Mislabeled Child Eide New Atlantis

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The mislabeled child
Article in New Atlantis (Washington, D.C.) · February 2006

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The Mislabeled Child
Brock L. Eide and Fernette F. Eide
When we first began treating children with learning and behavioral dif-
ficulties, we were struck by a paradox: although we found many different
professional groups willing to diagnose and treat such children—general
and developmental pediatricians, pediatric psychiatrists, psychologists,
neuropsychologists, educational specialists, and even a few neurolo-
gists—we found a surprising degree of uniformity in the approaches they
employed. Each specialty observed and categorized children’s behaviors,
rather than identifying the causes of those behaviors in a child’s unique
neurological wiring and life experience. In practice, this meant rely-
ing on the approach to diagnosis outlined in the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM ), with its behavior-based criteria for a grow-
ing variety of learning disabilities.
As a neurologist and a medical internist, this pattern of assessment goes
very much against our grain. We were trained never to rely exclusively on
behaviors for a diagnosis, because behaviors—like limps, clumsy fingers,
or coughs—can have many different causes. So can problems reading or
paying attention. Instead, we work backward from behaviors to locate spe-
cific causes in the nervous system, because effectively directing treatment
requires correctly identifying the source of dysfunction. The distinction
between behavioral and causal approaches is important, because adopting
one approach or the other has profound consequences for how we under-
stand and treat children with behavioral and learning challenges, and for
how we organize our educational, healthcare, and even parenting practices.
Diagnostic Confusion
Consider, for example, our approach to children diagnosed with Attention
Deficit/Hyperactivity Disorder (ADHD), perhaps the most well-known
learning disability in modern times. According to the American Academy
of Pediatrics, 8 to 10 percent (up to 14 percent of boys) meet the criteria
Brock L. Eide, M.D., M.A. and Fernette F. Eide, M.D. are physicians and consultants
to a wide range of parent, teacher, and clinical professional groups seeking more information
about brain-based difficulties and their solutions. Their book, The Mislabeled Child, will
be published by Hyperion Books in August 2006. This article is based on testimony before the
President’s Council on Bioethics.
46 ~ THE NEW ATLANTIS
Copyright 2006. All rights reserved. See www.TheNewAtlantis.com for more information.
THE MISLABELED CHILD
for ADHD. Most children who struggle in school frequently show some
ADHD-type behaviors, and many of these children end up taking stimu-
lants to treat their “condition.” Studies have also shown that nearly all chil-
dren stop paying attention when they’re confused, and become unmotivated
when they can’t succeed. Confused and unmotivated children are often inat-
tentive and restless. It’s important to distinguish causes from effects.
When we examine children who show ADHD-type behaviors, we
often find a variety of causes for these behaviors rather than a single
global problem with attention. Many have undiagnosed reading or hand-
writing problems; or brain-based visual or auditory processing deficits;
or sensory-motor processing deficits that make handling the barrage of
incoming information in the busy school environment, including social
signals, highly difficult. Or we find children with very strong or uneven
learning preferences, whose performance varies dramatically depending
upon their learning environment; or even highly intellectually gifted chil-
dren who are simply bored by an insufficiently challenging routine.
Understanding why a particular child is struggling with attention
involves more than simply documenting certain behaviors. It requires
completely assessing the physical, medical, neurological, cognitive,
behavioral, emotional, educational, and psychological aspects of the
child’s development, to see where breakdowns in the child’s attentional
or behavioral control mechanisms are occurring. Although many practice
guidelines—like those of the American Academy of Pediatrics—advise
considering such factors when making behavioral diagnoses, they provide
little guidance on how they should influence diagnosis; and because these
various factors are not adequately considered in the DSM, they are sel-
dom considered by practitioners when diagnosing ADHD.
For many children, schools are sources of enormous stress. Stresses
may arise from interactions with peers—involving struggles for accep-
tance or esteem, or even physical threats or bullying—or with teachers,
who are enormously important figures, especially during the elementary
years. Stresses may also arise from the learning process itself. Academic
pressures have intensified in recent years due to the standards movement.
While valuable in pointing out the problems with our current educa-
tional system, the No Child Left Behind program has—with an almost
Orwellian irony—raised the specter of grade retention and failure for
millions of children.
Enormous numbers of children are struggling to meet basic academic
standards in areas like reading, writing, math, and language. Many have
neurologically-based disorders of cognition and learning. Up to 10 percent
SPRING 2006 ~ 47
BROCK L. EIDE AND FERNETTE F. EIDE
of children have dyslexia, 18 percent have untreated visual problems, 13

