely  free of any moral responsibility, but certainly, those who diffuse sewer materials need to share their part of the blame.

3/ Certainly, TV could be a very good means of education and communication if it is not          abused for the service of commercialism. But when visual stimulation takes over other forms of sensorial and mental stimulation to become the overwhelmingly main source of input, then there is good reason to worry. Obviously,    TV   watching is taking over time from other activities such as

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play, reading, and physical training. This - we may call­ “visual over-stimulation”- may interfere with the child's ability to abstract and experience feelings. Studies need to be done to show whether persistent increased visual input has any influence on the individual's mental activity or not. But it seems that extreme visual realism would leave little room for the child's imagination. Heroes do not receive anymore the favor of the child's imagination, but they appear as Clint Eastwood, Charles Bronson etc... and guess what happens if our hero of tonight is arrested for DUI or illegal sex solicitations the next morning.

 

4/ So much water has run under the bridge since Jean Jacques Rousseau's Emile brought a new vision of the child to the world. Man celebrates his crown of laurel. History boasts itself of its transcendent evolution. At last, man has come to recognize and respect the "father of man" and pays tribute to him by serving his needs. And here we are 2 centuries later, coming back to the stage where as far as the intellectual food is concerned, the child just shares the adult's leftover!

 

We, adults know that the young days, when gone, will never come back. At any price, the world of the young ones cannot be sacrificed to a more adult-oriented society. If there is a time to love and a time to die, then there must be a time to be old and a time to be young! I believe that it is a crime to deprive   our  children of their youth, to take away that palpitating emotion, that innocent serenity, that creative fantasy and that naive perception which are unique and which make the child's world what they are: soft, sincere, sensitive and vulnerable. But unfortunately, in a society where we are so concerned about the problem of overt child abuse, there is this large scale of covert child abuse that goes on unpunished! Depriving the child of his right to live his life as a child, making him a subject of adult's experimentation in the name of liberalism, conservatism, secular humanism, you name it, are ultimate forms of child abuse with far reaching consequences, which nobody can predict. Already, we have seen serious problems surging and ringing a worrisome alarm. Many of us have started raising the question of child's suicide, of course this is not a new problem, but why suicides are going rampant particularly in our state of Oklahoma. There is of course no simple answer because the causes are multiple. But, if we examine our own conscience, somewhere, we would find out that the adults have to give the children

back their world of joys and wonders. We know that we have to take off their shoulders the burden of our life's conflicts that we, as adults, have compelled them to share with us, leaving them with little choice! The child needs to feel, to love, to behave and to be perceived as a child.

 

If we believe the functions of fantasy and imagination to be a temporary

 

 

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escape of the child from frustrating and troubled reality of life, if we believe that good children's stories  have   the capacity   of   giving  the child a broader sense of

reality, then there is no reason why we don't sit back and reexamine their usefulness and their applications and try to make juvenile literature more available and more interesting to the children. At a time when the extended family is no more, the nuclear family is disintegrating, we need many more Uncle Bill to tell our children of pirates' treasures or of a never-never land or even of a wonderland named America at a time when history was in the making. I hope there will be more evenings when human emotions could be shared from one old generation to a younger one,  when  the  child learns that there is more meaning to family than just

sit together. I also expect to see more children's stories books in          the school, more sessions when preschool children can travel through the wonderlands with their teacher. I believe it to be useful if convalescent kids in children's hospitals, once in a while, have their social workers read to them beautiful stories, because being ill often leaves the child with such threatening fantasies!

 

Ladies and Gentlemen,

 

Allow me to conclude with a little personal touch. In my life, I have gone through more hardship than good times. I have come to know such words as “labor camp" or “concentration camp" which are more than a futile word for those who have had an experience of them. I don't claim a strong personality, but I was fortunate to survive the storms and hurricanes of our country's unfortunate history. I was surprised to realize that strength and hope never left me in time of crisis. And I know that I owe it to All Mighty God and to my ailing mother who is still looking in anguish for the day to join me from this remote land which used to represent the most precious thing I have ever had in life. I still remember these evenings, when after a day, which we often happen to wonder how we manage to survive, I used to let my imagination wander into the fairy world which my mother used to make a beautiful painting of from legends and folklore which are so rich in our culture. Then I would ease myself into the most beautiful dreams I have ever had, to wake up early the next morning, ready for the hard reality of a new day. Most of the time, the images of my wife and children would slip into these fantasies! I want to share with you this part of my life and with the kids of this wonderful country. I wish that we shall come to the point some day when our kids will be able to enjoy their own world of much joys and little sorrows, and without interference.

 

To you my young little friend who, one gloomy day, may have felt frustrated and alienated from the adult world and to whom an empathizing friend is not available, I want to tell you that you are not by yourself. Only those who cannot find a companion in themselves are the ones who are truly alone. Find the

 

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friend who is within yourself, take him through the marvelous world of “Twinkle, Twinkle Little Star",     have    him      visit    the  castle   where   Cinderella     with

good cheer and virtue makes it to a happy life. And watch Jack climbing the beanstalk to struggle for his mother's and his own survival. And then, I want you to have a good dream and come back to this real world to learn that in this land called America, with struggle, dreams do come true.

 

Presented at the Oklahoma University Health Sciences Center

March, 1985

Son Vi Nguyen, M.D.

 

Dr. Nguyen is former Assistant Professor of Psychiatry

at:

 

-         The University of Texas School of Medicine at Houston

-         Texas Tech University

-         The Texas College of Osteopathic Medicine.

 

He was also Medical Director of several private psychiatric hospitals in Texas.

 
 

THE OBSESSIVE-COMPULSIVE DISORDER

 

                                                                                         by Son Vi Nguyen, M.D.

