Episode 177 – Working with children with autism and ADHD often means working intimately with their families. In this episode, we have a conversation with Umesh Jain, child psychiatrist at SickKids Hospital, about the biology and psychology of children with autism. He shares tips on how to identify children with autism in the early years, and how to work with families to support their development.
And so telling a family who have parents with the same condition, “By the way, you need to be structured and routine,” may not be that easy because they’re having the same issues. So, it’s not surprising that, then, when we deal with these kinds of conditions. We’re not treating kids anymore – we’re treating families.
Umesh, welcome to the Preschool Podcast!
Happy to be here!
We’re delighted today to have on the show Dr. Umesh Jain. He is a child- and adolescent psychiatrist at Sick Kids Hospital [Hospital for Sick Children] in Toronto, [Ontario,] Canada. He has a lot of experience when it comes to subject matters like ADHD [attention deficit hyperactivity disorder] and autism, aggression in children and parenting strategies. He’s given over 700 lectures worldwide in 40 countries. So, we’re excited to have him on the show today to gain some wisdom from his experience and his knowledge.
Umesh, welcome to the show. And let’s start off learning a little bit about you and why you decided to study this subject matter and gain increasing knowledge and share your knowledge and wisdom on this topic.
You bet. I mean, I think that child psychiatry – and psychiatry in general – is the last untapped frontier of humanistic and medical research. And so I came into medicine and into psychiatry as a researcher, trained in the University of Pittsburgh in the US and was recruited to Toronto to do academic research specifically in the area of ADHD genetics. And so it evolved from there. But it’s a wonderful area to explore.
And what attracted you to Sick Kids Hospital in particular?
Well, I’m Canadian. I went to a Canadian medical school and Toronto is the largest research center in Canada – one of the top ones in the world, frankly. And from a genetic standpoint I would say it’s in the top five worldwide. And so it was an excellent opportunity to explore a developing area that was really evolving. I mean, 20 years later, unfortunately, it hasn’t been satisfactory. But the hope at the beginning was, “What if we found the gene or genes that could have predicted from the beginning that you’re going to have something?” That’s what we started with.
Wow, fascinating. And while maybe you haven’t found the exact answer to that question I have no doubt you’ve gained a lot of knowledge in your time at Sick Kids [Hospital]. And one of the things that we try to emphasize on the Preschool Podcast is trying to connect science with what we’re doing in our work with children every day in the classroom. So, maybe what might be helpful is if you can try to explain, in layman terms, to me and in our audience… you use the word “genetics”. What does that mean in the context of things like ADHD and autism?
You bet. Well, I think one of the most important things, takeaways, I would say to any person listening to this is that as much as I work in science, common sense prevails. In fact, knowing too much can actually be a handicap because you overthink everything. So, in some contexts part of the agenda really is knowing as much as you can about normal children, how they grow up and understanding how they deviate from that normality. For example, every child that’s born cries – well, they can’t do anything else. I mean, “I want something; I have to cry. And if I cry, who do I want? Mom or dad? Well, of course I want Mom.” We dads don’t have those feeding accoutrements. “I want my mom.”
So, what does the kid learn from the time they’re born? “I have the power to control my mother.” That power of the control my mother, which is to push her button because she has no choice – she has to respond to my cry – is, in fact, the beginning of a learning experience, which is, “I have the ability to control lots of things. I just convert my crying ability – once I learn how to talk – into all kinds of other ways of yanking the buttons of my parents.”
And kids don’t do it because they’re trying to hurt their parents. They’re doing it because they’re trying to assert their power.
So, as a child grows up, the first four months of a kid’s life is entirely dependent on one thing: “I’m looking for food. It’s all I care about. I’m looking for something that gives me a sense of survival. So, what do I know? I know there’s something out there that makes me want to feel safe and that’s the breast – something round and something with a protuberant middle. And everything that I do, whether it’s a motor reflex or a rooting reflex or a sucking reflex, it’s all based upon me wanting a breast.”
Well, by the time a child is four months old, looking for that breast everywhere, what’s the closest body form that we have that looks like a breast? Well, turns out it’s the human face. If you think about it, the human face is round with a protuberant object called your “nose”. And if anyone has ever taken a kid, a little child, and put them on their cheek, do you ever notice they find their way to your nose and suck it? I mean, it’s kind of interesting.
But therein lies the issue: children’s natural instinct is to look at a face because it’s the closest resemblance to something that they’re familiar with. And what? Well, therein lies the first thing: kids with autism don’t do that; they don’t look for faces. They think, “The world around her revolves around me. I’m not looking for the breast. The breast should come to me. Why should I go looking for it?”