percent partial hearing loss, 5 to 10 percent disorders of central auditory
processing, 5 to 10 percent language disorders, and 6 percent motor coor-
dination disorders that impair vital functions like handwriting. Current
federal guidelines permit only 3 percent of a school’s students to opt out
of standardized assessments because of disability, so many students with
learning problems are under intense pressure to meet performance stan-
dards. We are imposing higher academic demands on the very children
we misdiagnose; we expect better performance yet often ignore the real
barriers to a child’s success.
Brain Problems, School Problems

Most learning or behavioral difficulties arise from one of two types
of problems. The first is a problem with one of the basic neurological
functions that underlie reading, writing, counting, and other basic aca-
demic functions. These neurological problems—which occur in areas like
perception, motor coordination, memory, attention, or pattern process-
ing—are often very difficult to diagnose, because they frequently don’t
present in ways that suggest their true nature. Yet these difficulties are
relatively common in school-aged children, and they are often mislabeled
as deficits in attention or as autism spectrum disorders. If correctly diag-
nosed, these problems can often be treated successfully using therapies
that take advantage of nervous system plasticity to repair the underlying
deficit—and eliminate the resulting ADHD-type behaviors.
The second type of problem is caused—or greatly exacerbated—by
instruction that is poorly suited to the way particular children are “wired
to learn.” While most of us learn better in some ways than others, for
some children these differences are profound and potentially debilitating.
Such children could learn very well in the right educational setting, but
they struggle in the standard classroom because information is presented
to them in forms they are not well suited to process. Frequently, these
children have difficulty taking in information through auditory-verbal
(lecture-based) instruction, or expressing information through hand-
writing. Because our educational system overwhelmingly stresses these
forms of communication, children with primarily visual, spatial, hands-
on, or novelty- and experience-based learning styles often suffer needless
problems with learning and attention.
Some children also differ markedly in the rate and depth at which
they prefer to take in information. Some are intellectual pythons, who
prefer extended periods to digest a single topic. Others learn like spar-
rows, needing frequent short bursts of learning interrupted by frequent
breaks. While all students must achieve certain basic competencies in
core subjects, they do not all need to pursue them in the same ways or
through the same routes. What they need is a form of education that’s
right for children who learn the way they do. Many children who struggle
in school do not have cognitive “impairments” or “abnormalities” in any
absolute sense, but simply differences in learning style—differences that
often render them well-suited for various adult occupations.
Our clinic, for example, is located in Seattle, so we see many children of
software designers and engineers who work for companies like Microsoft
and Boeing. Often the supposed “learning disorders” that have made these
children poorly suited for the auditory-verbal learning environments in
their schools are manifestations of the same visual and spatial reasoning
styles that have made their parents professionally successful and creative.
The conflict between the child’s learning style and his school’s teaching
style leads to unnecessary failures and frustrations. In response, we tend
to classify the child as “sick” rather than seeking to understand what
makes many healthy children struggle.
When children find themselves in environments where learning is
demanded but not facilitated, they often end up in a cycle of despair. They
struggle, fall behind their classmates, become anxious and ashamed of their
difficulties, and eventually even of themselves. Some even wish they had
never been born, like our patient who told her mother she wanted Santa to
bring her death for Christmas, or the boy whose mother found the note he
had written to himself saying he deserved to die for being so stupid.
For children like these, learning challenges aren’t just a question of