 

 

HISTORICAL BACKGROUND

 

Obsessions and compulsions have been the oldest recognized symptoms which make up the major features of Obsessive-Compulsive Disorder (OCD):

 

·         In 1467, cases of possession and obsession by the devil were reported in  Malleus

 Maleficarum.

·           Paracelsus  in “Obsessi” described cases of obsessions and compulsions.

·          The term obsession was coined by Esquirole in 1838.

·           The neurologist Westphal introduced the concept of involuntary intrusive thoughts.

·            Pierre Janet described a wide spectrum of obsessional phenomena. From “psychesthenia” which refers to a sense of imperfection to “forced agitation” which involves repetitive mental operations to the most severe form of “obsessions and compulsions”

·         In the case of “The Rat Man” reported in 1953, Sigmund Freud helped define obsessions and compulsions as we still recognize them at the present time.

 

GENERAL CONSIDERATIONS:

 

Clinically, the Obsessive-Compulsive Disorder represents a heterogenous  syndrome which requires essentially the presence of obsessions and  compulsions which by DSM-IV standard  have to meet certain required features:

 

1.       Obsessions which are persistent ideas, thoughts, impulses or images which present themselves as intrusive or inappropriate preoccupation which lead to marked anxiety or distress. These obsessive thoughts are not under the control of the subject and may cause significant dysfunction in the individual’s daily life functioning. The subject is aware of the inappropriate and intrusive nature of the thoughts but have little control of its process This leads to the qualification of those thoughts as “ego-dystonic”.  This remark is important in recognizing true obsessions from obsessive brooding, preoccupations or ruminations which may be unpleasant but are distinguished from true obsessions because they are not ego-dystonic, indicating that the person recognizes the ideation as meaningful even though excessive. But in spite of the involuntary aspects of those thoughts, the individual is aware that the obsessions arise from his or her own mind and are not imposed from without as in the case of a phenomenon call “thought insertion”. The most common obsessions involve repeated thoughts about contamination by shaking hands, repeated doubts whether one has offended someone in a conversation, hurt someone in an accident or left a door unlocked. Sometimes, certain words keep intruding in the mind repeatedly. The subject may constantly worried about something bad befalling certain loved-ones or about having things in a

particular order, exactness or symmetry. Also a frequent occurrence is the obsessive fear of aggressive or horrific impulses such as hurting one’s child or

 

continued…/2

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acting inappropriately in public places such as uttering obscenities in church. The obsession can come under the form of  sexual imagery of a pornographic content or thought of using a weapon to hurt someone or trying to remember every word of a conversation or thinking a word backward…

 

2.       Compulsions as defined in DSM-IV are “repetitive behaviors (e.g., hand washing ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification”. Thus, certain behaviors which used to be referred to as “compulsive” (e.g., compulsive gambling, drinking, sexual behavior or eating) do not fall within the definition of true compulsion because they are experienced as pleasurable even though the consequences may be unpleasant. The person is driven into performing the compulsion to alleviate the anxiety or tension or in his or her mind prevents the feared event or situation from happening. Common reports of compulsive acts involve washing/clearing, checking, counting. Washing hands thirty, forty times a day until the skin is raw or checking over and over the lock to make sure the door is locked, checking  street for dead animals,  checking for false alarm. Counting tiles, or counting numbers backward or forward to suppress an unwanted obsessive thought which is offending or threatening to the person. Some people have the compulsion to write down everything that are said to them, putting tools, clothes or other things in the house or office in certain order or entering the house or office building by following certain routes.

 

3.       In most instances, the person is aware that the obsessions or compulsions are excessive or unreasonable and may make attempts to resist them. But usually, this attempt will lead to a sense of mounting anxiety or tension which usually becomes unbearable. Frequently,  relief is obtained when  the person decides to yield to the compulsion. 

 

4.       The obsessions or compulsions cause marked distress, are time consuming, taking more than an hour a day, or significantly interfere with the person’s normal routine, occupational functioning or usual social activities or relationship.

 

5.       The above disturbances are not induced by chemical substance(s) or a medical condition.

 

CLINICAL ISSUES

 

As mentioned above, the person affected by OCD usually is aware of the excessive and unreasonable nature of the obsessions and compulsions, but DSM-IV does specify a clinical category “With Poor Insight”. This distinction only applies in adult but not children’s cases.

 

n       There are several subtypes of OCD.

 

1.       Patients obsessed with dirt and contamination which lead to compulsive washing and avoidance of perceived contaminated objects.

2.       Patients with pathological counting and compulsive checking.

3.       Patients with only compulsions but no obsessions.

 

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Patients with only obsessions and no compulsions which account for 10 to 20 percent of cases of OCD.

1.       Patient with essentially obsessional slowness. The patient may spent hours everyday getting washed, dressed or eating. With these patients, life take an extremely slow pace.

2.       Patients who are obsessed with hoarding. These people are unable to throw away anything because of the obsession that some of the discarded items may be needed some day.

 

n       OCD is more frequently  associated with certain other psychiatric disorders:

 

1.       Anxiety: The resistance to obsessions or compulsions provokes intense tension or anxiety which are relieved by yielding to the compulsion which explains why the DSM’s  including DSM-IV classify the OCD under the Anxiety disorder. But it important to  point out that the OCD and the Anxiety disorder may have different neurobilological markers since certain chemical agents known to provoke anxiety or panic do not exacerbate anxiety or obsessions of OCD.

2.      Phobias: OCD also often is associated with phobias. But generally the quality

      of the fear in OCD is different from that found in phobias.

