The Conundrum of Developmental Dysplasia of the Hip

I know I’m old.

I know I’m old because the bits of me that used to be supple and strong are now weak and stiff, and the bits of me that used to be stiff are now flaccid.

I also know I’m old because I’m now regaling medical students with stories, usually starting with the words, “Back in my day …”

Back in my day, we didn’t have the internet and had to to go to the library to get actual books!

Back in my day, we couldn’t go on-line, we had to stand in lines …

Back in my day, we were taught about congenital dysplasia of the hip, and learning the nuances of the Barlow and Ortolani manoeuvres was one of the most important skills a young paediatric house officer could possess.

While age has made me go soft and stiff in all the wrong places, it does give the benefit of hindsight.  And with hindsight and further research, it turns out that my view of Congenital Hip Dysplasia was all wrong.

It’s not that hip dysplasia isn’t really important – it is.  A child with moderate to severe hip dysplasia is destined for a lot of physio and possibly surgery to try and help them walk and run and play normally.

It’s more that congenital dysplasia of the hip isn’t necessarily congenital, and the tests we were taught to perform to diagnose it really aren’t that helpful after all.

Developmental dysplasia of the hip (DDH), as explained in layman’s terms on the Kids Health Info website, is “an abnormal development of the hip joint. In children with DDH, the ball at the top of the thigh bone (called the head of the femur bone) is not stable within the socket (called the acetabulum). The ligaments of the hip joint that hold it together may also be loose. Sometimes, the hips can dislocate early in life and this may not be noticed until your child starts to walk.”[1]

More formally, the condition and its definition are more nuanced.  As per eMedicine: “The definition of DDH is not universally agreed upon. Typically, the term DDH is used in referring to patients who are born with dislocation or instability of the hip, which may then result in hip dysplasia. More broadly, DDH may be defined simply as abnormal growth of the hip … This condition may occur at any time, from conception to skeletal maturity.”[2]

Although there are some inconsistencies in the literature regarding incidence of DDH, it is generally accepted that approximately 1 in 100 infants will be identified as having some hip instability at birth, and 1 – 2 in 1000 infants will be born with a dislocated hip.[3]

There are a number of generally accepted risk factors associated with developmental dysplasia of the hip[4](although their validity is controversial[5]):

  • Breech Presentation
  • Family History of developmental dysplasia of the hip (especially if in parent or sibling)
  • Female Baby (developmental dysplasia of the hip is four times more likely to occur in a female infant)
  • Large Baby > 4kg
  • Overdue > 42 weeks
  • Oligohydramnios
  • Associated with Plagiocephaly, Torticollis and foot deformities
  • First born baby or multiple pregnancies

Of these risk factors, the most significant are breech presentation and family history[6].

Traditionally, all newborns are screened for DDH a number of times throughout their first year of life using the Barlow and Ortolani manoeuvres.

In the Barlow manoeuvre, “gentle backward pressure is applied to the head of each femur in turn, and a subluxable hip is suspected on the basis of palpable partial or complete displacement”.

In the Ortolani manoeuvre: “the examiner applies gentle forward pressure to each femoral head in turn, in an attempt to move a posteriorly dislocated femoral head forwards into the acetabulum. Palpable movement suggests that the hip is dislocated or subluxed, but reducible.”[7]

In older infants, the Galeazzi test may be performed: “Hips are flexed to 90° and placed in neutral adduction/abduction, with knees in flexion. In this position, the vertical level of the knees can be assessed for asymmetry.”[8]

Limited hip abduction is also a test used to attempt to elicit developmental dysplasia of the hip[9].  Asymmetrical gluteal and thigh skinfolds have also been considered signs of developmental dysplasia of the hip[10].  (A video demonstrating Barlow, Ortolani and Galeazzi signs is here: https://youtu.be/iKfoovi5gvI)

All this is well and good, but the effectiveness of clinical hip screening programmes internationally have been disputed in the published literature[11].  The U.S. Preventive Services Task Force gives screening for developmental dysplasia of the hip an “I” rating (insufficient evidence to recommend for or against screening) while the American Academy of Family Physicians endorses this “I” rating[12].  This is partly because the tests and manoeuvres for developmental dysplasia of the hip have very limited capacity to correctly detect a positive finding, and/or have a limited impact on significant clinical outcomes.