grades or achievement: they strike at the very heart of a child’s self-image,
and for some can quite literally be a matter of life and death. Too often
they receive a variety of diagnoses—like ADHD, oppositional defiant
disorder, depression, conduct disorder, bipolar disorder—and a variety of
drugs (often 3 or 4 for a single child) to control behavior. In many cases,
the underlying problems go untreated, leaving children as the helpless
victims of a monolithic approach to diagnosis that often fails to discern
the real causes of the very behaviors it classifies.
Research Barriers
Better treatment begins with better research. Although the behav-
ioral approach has laid claim to scientific consensus, it has continued to
SPRING 2006 ~ 49
receive criticism from sources both inside and outside the research and
clinical communities. Not surprisingly, supporters of the DSM model have
responded with a vigorous defense of the validity of the ADHD diagno-
sis and the efficacy of stimulant treatment. Too often, they have done so
in a manner that has inhibited better research into the heterogeneity of
attention problems, enforced the notion that all children with attention
problems suffer from the same general disorder, and impeded the search
for more effective treatments.
For example, despite decades of heavy stimulant use, there has never
been a good study of the long-term safety and efficacy of these drugs
in children. Moreover, the only large study so far into risk factors for
the persistence of ADHD-like symptoms from childhood into adult-
hood—conducted by Harvard professor Ronald C. Kessler and colleagues
and published in Biological Psychiatry—found that those who were treated
for ADHD as children had an almost fivefold greater risk of suffering
ADHD-like symptoms as adults—hardly the kind of positive outcome
that should inspire confidence.
Surprisingly, the authors of this study failed to address the obvious
possibility that stimulant treatment for ADHD-like behaviors in children
might directly contribute to the persistence of ADHD-like symptoms
later in life. The study raises the question, then deliberately avoids it:
The possibility exists, of course, that childhood treatment promotes
adult persistence. Indeed, a suggestion along these lines has been made
that stimulant treatment promotes subsequent drug use disorders
among children with ADHD. However, review of long-term adult fol-
low-up studies of patients who, as children, were included in treatment
studies shows clearly that childhood stimulant treatment is actually
associated with a reduction in adult substance use disorders. Another
possibility is that history of treatment sensitizes respondents to the
existence of their current residual symptoms, which might actually
be substantially higher than in childhood if treatment was discontin-
ued, leading to more accurate reports about those symptoms among
respondents with a history of treatment than among those who were
not treated in childhood.
With this, the authors move on to other topics, having glossed over a
potential problem with the behavioral/stimulant approach. It may be true
that treatment for ADHD in children leads to lower rates of substance
abuse as adults—but might it also lead to higher rates of ADHD-like
symptoms as adults? Is it really convincing to claim that higher rates of
ADHD are due to greater sensitivity to its symptoms? Even if this were
true, can a treatment for a psychological disorder be considered successful
if those who are treated still believe they suffer from it? And what does
this say, if anything, about the capacity of ADHD treatment in children
to reduce the persistence of ADHD in adults, or to promote human flour-
ishing during childhood and beyond? Such hard questions go unasked
and unanswered. Such an oversight, though surprising, is unfortunately
characteristic of much of the literature on psychotropic drugs in children,
where difficult questions are often carefully avoided.
Given the virtual absence of data regarding long-term consequences
of pharmacotherapy, the growing practice of treating children with
stimulants, anti-depressants, and even anti-psychotics continues as a vast
untracked experiment in clinical neuropharmacology on an absolutely
unprecedented scale. The current concern about the possible relationship
between psychotropic drugs and suicide in children is only one dimension
of a larger, unstudied, potentially disastrous story.
The Pressure to Label