3.       OCD often occurs in association with major depression and seemingly, there  is a strong family history of depression in OCD patients.

4.       It is believed that 20% to 30 % of persons with OCD are also found to have  problems in the area of involuntary movements (e.g., Tourette’s syndrome) and motor coordination.

 

·        Obsessive-compulsive Disorder and Obsessive Personality Disorder:

                       

                        It is important to make a distinction between OCD (an Axis I diagnosis)
                        and O
bsessive-Compulsive Personality Disorder (Axis II diagnosis).
                        These two clinical 
entities share similar names but have very different
                        clinical manifestations.

                        Obsessive-compulsive Personality Disorder does not include the presence
                        of 
obsessions and compulsions, but involves a pervasive pattern of
                        orderliness, 
perfectionism, and control and begin only in early adulthood
                        whereas the OCD 
symptoms may happen earlier in childhood. 

 

PREVALENCE AND EPIDEMIOLOGY

 

            OCD has been previously considered as a very rare mental disorder. Early studies by Rudin (1953) placed the prevalence at 0.05%.. Studies by Woodruff and Pitts  reported an incidence of 5 in 10,000 persons. In 1984, Robins et al. report the results of the Epidemiologic Catchment Area (ECA) survey which put the prevalence rate for OCD at 1.2 to 2.4 %. There seems to be a continuum between childhood/adolescent and adult forms of OCD. Studies of prevalence of OCD in children/adolescent are estimated to range from 0.2% to 1.2%.

 

 

 

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page four/OCD

 

ETIOLOLOGY

 

·         Genetic Studies: The early studies of Lewis (1935) suggested that there is a high incidence of OCD in the first-degree members of the same family. Studies involving dizygotic and monozygotic twins seem to confirm the increased rates among first-degree relatives of clinical cohorts.  A survey by Carey and Gottesman (1981) found that there are a 81% concordance of OCD symptoms in monozygotic twins compared with 47% for dizygotic twins. In the studies by Swedo, Rapoport and Leonard et al. in 1989, 24% of  adolescent subjects with OCD had first degree relatives with OCD.

                         

·         Neurobiological and Imaging studies: Some Dexamethasone suppression test (DST)  surveys suggest correlation between OCD and  depression, but some other studies found an opposite result. On EEG studies, rapid eye movements (REM) latency are both increased in depressed and OCD subjects, but the REM density is decreased only in cases with depression. Cerebral Blood Flow studies shows decreased regional blood flow in the whole cortex in OCD patients when the anxiety level is increased.

 

·         Role of Serotonin: Observation on the treatment response to Serotonin reuptake inhibitors and related studies seem to indicate that OCD may be related to increased sensitivity to 5-HT receptors. This explains the positive response obtained by serotonin reuptake inhibitors such as clomipramine, fluoxetine, paroxetine or fluvoxamine which act by decreasing receptor sensitivity by chronically exposing the receptor sites to increased amount of 5-HT.

 

·         Psychoanalytic Theories: Sigmund Freud stipulated that obsessional symptoms derive from failures to defend against unconscious anal aggressive impulses which lead to the ego trying to adapt by developing “over-consciousness, cleanliness and piety”.

 

TREATMENT

 

1.       Psychodynamic therapy: OCD patients are anxious. The role of psychotherapy is to help reduce the level of anxiety and tension and to help the patient improve self-confidence and self-esteem. This therapeutic process is lengthy and may take several years.

2.       Behavioral therapy: The combination of flooding and response prevention has proven effective. For example a person with compulsive hand-washing is asked to touch objects that they feel are contaminated and then he or she is prevented from washing his or her hand for some time.

3.       Pharmacotherapy: As mentioned above, the medications increasing the level of serotonin at the receptor sites have proven to be effective in reducing the symptoms of OCD:

                       

                                    Tricyclic antidepressant: The one which has proven to be
                                     effective is

                                      clomipramine (Anafranil)

                                     Selective serotonin reuptake inhibitors (SSRI): fluoxetine,
                                     paroxetine, 
sertraline and fluvoxamine have all proven to have
                                     therapeutic response 
which are visibly better than placebo.

           

           

 

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page five/OCD

 

Usually, treatment can be done on an outpatient basis.  But it is imperative to assess the patient at every stage of the treatment, if the patient is deemed to be in an acute episode of crisis and the risks of self-harm or harm to others are increased, then inpatient treatment should be considered.

 

CONCLUSION

 

            OCD is a complex and multi-dimentional syndrome which still needs to be explored further. Research which are based on the neuroanatomic, neurochemical, and psychological models will need to be further pursued to better understand this complex clinical entity. For the treatment to be fully effective, a comprehensive approach is beneficial and should include pharmacological agents, psychological and behavior-cognitive  techniques.

 

 

Published in the Journal of the Potter and Randall County Medical Society

 
 

The Attention Deficit Disorder

                                      and

                        Associated Disorders

                       

                                                                                                                    by Son Vi Nguyen, M.D.

 

 

HISTORICAL REVIEW

 

Over the past 25 years, Attention Deficit Disorder (ADD) has grown into one of the most heavily used diagnoses  in American psychiatric practice, and yet ADD remains an obscure clinical entity which is pretty much unknown in spite of numerous research efforts to understand it. It has received different names such as The Attention Deficit Hyperactivity Disorder (DSM-III-R), Attention Deficit Disorder with and without Hyperactivity (DSM-III), Minimal Brain Dysfunction, Minimal Brain Damage, Hyperkinetic-Impulsive Disorder, Hyperkinesis, Strauss-Lehtinen Syndrome and the Hyperactive Child Syndrome. These changing terms reflect a change in concept pertaining to the origin, phenomenology, and diagnostic criteria for this syndrome.