And so autistic kids live within themselves. It’s like, “The world revolves around me. I really don’t care what anybody else.” And so right from the beginning you start seeing that mom’s attachment – and vise versa – to this child seems to be like she’s holding the bag of potatoes, that’s what it feels like. It’s like, “The kid’s not melting into me. The kid doesn’t feel me as if it’s an emotional connection. This is like holding that bag.” And so, in that context, we already see the beginnings of an attachment issue. You start seeing the beginning of a not needing to want to progress the developmental cycle.
The second thing that you see is, as soon as kids learn to walk and talk, “I don’t want to be hanging around you, Mom.” Now we’re talking about a one-year-old [child]. So, what do children do? Try to understand communication. Well, the second type of communication is eye contact. Eye contact is fundamental to children’s ability to understand cueing systems. That starts at the age of six months to about a year-and-a-half.
When the kid knocks over a vase, the first thing he does, he doesn’t cry. He looks at your face. He looks at you and then says, “Should I cry or should I make this a happy thing?” So, clearly, kids have been reinforced by the eye contact, whereas at the age of a year when children are starting to learn to walk and talk that they’re now showing their need to want to exercise their control but also, “How far I can go.”
Any parent… I always say, any parent who thought of a leash for their kid, whether you had one or not, that kid had a lot of energy. And that’s the kind of kid that would have walked away from you. And you would have noticed that by the time that kid is 18 months old to two-and-a-half years. That kid seemed to start the world already trying to emancipate but trying to take off on you because he was just interested in exploring everything.
So, something changes by [age] two-and-a-half. And parents can often say, “I could tell at 18 months to two-and-a-half that this was the kind of kid that was strong-willed, the kind of kid that I knew was going to be hard.”
I always call ADHD kids or autistic kids, “natural contraceptives for parents”, because if you’ve got a kid like this you’re not going to have another one, I’ll tell you right now, so far. It’s because it takes a heck of a lot of energy to manage a kid who has that much energy inside of them.
And what you’ll notice is, it’s the moms who get drawn into it, not the dads. In fact, dads often say something like, “I don’t have a problem with the kid. The kid’s fine. He seems to be okay.” I said, “Buddy, this is not your scintillating parenting ability. You’re just a guy. He doesn’t care about you. He cares about his mom. She’s the source of survival. Why do you think he’s so hard on her for?”
And that’s really important. It’s moms who take the hit. Moms are the ones that always feel as if they’re being pressured to manage this because she can’t walk away from the kids – dads can.
So, right away, you see differences in parenting style. And these kinds of differences the kid picks up on and you start seeing a lot more oppositional-defiant behavior because the kid learns the split. He already knows how to yank your cord. Now he’s going to make it, “Divide and conquer!” You see that by two to three years of age. And so already in the first just two years of life, this kid’s natural development is already moving towards a trajectory based upon his genetics. He has a need to do this and he’s exercising his control.
Sounds like a very familiar story in our home front of our two-year-old dividing, conquering.
Yes, and it’s a natural instinct. The vulnerability of a parent fundamentally causes children to want to oppose. Children don’t look at a parent and say, “Well, my mom has a headache. I think I should be nice today,” – just the opposite. When we as parents are vulnerable children exercise their need for control. And the kids will do, of course, one of these five things as a way of yanking the button, which is simply an extension of that cry episode – “I cry, my mom is coming.”
Number one, children use the Charmer: “Gosh, mom, I just love you. Did you change your hair today? Because I really need an Nintendo PlayStation.”
Number two, the Martyr: “Nobody loves me. I hate you. You guys are unfair and unjust. How come everyone else can play Nintendo ‘til 3:00 in the morning? Are we poor?”
Number three, the Intimidator: “I’m going to run away; I’m going to kill myself; I’m calling Children’s Welfare; you’re abusing me; I’m going to go live with my grandparents. They love me more than you. You suck as a parent.”
Number four, the Threat: “I’m going to hurt you; I’m going to break something of yours; I’m going to irritate you until you crack your head open and give in to me.”
Number five, the Passive Aggressive Kid: cold shoulder, stalling, forgetfulness, rolling eyes, sarcastic, swearing.
I’m going to tell you right now, Ron, if you’re getting sucked in, intimidated, frightened, provoked into anger or simply frustrated, every one of those behaviors is normal in kids, every single one. It’s an extension of crying. “I cry, you need to rescue me. I simply just use the same format of knowing that you have no choice and convert it, now that I can use language, to yank a cord even harder.”
The differentiation of autistic kids and ADHD kids is they do exactly what every other kid does, but they just do it all at once. By gosh, they yank your cord. They yank it so hard and all the same time it’s relentless. And you’ll see parents by two years of age to two to three years of age: “We’re just tired.” And it’s moms who typically take it.