Not surprisingly, schools and daycare centers are the leading catalysts for
diagnosis. In nearly 60 percent of cases, teachers are the first to suggest
the ADHD diagnosis, though many teachers over-identify children at risk.
In one study of teacher perceptions, 72 percent of teachers identified over
5 percent of their students as having ADHD, and fully one-third identified
between 16 and 30 percent. Interestingly, rates of identification increased
with class size.
Placing teachers in the role of diagnosticians creates a difficult dynam-
ic, in which parents often feel pressured to pursue a formal diagnosis and
initiate drug therapy. In our clinic, we have heard from many parents who
have been told by teachers or other school officials that a refusal to place
their child on stimulants would harm the child’s education and undermine
the classroom environment. Although legal protections have prevented
the most overt forms of coercion, teachers still hold considerable author-
ity, and function as gatekeepers to success through their abilities to assign
work, provide grades, and recommend retention.
Problems with diagnosis and treatment also occur in physicians’
offices. Studies have shown that in over half of cases where primary care
doctors make the diagnosis of ADHD, they do so without following estab-
lished guidelines or formally assessing the child’s attention. One study
of children receiving stimulants found that over 40 percent had no docu-
SPRING 2006 ~ 51
mented diagnosis of ADHD. Another study found that in roughly one

quarter of visits in which psychotropic medications were prescribed, there
was no associated mental health diagnosis in the patient’s chart.
To be fair, primary practitioners face a difficult situation. Most are
not trained in alternative approaches to attention problems, and many feel
short of other options. They often face desperate parents and suffering
kids, and they are expected to “do something” to solve the child’s problem
within the confines of a ten-minute appointment.
Similar problems occur in the area of autism and autism spectrum
disorders. One paper the journal Pediatrics showed how Department of
Education statistics on autism were compromised by variations in state
definitions of the disorder. Oregon, for example, lists autism criteria as
simply, “Impairments in social interaction.” So defined, autism is little
more than “oddism,” and any child who differs from peers can be so
labeled. Predictably, Oregon has had the highest autism rates in the coun-
try—2 to 3 times the national average—since statistics were first kept in
the early 1990s. This is not meant to cast aspersions on the diagnosis of
autism, which is a legitimate pathophysiologic entity. Rather, it is meant
to point out how diagnoses made primarily on the basis of behaviors often
undergo a process of diagnostic mission creep. After establishing a beach-
head in an area of true impairment, the diagnosis is extended by analogy
to include a much greater range of behaviors of far less severity until they
shade imperceptibly into normal.
An additional source of difficulty arises when pressures faced by
schools and physicians combine to create incentives to label children with
specific behavioral diagnoses. The Individuals with Disabilities Education
Act (IDEA) has effectively tied school services and insurance payments to
a limited set of “funnel diagnoses,” like ADHD and autism. Disabilities in
reading, math, language, and writing are lumped together under the head-
ing “specific learning disability,” and amazingly in many districts these so-
called “academic” disabilities will not qualify a child for an individualized
education plan while so-called “medical” diagnoses like autism and ADHD
will. Two results follow. First, there is often pressure to diagnose a child
with ADHD or autism simply to access needed services or accommoda-
tions for a learning problem. We see such cases every week—with parents
of dyslexic children, for example, told that they could get special help
for their kids if they could get them diagnosed with ADHD. The second
unwelcome result is that teachers receive lopsided and incomplete train-
ing on the nature of children’s learning challenges. Autism and ADHD
receive star billing, and common disorders like dyslexia or handwriting
impairments often receive little explicit coverage. Consequently, teach-

ers often tell us that they have little idea how to adjust their educational
strategies when a student struggles, other than to refer him or her to a
learning specialist.
Unfortunately, many learning specialists also receive little training in
brain-based cognition and neurodevelopment, and often follow general
rather than individualized approaches to helping struggling children.
Even many school psychologists have little idea how to diagnose and treat
children with neurological injury, dyslexia, visual perceptual problems, or
any of the many other conditions that affect the capacity to learn.
All of these factors combine to funnel growing numbers of children
into behavioral diagnoses (like ADHD) and onto psychotropic drugs
(like stimulants). Between 1994 and 2001, psychotropic drug prescrip-
tions soared for teenagers by 250 percent. By 2001, one in every ten
office visits by teenage boys led to a prescription for a psychotropic drug.
In testimony before the President’s Council on Bioethics in 2003, Dr.
Steven E. Hyman speculated that much of this explosion has been driven
by inadequately trained primary care practitioners who aren’t following
guidelines for treatment. While this unquestionably contributes, if it were
the major driver in the growing use of psychotropic drugs, we would
expect to see many children who’d been placed on medicines by primary
practitioners taken off them by psychiatrists and behavioral pediatricians.
But we very rarely see this. Instead, specialists typically switch or even
add medicines. Although primary care practitioners may sign the major-
ity of prescriptions, they appear to be reflecting the practices of specialist
practitioners.
Moral Underdevelopment
The trouble with the current situation is not only academic but moral.
A recent article in the New York Times on psychotropic self-medication
in young adults, entitled “Young, Assured, and Playing Pharmacist to
Friends,” is obviously not a formal study, but it does offer some important
insights into the kinds of habits that can develop in children who grow up
taking behavior- and mood-altering drugs. One young adult was quoted
as saying “I feel like I have been programmed to think, ‘If I feel like this
then I should take this pill.’” Notice both the passivity and the sense of
mechanism in the phrase “have been programmed.” These feelings mark
the transfer of causal efficacy from will to pill, where the role of the will is
reduced to the agent that picks the mood and selects the drug to reach it.
SPRING 2006 ~ 53
This is a considerable decline in the will’s domain, and a reminder that