 

The connection between brain damage and hyperactivity has been discussed since the beginning of this century. In 1902, Federick Still, in his article, "The Coulstonian Lectures on Some Abnormal Physical Conditions in Children" published in the Lancet, discussed children presenting with a hyperactive syndrome with minimal physical symptomatology but a history of brain damage. The epidemics of encephalitis in 1918 seemed to illustrate Still linkage between brain damage and behavior disturbances. Soon, the hyperactive syndrome seemed to be better defined. with a cluster of symptoms including motoric hyperactivity, attention deficit, distractibility, aggressivity, impulsivity, impaired judgment and mood lability. Pediatricians and neurologists were the first professionals  involved  in the  treatment  of  this  syndrome.  The term minimal brain dy s function ( MBD ) became popular . It  was later observed that neither perinatal birth trauma nor "soft neurological symptoms" were necessary for the development of the hyperactive syndrome. The presence of soft neurological signs or a history of brain damage does not necessarily lead to the hyperactive syndrome. It was soon apparent that the syndrome of hyperactivity includes two main components: 1) the motoric hyperactivity, and 2) the attention deficit. The emphasis on the hyperactivity or the attention deficit seems to change with time with either the hyperactivity or the attention deficit being the center of the focus of the syndrome. Also, the combination of hyperactivity and attention deficit changes with time. DSM-III seems to downplay the role of hyperactivity, focusing more on the attention deficit. Thus there are two subtypes of ADD: with and without hyperactivity. DSM-III-R seems to put an emphasis on the association of attention deficit and the motoric hyperactivity, calling the syndrome "Attention Deficit Hyperactivity Disorder". The subtype " without hyperactivity " is abolished and is classified as ADHD, unspecified. This concept is maintained in DSM-IV. This seems to deviate far from the original concept of the syndrome, with hyperactivity being the focus of study. Attention deficit manifests itself through a cluster of "daydreaming. short attention span, inattentiveness", characteristics that were labeled as signs of "immaturity". It is also important to point out that the use of stimulants in the treatment of  ADD is an old fact in ADD history. The first use of amphetamine sulfate (Benzedrine) dates  back to 1937. It was used to treat a heterogenous group of boys with a wide range of behavior problems. It was also recognized that the attention deficit syndrome is not only associated with hyperactivity, but also with a wide spectrum of symptoms or conditions ranging from conduct disorder, aggressivity, and impulsivity, to anxiety, substance abuse, mood disorders, learning disorders and personality disorders. This causes the syndrome to be a more complex and heterogneous clinical entity.

 

DIAGNOSTIC CRITERIA

 

I. (DSM-III-R)

 

DSM-III-R puts the emphasis on motoric hyperactivity, impulsivity and attention deficit. It requires a disturbance of a period of at least six months during which a combination of at least eight of the fourteen described symptoms are present to make a positive diagnosis. It is interesting to note that even though emotional lability is a well known feature in many cases of ADD, it is not included in DSM-III-R. Motoric hyperactivity is described as: fidgeting with hands or feet or squirming in seat, the difficulty of  remaining seated when required, or talking excessively.   In adolescents, the hyperactivity may be limited to subjective feelings of restlessness. Impulsivity is  most emphasized with several features as part of the diagnostic criteria. The child has difficulty awaiting turns in games or has difficulty playing quietly, often interrupting or intruding on others, (for example, butting into other children's games). The child often becomes involved in dangerous activities without considering possible consequences.   Attention deficit is described as being easily distracted by extraneous stimuli, having difficulty following through on instructions from others, often shifting from one uncompleted activity to another, often seeming not to listen to what is being said to him or her, and often losing things necessary for tasks or activities at school or at home.

 

II. (DSM-IV)

 

   It is interesting to note that DSM-IV seems to differ significantly from DSM-III-R in terms of classifying the cluster of symptoms of ADHD. But this new approach has nothing new, in fact DSM-IV seems to go back to DSM-III by presenting the ADHD symptomatology into three clusters of symptoms:

 

Inattention:

 

       Six (or more) instead of three (as in DSM-III) symptoms are required for a duration of at least 6 months. Those symptoms must cause maladaptive functioning and are inconsistent with the developmental level.

 

Hyperactivity-impulsivity:

 

      Six (or more) symptoms instead of five as in DSM-III (3 for impulsivity and 2 for hyperactivity) are required and the must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level.

 

      The age criteria still requires that the symptoms leading to maladaptive functions must have started before age 7. What is new is that DSM-IV emphasizes on the settings where the symptoms occur. It is required that the maladaptive symptoms occur in at least two or more settings such as at school or at home. The emphasis is also on significant impairment in social, academic, or occupational functioning.

 

      DSM-IV seems to give equal importance to the problems related to inattention, hyperactivity or impulsivity. This is reflected in the way the subtypes of AD/HD. There are three subtypes:

 

1. Attention-Deficit/Hyperactivity Disorder, Combined type

2. Attention-Deficit /Hyperactivity Disorder, Predominantly Inattentive Type.

            3. Attention-Deficit /Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type.

 

DIAGNOSTIC EVALUATION

 