So that was kind of my question: a lot of these behaviors, like you said, are just normal for any child. And so how do you know when it’s normal or abnormal when it’s all they know? As you said, all at once and really challenging, what does that mean?
Well, the technical term in psychiatry is “functioning” if it’s causing an effect that’s making you not follow the path of your normal trajectory. So, if you’re so impulsive and so energetic that you can’t sit in class, that you can’t sit at your dinner table, that you’re racing around and jumping off furniture and doing high dives off of the second floor windows, I think anyone would agree that that kid’s not functioning well.
And of course you take that kid, how is he going to get to the daycare? Daycares are neatly going to say, “There’s something wrong with this kid. We need a lot of personnel to keep him. He’ll walk out of our facility. He knows how to open the doors.” You know, the standard story of a kid who’s just 18 months old crawling out of his crib at 2:00 in the morning, standing on two chairs, looking at the cookie jar. “How’d you do it?”
Well, clearly when a kid is acting in ways that seem to be beyond that of the usual it’s affecting this kid’s functioning and, frankly, the functioning of the family. I mean, many times parents will often say, “I’m being held hostage in my own house.”
And forgive my ignorance of this question, but is this something that continues to develop over time? Like, you mentioned already at even potentially under 6 months there might be signs. But is it safe to say that that’s not all the time? Like, maybe only you’ll start to see signs at an older age? Or is it typically consistent?
Well, the diagnostic criteria says [that] you have to show the signs before the age of 12. In actual reality the signs are actually very strongly prevalent. And it’s a very genetically-based disorder. So, technically speaking, it’s started from the time the kid came out because he was born this way. These are very genetically-based conditions. In fact, ADHD may be one of the most genetically-based conditions of all conditions in medicine. It’s so obvious that it runs in families.
Not always this case but this is the most common family that I see: a hyperactive, impulsive, short-fused, somewhat childish father who marries a highly obsessional, worrywart mom who was shy and quiet as a kid. And her brother has the same kind of qualities of being hyperactive. “Oh, my gosh, the parents are completely opposite in temperament. How did you find each other?”
Well, opposites do attract. Next thing you know you’re probably carrying recessive alleles and popped out these kids. There you go. If you have ever seen the movie Mrs. Doubtfire – it’s a very popular movie in America – well, that’s the standard ADHD Family. Robin Williams married Sally Fields and popped out of ADHD kids.
And so this is the next logical extension of this conversation is, “How do we work with children with these types of challenging behavior, whether a parent or an educator in the classroom? Any recommendations?
My first recommendation is [to] protect the moms. Moms are always maligned: “She’s a bad parent; she should do better.” And moms, in their defense, try really hard to look after this. And the reality is, is that, “If I don’t look after mom’s mental health and we need to I don’t look after this kid.” So, the end of the day, whatever it takes to make sure Mom has respite, Mom has support, Mom is not maligned, Mom is not made to blame.
And the first thing I do is get Dad off the high horse and say, “Buddy, you’re not a better parent than she is. She’s different than you. You need to be supportive and make sure that you are a part of this,” as opposed to saying things like, “Well, I was the same way when I was a kid. I turned out okay!” Really? Really? Okay. So, I mean, these are the kinds of things that fundamentally can be divisive. And so step number one, look after moms.
Step number two, try to make sure that there’s structure in the family. That applies to all children but these kids need a lot of structure, routine, consistency. They need to know that life is predictable. And try to construct as much habit as you can. And that only happens if you have structure. The problem is, because these are genetically-based disorders, the parents themselves probably have ADHD or have some other kinds of conditions besides autism.
And so telling a family who have parents with the same condition, “By the way, you need to be structured and routine,” may not be that easy because they’re having the same issues. So, it’s not surprising that when we deal with these kind of conditions we’re not treating kids anymore – we’re treating families.
Yeah, that’s a good point. So, in your work, do you find yourself often dealing with the child, but then also with the parents as well?
Absolutely. So, I used to work for 25 years at the Center for Addiction and Mental Health here in Toronto, which is adult services. And I ran the adult ADHD program at a time that no one knew that adult ADHD existed. And it was only identified in 1989 in a book that was written by Canadian researchers Lily Hackman and Gabrielle Weiss in a book called [Hyperactive Children Grown Up : ADHD in Children, Adolescents, and Adults].
Now, up to this point, we thought that ADHD was a childhood condition that simply burned out. It doesn’t burn out. It turns into anxiety and depression. That’s what we’ve been hiding in all these people all those years. By adolescence it goes inwards. So, whenever you look at people with anxiety and depression and you ask them the question, “Did you have any of this stuff when you were a kid,” and they say, “Yes,” you might be dealing with ADHD.