other things may be lost when control of troubling behaviors or moods
is pursued through chemical shortcuts in an attempt to achieve a form
of “non-developmental development.” Drugs don’t teach self-awareness,
self-restraint, the ability to delay gratification, persistence, resiliency, or
any of the other skills that children need to control their own behavior.
Yet developing these traits is one of the crucial missions of education. The
goal of teachers and parents should be to help children develop into com-
petent and productive adults, not simply to control their behavior.
Behavioral labels can dramatically affect how adults perceive and
behave toward children, by purporting to describe limitations in their
abilities, feelings, personal will or agency, and moral capacity. We’ve had
many parents tell us how teachers or therapists, after casually diagnosing
autism, have made sweeping pronouncements about their child’s cognitive
and emotional limitations: like the speech therapist who told one mother
that her son’s apparent maternal attachment was not true affection,
because he had Asperger’s syndrome; or the many teachers who ascribe
the intense, advanced, and often specialized interests of highly gifted chil-
dren to the perseveration of autism or the hyperfocus of ADHD, rather
than seeing them as healthy manifestations of special intelligence.
Diagnostic labels can also convince parents that their children cannot
control or prevent their misbehaviors, which often feeds into the cycle of
bad behavior. For example, we failed to convince one highly educated and
professionally successful couple that their son, who’d been diagnosed with
ADHD and Asperger’s syndrome, needed to be disciplined for repeatedly
trying to harm his younger sister, rather than simply having his medica-
tions adjusted. If misbehavior is always the result of a disease, and pills
can make the behaviors go away, then the scope of adult responsibility
shrinks to providing the right drugs, rather than disciplining, training, or
modifying the home or educational environment.
A Victory for Whom?

One of medicine’s most basic ethical principles is that interventions are
justified only when they benefit the patient (with rare exceptions, such as
when medical inaction places others at serious risk). In the case of chil-
dren whose ADHD-like behaviors are so severe that they have difficulty
functioning in almost any environment—a group most experts would
place at between 2 and 3 percent of all children—the benefits of treatment
are easier to cite: improved relationships, fewer risky behaviors, and so
forth. But in the much larger group of children whose functional deficits
are less severe, the benefits of stimulants are far less clear.
One benefit frequently sought is improved academic performance.
Many parents and teachers believe that stimulants can make children
better learners. But data demonstrating long-term academic benefits are
extremely thin. In the Multimodal Treatment Study of children diag-
nosed with ADHD, for example, scores on achievement tests were virtu-
ally unchanged by stimulants. The sole demonstrable benefit—a one point
rise in a reading achievement test—is comparable to a one point rise in IQ.
Although stimulants often do make it easier for children to stick with and
finish assignments, they don’t make them better readers, mathematicians,
or historians. Stimulants help children conform better to the schedules
and activities they’re assigned, but not perform better in the sense of
measurable long-term gains in learning. For many parents and teachers
who’ve grown weary of scolding, cajoling, or wrestling with easily dis-
tracted youngsters, this can seem like a big victory. But the question is: a
victory for whom?
The other key factor in determining the risk/benefit ratio is risk, a fac-
tor that cannot be clearly established at present. In all but the most severely
affected children, the benefits of stimulants accrue largely to others by
controlling behavior, while the potential risks (and clear short-term side
effects, including appetite suppression, anxiety, and sleep problems) accrue
entirely to the child. In such a setting, “Do no harm” should be given more
weight than it usually is. At the very least, the medical community should
provide parents with a more complete and more accurate assessment of the
realistic benefits and uncertain risks these drugs may cause.
At the same time, parents need to know that there might be thera-
peutic alternatives. Although chemical states in the brain do influence
behaviors and moods, and drugs can influence these chemical states, it’s
also true that non-medicinal interventions can alter brain chemistry and
behavior in desirable ways. Unlike medicines, which largely work only as
long as taken, changes induced by new habits, new ways of thinking, and
new ways of behaving really do become part of a child’s neurological and
behavioral fabric. These changes, often cultivated in specific controlled
environments, affect the child’s general capacities.
And here lies the crucial difference between the behavioral approach
and the causal approach to caring for struggling children. The behavioral
paradigm fails to look deeper into the physiological causes of many learn-
ing problems, yet ultimately relies most heavily on purely physiological
solutions—like stimulants. The causal paradigm tries to break down seem-
SPRING 2006 ~ 55
ingly similar behavioral problems in terms of their precise physiological