Because of its multiplicity in terms of etiology and symptoms, the diagnostic evaluation is not as simple as many tend to believe. Psychodynamic, psychosocial, and developmental factors need to be taken into consideration. It is of crucial importance to obtain the accurate report concerning grade and behavior at school. Behavior must be observed in the different places of the school environment including in the classroom, on the playground, in the cafeteria,  and on the bus. Obstetrical history including maternal    alcohol   use,    fetal   overactivity, prenatal, perinatal  and postnatal injury should be obtained. Family residence   can play a role depending on the existence of lead containing products (in paints or pipes) . In the diagnostic evaluation, one should not forget the importance of family psychiatric and medical history (thyroid disorder) along with medication usage (barbiturates, benzodiazepines, stimulants, and adrenergics), Other factors to look at include a history of child abuse or neglect, child learning disorders, mood disorder or other major psychiatric disorders including bipolar or schizophrenic disorder. One should find out if there is a child or parental history of substance abuse ( particularly alcohol abuse), conduct disorder, antisocial personality disorder, aggressive or explosive behavior. A physical examination is necessary to look for physical anomalies. thyroid disorder, neurological symptoms suggesting cortical damages, ties and dystonias. Since the association between ADD and Tourette's Syndrome (TS) is rather frequent, it is important   to   have  a      handwriting   sample   for close examination    since handwriting presents significant difficulty in TS. In the diagnostic protocol, it is necessary to have a thyroid function test, blood lead level, free erythrocyte protoporphrin (FRP) and an EKG. Many conditions can cause the child to be hyperactive or inattentive. Major depression, neurological damage, hunger or constipation, can all cause the subject to be restless and hyperactive. One has to remember that a response to stimulants is not proof to confirm the diagnosis of ADD, since even "normal" children will respond to a certain degree to stimulants. One also has to remember that a certain degree of hyperactivity in children is "normal". A child seeking attention or trying to be manipulative can be pretty hyperactive. The factors mentioned above need to always be part of the differential diagnosis. One needs to be cautious if a psychotic condition is suspected, since stimulants can make the condition significantly worse. In ADD, the restlessness and hyperactivity are sustained in time with gradual improvement as the child moves toward adulthood. In the case of childhood psychosis, the behavior problems are unpredictable with the tendency to worsen with time.

 

Often, the positive diagnosis of ADD can prove to be elusive, and an empirical trial with pharmacotherapy may be initiated even though a response or a lack of response to treatment does not necessarily rule in or rule out ADD.  Differences between boys and girls with ADHD: The subtypes of AD/HD and whether it involves boys or girls can present significant clinical differences.

 

      The AD/HD children with significant hyperactivity used to present with aggressive and antisocial behavior and are likely to have a family history of antisocial/sociopathologies. Children without hyperactivity present with deficits along the attentional/cognitive axis and in general do not have the problems with impulsivity. Derry and colleagues (1985) have found some significant differences between boys or girls with AD/HD. The ADD girls with hyperactivity seem to have more cognitive impairments and they are younger at the time they are referred for evaluation and come from families of lower socioeconomic status. ADD girls without hyperactivity are more inclined to have poorer sel f-esteem and more likely rejected by peers than their male counterpart . They are also believed to be underdiagnosed.

 

CLINICAL MANIFESTATIONS:

 

1. Inattention : The attention impairment depends upon the degree of alertness, hunger, sleep deprivation, environmental pressure (how much the environment is crowded or noisy ) , and the emotional state of the subject . The attention deficit can cause the child to be even more impulsive, acting before thinking and not able to be aware of the consequences of his or her actions. In the classroom situation, the child will not be able to concentrate on the topic being taught and, in the process, is not able to catch up with the progress of the educational program. This causes the child to be more anxious, which in turn causes further distraction, thus establishing a vicious cycle. The end result is a significant impairment of academic achievement which puts pressure directly on the child. There is also increased pressure coming from the teachers and the parents. At home,   the distractibility causes the child to fail  to accomplish or finish his assignment, to not do his homework, and to start different projects without finishing any of them.

 

2. Impulsivity : The impulsivity level seems to correlate with the degree of attention deficit, but many independent studies seem to find only a weak correlation. The impulsivity is also dependent upon the physiological state, the degree of alertness and physical energy, sleep deprivation, hunger, anger and aggressivity. Usually, the impulsivity leads to very disruptive behavior, particularly in structured situations or when the child is expected to have more control over his behavior, such as in a classroom situation. The impulsivity causes him to talk out of turn, to act before he thinks, to act inappropriately, to interrupt others when they are talking, or to become intrusive. The impulsivity also causes the child to get into dangerous activity without being able to evaluate the consequences of such behavior and the child thus becomes accident prone. The impulsivity can also lead to exploratory activity, particularly in a new environment, causing the child to explore the environment as soon as he or she enters it. When entering a room. the child may immediately begin to touch or climb. The exploratory behavior may lead to rough handling of objects, accidental breakage, and intrusive entry into unsafe areas. Property damage may occur without intent. Destructiveness in this case occurs without anger.

 

3. Hyperactivity: Hyperactivity usually goes hand in hand with impulsivity and it is governed by the same factors which influence impulsivity. In fact, in situations where increased activity is expected, the hyperactive child is not much different from the normal one. The difference is more visible where more controlled behavior is expected. It is interesting to note that the hyperactivity seems to continue when the child is asleep. The hyperactivity is exacerbated with malnutrition, hunger, anxiety, certain medical conditions such as hyperthyroidism or by drugs such

as Tegretol, Phenobarbital or benzodiazepines.

 

4. Sex Differences: As mentioned earlier, boys seem to have more conduct disorder, more aggressivity, and more impulsivity with the tendency to be more accident prone. Girls are less impulsive, have less acting  out, less aggressivity, more fear, more mood swings,  and more cognitive and language problems.

 

ETIOLOGY

 

ADD is a complex clinical entity with multiple clinical manifestations and multiple causal mechanisms. Family studies seem to prove a genetic etiological component which is polygenic in nature.

