Treating Huckleberry Finn: A New Narrative Approach to Working With Kids Diagnosed ADD/ADHD • Unraveling the Mystery of Autism and Pervasive Developmental Disorder: A Mother's Story of Research and Recovery

Each of these books is critical of established psychiatric practice. David Nylund, a licensed clinical social worker employed in a large health maintenance organization in California, believes he has uncovered a plot by Ciba-Geigy and the medical profession to profit from diagnosing attention-deficit hyperactivity disorder (ADHD) in children and treating them with Ritalin. Karyn Seroussi, mother of an autistic child, believes that autism results from a reaction to certain foods and vaccines in vulnerable children.

Nylund objects to the ADHD "label" given to creative, spirited children who do not conform to the expectations of parents and schools. His book contains logical errors and specious arguments, and it misrepresents current scientific and medical practice. He offers no evidence to back his claim about profiteering by the pharmaceutical industry and the medical profession.

He takes uninformed sideswipes at Russell Barkley, citing his 1990 Attention Deficit Disorder (1) as "pushing" medications to the exclusion of "talk therapies"; however, at least half of Barkley's book—now updated (2)—is devoted to behavioral and family-centered treatments. Nylund cites one of Joseph Biederman's epidemiological studies of ADHD as an example of how "children were diagnosed with ADHD after the therapist briefly interviewed the parent over the telephone."

He falsely criticizes Children and Adults with Attention Deficit Disorder (CHADD) for backing an exclusively biological approach to treating ADHD. According to Nylund, viewing ADHD as a biological disorder forces parents and children to see the child as defective and helpless, leading the child to settle for a diminished future and to use ADHD as an excuse for bad behavior. These are tired old claims, offered without proof. If Mr. Nylund were to actually read Russell Barkley's work or attend a CHADD national conference, he might find the answers he claims to be seeking.

Readers who endure the opening section of the book and get to the meat of what Mr. Nylund has to offer will find some interesting and useful therapy techniques. Mr. Nylund has named his technique "SMART therapy," which allows him to refer to "SMART therapists"—cute, but annoying. The acronym stands for "Separating the problem of ADHD from the child; Mapping the influence of ADHD on the child and the family; Attending to the exceptions to the ADHD story; Reclaiming special abilities of children diagnosed with ADHD; Telling and celebrating the new story." He includes two useful questionnaires for identifying the child's strengths at home and at school. He does not give—and I suspect he does not have—outcome statistics or long-term follow-up data for children treated with his method, and no norms or standards are offered for the questionnaires.

Throughout the book, Mr. Nylund refers to Huckleberry Finn as an archetype of the misunderstood child who today is diagnosed as having ADHD and for whom Ritalin is prescribed without attention being given to the whole child. In Huck's case, important factors were an alcoholic and abusive father, lack of a permanent home, need for serious remedial education, and a strong character.

I can assure Mr. Nylund that despite pressures from managed care, the biopsychosocial model is used in treatment, and real children (as opposed to fictional characters) are cared for with attention to the whole child in the context of family and community. Psychotherapy methods are useful in the treatment of ADHD—but after the family has acquired a clear grounding in the biological basis of this disorder, and in the context of a careful exploration of what pharmacotherapy has to offer. The Multimodal Treatment Study of Children With Attention Deficit Hyperactivity Disorder (3), conducted by the National Institute of Mental Health, clearly demonstrated the effectiveness of medications and the benefits of a combined approach.

Karyn Seroussi's book mounts a more subtle attack, this one on current scientific and medical approaches to autism. Seroussi is a far better writer than Nylund. She is also a layperson and the mother of an autistic child, so she is not held to the same professional standards and may be forgiven if her zeal prevents her from exercising genuine scientific skepticism. Her book unfolds like a detective story, detailing one of the prevailing outsider theories about autism.

According to this theory, some children are born with an allergy-type vulnerability to certain foods, the primary suspect being cow's milk products. After the gut has been challenged and irritated by cow's milk formula, the infant is subjected to the current combination of multiple vaccines, including the measles, mumps, and rubella (MMR) vaccine. The measles component of the vaccine, according to this theory, creates microscopic pitting in the small intestine of some vulnerable children. The bowel wall becomes "leaky," permitting proteins and complex carbohydrate molecules that ordinarily would be held in the gut for further breakdown to enter the bloodstream. The child's brain is thus subjected to toxic and hallucinogenic molecules, producing the classic symptoms of autism. In addition, many of these vulnerable children also have high levels of circulating sugars in the bloodstream, leading to yeast overgrowth and production of additional neurotoxins.

The suggested treatment for autism is thus to avoid cow-based dairy products, eliminate gluten-containing foods, avoid or delay the MMR vaccination, administer nystatin, and restrict or eliminate refined sugars from the child's diet. If further treatment is needed, salicylate-containing foods are eliminated. Seroussi also advocates early intervention with intensive speech and language training, a conventional therapy with proven results. The last several pages of the book are devoted to diets and recipes.

This outsider theory has some superficial appeal. It is also testable, and it is being tested by recognized researchers. At this point the evidence is not persuasive enough to allow mental health professionals to recommend highly restrictive diets to these vulnerable children and their stressed families. The yeast overgrowth theory, the hypothesis that sugar causes problem behavior, and Feingold diets have been around for a long time and have been debunked.

Outsider critics often assert that recognized medical researchers are afraid of the economic and political consequences of having conventional theories challenged. According to Seroussi, if medical science were to prove a causal connection between autism and the MMR vaccine, the economic consequences would be devastating.

In fact, however, medicine has repeatedly adopted new ideas that genuinely advance diagnosis or treatment of illnesses, regardless of economic consequences. A few examples from among the hundreds available will suffice. The development of the Salk vaccine closed down polio hospitals and iron lung manufacturers—and physicians cheered. Gastric ulcers were shown to be caused by Helicobacter pylori and curable with antibiotics; virtually overnight, tons of materials for educating patients in ulcer diets and the proper use of antacids became landfill material. Across the country, medical professionals continue to lobby for seat belt and helmet legislation; they do not want to make money off of head injuries.

The reality is that if genuine scientific evidence emerges to demonstrate that vaccines are harmful or that eliminating dietary gluten is a reliable way to treat autism, such findings will be published and swiftly turned into practice. In the meantime, science retains a hard eye. Accurate diagnosis and treatment of neurodevelopmental disorders is exacting and difficult. But research on the brain continues, and the future looks bright. Those of us who work in the field will continue to separate the wheat from the chaff in the research and direct our patients to the best possible proven treatments.