and environmental causes; it looks for problems in the child’s brain that
we can locate and fix with appropriate experience-based therapy, and for
problems at home or at school that we might alter or ameliorate by modi-
fying the child’s environment. The behavioral approach rules the day, but
it often does not serve its supposed beneficiaries.
Positive Neurology
This brings us to the question of the fundamental needs of children. One
overwhelming need is an approach to education and development that
works with, rather than simply on, their developing nervous systems.
In contrast to the behavioral approach, whose disconnect with causation
leaves it dependent upon the promise of “better living through chemistry,”
a more neurologically-based approach holds out the promise of “better
chemistry through living”: that is, better neurological development and
function through targeted experience.
The brain possesses a remarkable capacity to “re-wire” itself in
response to experience. By carefully targeting inputs (through teach-
ing, therapy, or play), existing brain pathways can be trained to function
more smoothly, old blocks can be bypassed by new learning pathways,
and children can master skills that they previously found impossible.
By breaking down complex behaviors—like reading, listening, or pay-
ing attention—into component functions, then training those functions
through targeted experience, researchers have dramatically improved
function in the most complex human activities. For example, Dr. Torkel
Klingberg and colleagues in Sweden have significantly improved work-
ing memory and reduced ADHD-type behaviors using a computer-based
training program. For children with reading difficulties—who are often
diagnosed with ADHD because of difficulties listening or concentrating
on visual materials—researchers like Harold Solan at the State University
of New York and Michael Merzenich at the University of California, San
Francisco have shown that children can improve their reading skills by
interventions that improve visual attention and auditory discrimination.
Work like this should lead us to abandon the view that children with
learning and behavioral challenges are simply deficient in various brain
functions or chemicals, and see them instead as needing new experiences
that can help them learn and function in new ways. A child’s brain is
remarkably “resource-full,” because of its plasticity and diversity of sys-
tems. That’s why most children with learning and behavior problems can
be greatly helped by reshaping their experiences—by changing the child’s

environment at home and at school, and with targeted exercises that aim
to improve brain function.
This approach might be called “positive neurology,” in analogy to the
positive psychology movement that has shifted that field’s emphasis from
relief of mental illness toward pursuit of mental health. A similar trend
in neurology, which aimed beyond cataloguing weaknesses to developing
strengths, could revolutionize our approach to struggling children. The
key is building institutions and providing services that take brain-based
differences in learning into account.
Even though children differ markedly in the ways and rates at which
they develop, and a given child’s progress may differ greatly in differ-
ent areas, the expectation of uniformity shapes the curriculum of most
schools. It is as if we had adopted a factory farming model, where cacti
and orchids were treated just like potatoes. No one would try to raise
plants this way, and it works no better with children.
Young boys are particularly likely to be disadvantaged, because audi-
tory processing and motor delays are much more common in males,
and often present as difficulties in attention. One-third of five- and six-
year-olds cannot process a sentence longer than nine words; so all that’s
retained from, “When you need to go to the restroom, raise your hand and
wait till I call on you,” will be “when you need to go to the restroom.” It’s
easy to see why such children appear impulsive or inattentive. Likewise,
children with sensory-motor delays who require frequent movement to
stay attentive may suffer learning and behavior problems when classroom
schedules require lengthy seated work. Rather than trying to modify chil-
dren to fit the arbitrary educational frameworks of our schools, we should
design our schools to promote healthy neurocognitive development for
children with all sorts of learning and processing styles. There is no one
right educational approach for all children, and trying to design our insti-
tutions as if there were will inevitably cause difficulties.
The Most Basic Skills