 

Family factors:   ADD runs in families, particularly in male relatives of ADD children. The prevalence of psychopathology is two to three times higher in relatives of ADD children. In the case of adopted children, biological parents have more psychopathology than adopting parents. ADD also seems to run in families with antisocial personality disorder, mood disorder, anxiety disorder, alcohol dependence, aggressivity in male relatives, and histrionic personality disorder in female relatives. Genetic and psychosocial mechanisms account for the family transmission of ADD. But it is believed that some children may be the primary genetic source of ADD. Even though the prevalence of ADD in girls is much lower than in boys, they seem to have a heavier genetic loading for ADD. This has been explained by Vandenberg as a reduced penetrance for the expression of ADD in girls, which is explained by a "gender threshold effect" governed by biological, psychodynamic and cultural factors,

 

Neurophysiological factors: There are other factors which can account for the development of ADD. Certain conditions are more associated with ADD such as brain damage. There seems to be an increased incidence of certain abnormal EEG pattern such as the absence of an age appropriate number of well-organized alpha waves. The abnormalities are attributed in general to delayed maturation of the central nervous system which seems to be confirmed by increased normalization of EEG in AD/HD children as they grow older. Low birth weight is highly predictive of ADD. Contrary to the old belief that attaches a direct connection between perinatal trauma such as hemorrhage or hypoxia to ADD, those factors seem to play only a minor role, Prenatal and postnatal factors seem to have a more important role in the development of ADD. Intrauterine exposure to toxic chemical substances such as alcohol seems to play a major role. In fact, the fetal alcohol syndrome is reported by Herskowitz,  in 1987, to be highly associated with symptoms of AD/HD.    Children with ADD have higher levels of lead than their   normal siblings. Children living in housing projects with higher exposure to lead through paints, water pipes or other materials seem to have a significantly higher rate of ADD. Postnatal factors such as encephalitis or other cerebral infections seem to account for later onset of symptomatology. Frontal lesions are found in many cases of ADD. Many studies indicate an increased blood flow in primary sensory regions of temporal and occipital lobes and low blood flow in frontal cortex and caudate nuclei . An abnormal EEG is found in 20 % of ADD cases versus 15% in the general population. Many "soft signs" such as clumsiness, left-right confusion, perceptual-motor dyscoordination, and dysgraphia are found frequently in cases of ADD, but those soft signs can also be found in normal children. Interestingly, in the case of brain damage, Voeller, 1986, found that 93% of the lesions are in the right hemisphere.

 

PHYSICAL AND LABORATORY FINDINGS

 

Many findings are usually encountered in the work up of ADD children. Those findings usually apply to only a certain number of children with ADD but not all of them. As mentioned above, there may be an increase in blood lead level, abnormal thyroid function tests with the tendency to point towards hyperthyroidism, and more frequent abnormal EEG's. Also observed are a change in autonomic manifestations, decreased REM latency, increased sleep latency, and a restless sleep, There are mixed findings in CSF with decreased levels of Norepinephrine and Phenylethylamine, and elevation of serotonine.

 

EPIDEMIOLOGY

 

ADD affects about ten percent of boys and about two percent of girls, with a ratio of boys to girls between the ages of three and five and an average prevalence of three to ten percent . ADD accounts for 30 to 50 percent of psychiatric outpatients and 40 to 70 percent of inpatient psychiatric admissions for children. About 17 percent of ADD children are extrafamilial adoptees compared with four percent of child psychiatric patients and one percent in the general population. Psychostimulants are prescribed for 20 percent of special education students. ADD is much more frequently diagnosed in the U.S.A. than in any other country in the world. In Great Britain, only about two percent of the children seen in outpatient psychiatric clinics are diagnosed with ADD, compared with about 40 percent in the U.S.A. It should be noted that, in Great Britain, ADD plus

conduct is diagnosed as conduct disorder, but in the U.S.A. it would be diagnosed as ADD.

 

ASSOCIATED DISORDERS

 

1. Conduct Disorder: About 30 to 50 percent of ADD children have an associated conduct disorder including oppositional defiant disorder. Twenty five percent of ADD children develop antisocial personality disorder as adults. The familial risk for antisocial personality or oppositional disorder is much greater in a family with an ADD child who also presents with symptoms of conduct disorder. The risks of the family for antisocial disorders are the same as for the general population if the ADD child does not have conduct disorder. Follow up studies of children with ADD and conduct disorder indicate that, once an adult, the subject is at a much higher risk for alcoholism,   antisocial disorder, psychiatric problems, social adjustment, and criminal activities. Often, the teachers or the parents, in the case of ADD associated with conduct disorder, have the tendency to consider the symptoms of conduct disorder as part of ADD.

 

2. Mood Disorder: Mood disorders are found in 20 to 30 percent of children with ADD. Parents with mood disorders have a higher rate of offspring with ADD. The association of ADD and    mood disorder predicts a very serious future morbidity.   In fact, ADD children with mood disorder have a much higer   rate of suicide as adults.    Fifty percent of children with mood disorder and ADD will respond to lithium.

 

3. Anxiety Disorders: Comorbidity between ADD and anxiety disorder is about 30 percent. Studies of comorbidity in this area show that the rate of anxiety disorders among the relatives of patients with ADD is much higher compared to the general population. The risk for anxiety disorder is significantly higher in relatives of subjects with ADD and anxiety disorder compared with relatives of children with ADD without anxiety disorder. The two traits cosegregate within families.

 

4. Neurological Disorder: ADD without hyperactivity seems to be linked more to neurological disorder, lower IQ and other cognitive deficits. The localization of the lesion dictates the nature of the symptoms.