And so at the end of the day we see that, within the family, I’m treating the kid. But who’s treating the adults? You can’t treat the adults. And you can’t really treat the kid because you require everyone to be on the same page. And so it’s a difficult prospect and one that necessarily is an ongoing area.
But the good news, I always say, is whenever I see a kid who’s impulsive – say, [with] ADHD – I always say to a parent, “Impulsiveness may be the toughest thing he has and yet the best thing he has. But he just doesn’t know where the on-off switch is. But if he knew where the on-off switch was we could help him. What he is, in the future is now called Entrepreneurship, Opportunism, Rescuer, the Risk Taker, Problem Solver. Maybe the best thing he has is his being impulsive.”
But you’ve got to know how to shut it off. It’s not [being able to shut] it off [that] causes the impairment. And that’s a learned trait and a developmental delay because these kids are simply slower at learning that “No” word. And so once they figure it out, they’re fine. In the meantime we may have to help them medically, that’s all.
Yeah, that’s an interesting perspective in terms of the advantages of having some of those different behaviors.
Well, you can just say to yourself, “The poster child for ADHD as Michael Phelps. Would he have 22 gold medals if he didn’t have ADHD?” In fact, it’s endemic in Olympians; it’s endemic in professional athletes because these kids are typically stronger and more active and capable. And so if you can get them into sports early it actually may be one of the most protective traits that these kids will have.
For autistic kids, what we want for them is we want to engage these kids as early as possible. And one of the brain-developing steps is communication. Speech-language is such a critical component for them. So, getting early speech-language intervention strategies and helping them to express themselves and then from there being able to help them work on social cues and developing a sense of friendships and connection is very important.
So, this story is all about the first five years of life. You can do a lot for kids fundamentally in providing them protection and abilities. And here’s probably the best thing I always say: What we do for ADHD kids and autistic kids in a school or as a parent, we don’t have a choice. We have to do it a certain way. But if you apply the same skills that you learn for ADHD kids and autistic kids and apply it to every kid, every kid is better off because every kid does better if you talk about positives.
So, I always say to parents and I say to teachers, it’s good that we have these kids in the school because the skillset that you have to learn and applying it to every other kid makes the school a better place. And that’s a good thing.
That’s a good point. I definitely would have never thought about that either. The same principles apply. And even things you talked about with routines and things like that, even if child children don’t have those challenging behaviors, they would still benefit.
Absolutely. So, just a quick way of showing the difference: The difference between saying to a kid, “Stop swearing, that’s rude and obnoxious,” versus learning the opposite, which is, “You know, if you want to get angry, I’m okay with the word Fudge.” Learning to say a positive refrain is what you need to do for kids with these kinds of disorders. But as you could quickly say, once you know that you can reframe something without using the words Stop, Don’t or No and you can do it in a positive way and apply it to every kid, every kid is better off.
Why do you think these kids have such a problem with the words Stop, Don’t or No? Because it’s a developmental word that starts at the age of two. That’s what the word is that pushes away you away from your mother. “No, I want to feed myself; No, I want to do things my way; No, you can’t control me.” Well, guess what these kids act like? Two-year-olds. They’re stuck as two-year-olds.
The one word they can’t handle is the word they hear every day of their lives: “Stop that; Don’t do that; Why’d I tell you that for?” Well, if you barrage a kid with [negativity] every day of their lives, why do you think they don’t… why do you think their self-esteem sucks by adolescence? Why do you think they go into anxiety? Because now they realize, “I’m being yelled at. People are yelling at me all the time. I can’t stop this.” And they go inwards.
So, if you learn positive language, learning to redirect behavior and using positive statements, fundamentally every kid benefits. But you have no choice with an ADHD kid. If you don’t talk that language you hurt the kid.
Umesh, this has been a fascinating conversation with you. I’ve learned a lot in this brief time that we’ve had with you. For our listeners who might want to learn more about this subject matter, [are there] any resources that you think would be helpful to direct them towards?
Absolutely. The Canadian resources call www.CADDRA.ca. This is the national network of physicians who work in ADHD. The guidelines that are written there are free and downloadable. We love that in Canada, everything is free and downloadable. Similarly, you can go to the Autism Society of Canada, great websites and their links to other websites.
But this is a starting point. Start here, understand the nature of this information and then go to the links to get more information that [is] specific to your kid. But the end of the day that’s one good thing that we have in Canada: we tend to disseminate information widely. And that information is worldwide.
Cool. Umesh, it’s been a real pleasure having you on the show. Thank you so much for joining us!
Thank you for having me!