One key area in which a more neurologically appropriate understanding
is needed is in the concept of basic skills. When we ask educators, “What
are basic academic skills?” most cite memorizing the alphabet, learning
letter sounds, counting, performing simple calculations, and mastering
penmanship. In reality, these academic skills require complex mixtures of
many underlying functions. Before children can master ABC or 123, they
SPRING 2006 ~ 57
must first master many more basic neurological skills, like auditory dis-
crimination, speech-in-noise perception, visual perception, sensory-motor
skills, memory and language skills, and attention-related skills like mental
focus, motivation, and impulse control.
Normally, these skills are developed through interactions with parents,
siblings, and peers. But for some children—often those with impairments
in sensory input or the connections that integrate functions—routine
activities may be too confusing to stimulate optimal development. These
children must have their needs specifically assessed, so lagging functions
can be developed through targeted, experience-based treatment. For most
children, this will involve the use of highly structured play activities,
where incoming patterns are simplified for easier processing, and repeti-
tion is used to enhance retention and increase the possibility of forming
new associations. For example, for children with deficits in auditory-
verbal working memory or sound-processing, computer games have been
created that start by delivering simplified sound messages, then require
children to process and retain those messages to score points and advance
to more difficult levels. Similarly, for children with sensory processing
and motor coordination problems that make even casual play with other
children extremely difficult, highly simplified activities involving balance,
postural muscle control, and bilateral hand and leg interactions can be
highly successful.
In general, children would benefit tremendously from a continuing
breakdown of the artificial barriers that divide play, education, develop-
ment, and therapy. Both schools and therapy centers would benefit from
an increasing use of technologies that allow sensory inputs to be precisely
and repeatedly delivered, feedback to be immediate and direct, and prog-
ress to be monitored by not only therapists and teachers but also by the
children themselves. This is one area where government can play a vital
role, by bringing together experts in education, neurocognitive devel-
opment, and the software and video game industries to discuss ways in
which healthy neurocognitive development can be promoted through edu-
cational, therapeutic, and entertainment programs. We are already begin-
ning to see games developed purely for play that can be used therapeuti-
cally to improve mental focus, impulse inhibition, and motor control—like
the popular Dance Dance Revolution, where children imitate movements
on a screen by dancing on a pad that registers their movements. By
intentionally promoting needed skills, companies like Electronic Arts,
Nintendo, Microsoft, and Sony could promote gains in behavioral control
undreamed of by Pfizer and Merck.
The key is providing incremental challenges tailored to each child’s

learning style and adjusted continually through ongoing assessment.
When children fail to achieve a critical ratio of success, motivation plum-
mets and they stop trying. After repeatedly facing challenges that demand
unmakeable rather than incremental leaps in their exercise of skill, they
simply lose heart and give up. But even thoroughly discouraged children
can be reinvigorated by success. We often see children who had given up
on reading or math work hard on demanding remediative therapies once
they’ve seen how small successes build in a stepwise fashion. Success
breeds success by developing a taste for mastery. Research has shown that
mental focus increases dramatically in children who have been diagnosed
with ADHD when they are given meetable challenges, and deteriorates
both when challenges are unmeetable, or—crucially—not challenging
enough.
From Better Medicine to De-Medicalization

Of course, such an approach—better chemistry through living—is more
demanding than writing prescriptions for Ritalin. And we are not naïve
enough to believe that every child will ever get access to the best brain-
based teachers and therapists, or that parents will become experts in
brain-based learning. Yet we do believe that the time has come to move
beyond the behavioral approach, to lessen our dependence on pharmaco-
therapy, and to seek more precise ways to help struggling kids. The devel-
opment of a child’s mind is a kind of unfolding or flowering that we can’t
wholesale create but can nurture into fullest bloom. The metaphor is the
garden, not the factory farm and certainly not the neurochemist’s labora-
tory. This approach demands a commitment both to better medicine and
to the de-medicalization of childhood—a commitment to uncovering the
brain-based causes of many behavioral problems, and a recognition that
many children whom we now classify as sick are really healthy. They are
failing because we are failing them, not because of the brains and bodies
nature has given them.
SPRING 2006 ~ 59
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The mislabeled child

Article in New Atlantis (Washington, D.C.) · February 2006

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46 ~ THE NEW ATLANTIS

of children have dyslexia, 18 percent have untreated visual problems, 13

Brain Problems, School Problems

48 ~ THE NEW ATLANTIS

50 ~ THE NEW ATLANTIS

The Pressure to Label

mented diagnosis of ADHD. Another study found that in roughly one

52 ~ THE NEW ATLANTIS

impairments often receive little explicit coverage. Consequently, teach-

This is a considerable decline in the will’s domain, and a reminder that

A Victory for Whom?

54 ~ THE NEW ATLANTIS

ingly similar behavioral problems in terms of their precise physiological

56 ~ THE NEW ATLANTIS

be greatly helped by reshaping their experiences—by changing the child’s

The Most Basic Skills

58 ~ THE NEW ATLANTIS

The key is providing incremental challenges tailored to each child’s

From Better Medicine to De-Medicalization

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