 

5. Tourette's Syndrome (TS):  Twenty to sixty percent of males with TS also have ADD and likely obsessive-compulsive disorder. The incidence of having ADD and TS is six to ten times higher for males and twenty to forty times higher for females. In addition to the symptoms of ADD, those people with TS also suffer the symptoms of TS which include: ties, difficulty with written language manifested by slow writing and hardly legible handwriting, and difficulty with arithmetic usually two grades below age expectation.

 

6. Schizophrenia: Children with ADD who have a mother who is schizophrenic will have an increased risk of developing schizophrenia when they reach adulthood. The siblings without ADD are at a lower risk of schizophrenia.

 

7. Other conditions: Certain conditions seem to have a higher rate of association with AD/HD: Pica, learning disabilities, speech disorders, pervasive developmental disorder, hyperthyroidism, pinworm infection.

 

ADD IN ADULTS

 

It was originally thought that all children with ADD would outgrow their ADD once they reached adulthood. However, there are many cases of ADD which continue into adulthood. The symptoms in these cases vary. In some cases, the symptoms of childhood ADD persist. In other cases, the clinical picture varies to some degree with attention deficit being one of the major symptoms most of the time. This attention deficit manifests itself under the form of difficulty in completing tasks and in listening to or following reports. However, with interesting activities, attention and concentration can be maintained normally. Attention deficit can greatly impair the patient's capacity to acquire new vocational training and education. The residual symptoms of ADD in adults also include:

 

1. Abnormal motor behavior can be reflected by restlessness, inability to relax, the need to       have something to do all of the time, and fidgetiness.   This seems to impair the patient in certain sports activities.

 

2. Quick or excessive temper will cause the patient to be considered "short fused'. He is quick to react in an explosive manner, leading to frequent arguments or physical fights. Many of these patients learn to project their anger, which is usually short lived, in contradiction with the more persistent anger found in borderline personality disorder.

 

3. Poor impulse control will lead the patient to do or say things he later regrets. Impulsivity may cause the patient to be intrusive, interrupting other people in the middle of their conversation. Poor control over drinking may lead to alcoholism.

 

4. Mood disorders, with their mood changes, are mostly environmentally related with the depressed mood being the more dominant one in duration and frequency. Suicide risks are increased. The depression lacks biological abnormalities.

 

5. Low tolerance to frustration causes the patient to appear tense and unhappy most of the time.

 

TREATMENT OF ADD

 

A.  Environmental arrangements:  Rearrangements of the environment at school and   at home  are needed to reduce stimuli and distraction.  At home, create quiet places. Use simple furnishings and  subdued colors. Toys should be placed in closets after use. Allow only one friend at a time to visit. Avoid taking the child to crowded places or parties. Encourage fine motor exercises such as jigsaw

puzzles.

 

B. Behavior approach: At school, small, self-contained classrooms, small group activities, a selection of seating locations to minimize stimulation, and a low student to teacher ratio are beneficial. There should be a predictable structure with a well scheduled program, an individualized education plan (IEP). and careful planning in advance in case of the transfer of schools. Maintain close monitoring of behavior and academic results. Address feelings of insecurity, low self esteem, and rejection. Also, a well thought out and  consistent plan intended to promptly reward positive behaviors and discourage disruptive ones will be very useful. The child does better on an one on one basis. Orders need to be concrete and given one at a time. Corporal punishment is very counterproductive.

 

      Anger Management and Social Competence : The acquirement of better social skills can improve self esteem and secure feelings, thus improving certain behavior problems in AD/HD kids. The kids are also taught to improve self-control in sessions where the child learnt to manage his anger more efficiently by exposure to the stressful situation and to learnt better problem-solving skills. The child also learn to evaluate him/herself and to set up definite target for improvement of his/her behavior. In a four-session program, Reid and Borkowski paired a cognitive behavioral therapies program with instruction and coaching in effort attribution for both failure and success experiences. Specifically, when errors are made, children were encouraged to attribute the failure to the lack of use of self-control strategies they had learned or when they succeed they learn to attribute it to the successful use of those strategies.

 

      Self-instructional Training: Self-instructional procedures derived from the concept that children acquire self-control through the gradual internalization of guiding speech. The strategy training techniques developed by Meichenbaum and Goodman follow the following sequence:

 

      1. The trainer first performs the task while talking aloud about the nature of the problem and the strategies he or she is using (cognitive modeling).

      2. The child -then performs the same task under the verbal direction of the adult (overt external guidance)

      3. The child then performs the task while instructing him or herself aloud (overt self-guidance).

      4. The child performs the task again while whispering the instruction (faded overt self-guidance)

      5. The child then performs the task while guiding his or her behavior with private speech covert self-instruction.     

      

Self-evaluation: AD/HD children's behavior are characterized by accurate reflection over recently committed disruptive/aggressive behavior. They do not seem to be aware of the very inappropriate/troublesome nature of their behavior. They do not seem to be embarrassed over the disruption and problems they cause to their environment. By helping the child to monitor, self-evaluate their behavior and establishing better standard of behavior, it is expected that the child will be able to readjust their inappropriate/impulsive behavior. As the children are performing academic work, social problem-solving, they are actively monitoring and self-evaluating their performance. In practice, the trainer announces a target behavior to be achieved such as: "To pay attention". The children then discuss what to pay attention means and give examples of behavior proving that a child is "paying attention" . The trainer can  start by role playing a kid in the group by discussing  out loud what he has done to help with maintaining  attention. After a few minutes, the children were shown   a "Match game " sheet and they are explained about the    role playing and about trying to match the 5-point rating he or she will give to each others and they will fill-in a Match Game Form. Then the group leader would give his/her assessment of the children. Bonus points are given to children who more accurately assess themselves.

 

      Anger-Management: Hinshaw et al (1981) devised a group curriculum for training in anger management. The children are asked to report the most offending name calling but they were subjected to by peers at school and the are informed that those names will be used to practice in anger-control. The sessions used to follow the following steps:

 

      1. The children are asked to report the most offending name-calling.

 

      2. The adult-trainers will role play the situation including name calling and the reactive aggressive/angry behavior. Then the group would continue to discuss about this reaction and other possible alternatives. Another step is to ask the group to reflect on their internal anger cues such as feeling states or incipient behavior leg. Clenching a fist) which will help them monitor their anger. The youngster is then ask to adopt a particular strategy/coping behavior to deal with the anger.

 

      Attribution Training:  In 1987, Reid and Borkowski devised a four-session strategy  to link self-control with attribution training. Initial    sessions are focused on "antecedent attributions" which are the long belief system of the child regarding success or failure. The child learn the importance of attributingt success or failure to factors related self-control or anger management.

 

      Response Cost : This involves the loss of previously earned reinforcers at the display of unacceptable behavior.

 

C.  Pharmacotherapy:  Pharmacotherapy remains one of the major treatment modalities of ADD. They include stimulants, antidepressants, and Clonidine. Other medications, which may prove helpful in certain situations, include the major tranquilizers and lithium carbonate. Benadryl and chloral hydrate have proven to be useful in the case of insomnia. The stimulants include two rather short acting products, namely dextroamphetamine sulfate (Dexedrine), methylphenidate hydrochloride (Ritalin), and a longer acting product, magnesium pemoline (Cylert) which has a half life of about 12 hours. The stimulants prove to be effective in up to 75 percent of cases and exert favorable action on hyperactivity, impulsivity, attention deficit, and emotional lability. Side effects of the stimulants include anorexia nervosa, insomnia, mild blood pressure and pulse rate increase (particularly with Dexedrine), irritability, and ties. The stimulants tend to have a rebound phenomenon after the action of the medication wears out.

 

    * Dextroamphetamine sulfate is effective for both impulsivity and distractibility. It can be used in younger children. It is available in liquid suspension, tablets, and slow release capsules. The duration of actions is about five to six hours with a half life of ten and one half hours. Dosage range is between 10 and 40mg per day in divided doses. Dextroamphetamine can have an effect on

blood pressure and pulse rate and it may slow down growth. There is the high potential of abuse.

   " Methylphenidate hydrochloride (Ritalin ) is the most popular among the stimulants used in the U.S.A. Ritalin is rapidly absorbed and enters the plasma in low concentration which makes it highly effective. The low plasma binding allows a high ratio to enter the blood-brain barrier. The product is conjugated in the liver. Ritalin proves to be highly effective with both impulsivity and inattentiveness. Seventy five percent respond to the drug compared with eighteen percent for the placebo. Favorable response happens within ten days, but four weeks may be needed for Ritalin to reach full effect. Dosage range is from 20mg to a maximum of 60mg per day. A 20mg sustained release tablet is available and has a half life of 8 hours and peaks after 4.7 hours. There is no evidence that the slow release form is better than the regular ones. Ritalin should not be used in the case of Tourette's syndrome (TS). Growth slow down may happen,

   * Magnesium  pemoline is a dopamine agonist which has proven to be an efficient treatment of ADD. Its half life of 12 hours is  long enough to work around the clock. It can be prescribed using regular forms. The strongest action happens around three weeks or later. The dosage range is between 18.75mg and 112.5mg per day.   There is a one to three percent risk of hepatotoxicity, so a complete blood count with liver functions needs to be done every six months.

   * The antidepressants have therapeutic effects which last more than 24 hours. Low dosages of antidepressants (for example Imipramine 0.3 to 2.0mg per kg per day) prove to be sufficient. There is no rebound phenomenon. They are used when stimulants are contraindicated (tics, insomnia, and

severe anorexia), when there is significant mood disorder in the ADD clinical picture, or when drug addiction is a problem. They are convenient because they can be given once a day, which helps with compliance.

  * Clonidine, an alpha adrenergic agonist, proves to be a promising medication for ADD. It is as efficient as Ritalin in improving behavior disorders of ADD. Parents tend to rate a better response to Clonidine regarding hyperactivity and behavior problems. Teachers, on the other hand, tend to rate Ritalin higher for its action on attention deficit. The best action of Clonidine is obtained with children who are "highly aroused, very hyperactive, and energetic" Clonidine can work around the clock. Clonidine contraindications include children with a history of depression, children with thought disorder, or children with attention deficit without hyperactivity.   Clonidine is also indicated in cases where high doses of Ritalin are needed, where there is more aggressivity and explosiveness, when there is significant weight loss or ties from stimulants, when there is a prominent roller-coaster effect from stimulants, and when there is marked insomnia, loss of spontaneity, or growth impairment,   Clonidine usually works in four to eight weeks. It can cause significant drowsiness, blood pressure drop, or localized itching when the patch is used. The average dosage ranges from 0.05mg to 0.3mg per day, starting at the lowest dosage. This article does not replace a direct consultation with a psychiatrist. Only careful consideration pertaining to history and accurate observation of symptoms and evolution of the disorder will lead to an accuate diagnosis and the formulation of an adequate treatment plan.

 

A condensed form of this article has been published in the Magazine of The Potter and Randall County Medical Society in Texas.

 

Dr. Nguyen is a former Assistant Professor of Psychiatry of:

 

-          The University of Texas, School of Medicine at Houston

-          Texas Tech University

-          The Texas College of Osteopathic Medicine

-          He was also Medical Director of several Psychiatric Hospitals in Texas.

 
   
   
   
   
   
   
   
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