For example, the Ortolani test has a sensitivity[13]of 0.6 and the Barlow manoeuvre has a positive predictive value of just 0.22[14].  The Barlow and Ortolani manoeuvres fail “to identify two thirds of the hips which subsequently need surgical treatment and has made little or no difference to the number coming to surgery.”[15]

Hip abduction “is a relatively insensitive and nonspecific marker of DDH in early infancy but becomes more accurate after 3 to 6 months of age and with more severely affected hips.”[16]  Also, “physical examination findings sometimes linked to DDH include asymmetrical gluteal and thigh skinfolds, and leg-length discrepancy. No studies from the past 40 years were identified that assessed the value of these findings in diagnosing DDH.”[17]

So if clinical screening is next to useless, what about universal screening for DDH with ultrasound? Well, a Cochrane review showed that universal ultrasonography (versus clinical examination alone) resulted in a higher rate of detected developmental dysplasia of the hip and a higher rate of treatment, but it did not reduce the rate of missed (late-diagnosed) developmental dysplasia of the hip or the need for surgery.[18]

Why?  I’m not going to pretend to be an expert, but I think the key is that DDH isn’t fixed and stable, but is actually a dynamic condition in which the hip abnormality may improve or deteriorate with growth[19].  Paton wrote, “The term Congenital Dislocation of the Hip (CDH) was superseded by the new name of Developmental Dislocation of the Hip (DDH) in 1989. This was in recognition of the fact that not all cases of pathological hip conditions associated with DDH were present at birth.”

So, to screen or not to screen?  A generally accepted view is that screening with physical examination, compared with no screening or universal ultrasonography screening, would result in fewer adults having osteoarthritis of the hip at 60 years of age.[20] However, there is no published statistical difference in outcome measures of developmental dysplasia of the hip when comparing the various combinations of screening utilising clinical examination and ultrasonography.[21]

What does it mean medico-legally?  Some commentators believe it’s a very important point. Paton again, “If some hip joint conditions that are stable at birth deteriorate and are diagnosed at a later date as an irreducible hip dislocation, they cannot be considered to be ‘missed’ cases following negative neonatal clinical hip screening by a competent screener.”[22]

Lomax writes, “Medico-legally, if a clinical screening test is undertaken by an individual who has been properly trained and assessed as competent in the clinical test and a late irreducible dislocation occurs, this should not be considered negligent due to the poor sensitivity and positive predictive value of the tests.”[23]

For mine, I think the key is to remain vigilant.  It may not make a massive difference to the eventual outcome, but given that Barlow, Ortolani and Galeazzi tests are easy to learn and very cheap to do, I think we should continue to perform them.  Having said that, we should remain vigilant and not ignore an infant who has limited hip abduction or a limp at any age.

I think that’s sage advice no matter how young or old you are!

Summary points:

  • Developmental dysplasia of the hip refers to patients who are born with dislocation or instability of the hip or more broadly as an abnormal growth of the hip
  • DDH is a dynamic condition which may occur at any time from conception to skeletal maturity
  • The most significant risk factors for DDH are breech presentation and family history
  • The most common tests for diagnosis of DDH are Barlow, Ortolani and Galeazzi signs
  • However, the tests and manoeuvres for developmental dysplasia of the hip have very limited capacity to correctly detect a positive finding, and/or have a limited impact on significant clinical outcomes
  • Universal ultrasonography resulted in a higher rate of detection and reatment, but no reduction in missed (late-diagnosed) DDH or surgery
  • Consensus is that screening with physical examination, compared with no screening or universal ultrasonography screening, would result in fewer adults having osteoarthritis of the hip at 60 years of age.
  • However, there’s no published statistical difference in outcome measures of DDH comparing various combinations of screening utilising clinical examination and ultrasonography.

References

[1]Kids Health Info, “Developmental dysplasia of the hip (DDH)” Royal Children’s Hospital, Melbourne, 2018. https://www.rch.org.au/kidsinfo/fact_sheets/Developmental_dysplasia_of_the_hip_DDH_treatment_and_hospital_stay/ (Accessed 12/4/2018)

[2]eMedicine, “Background / Developmental Dysplasia of the Hip” https://emedicine.medscape.com/article/1248135-overview Updated: Feb 26, 2018 Accessed: 12 Apr 2018

[3]”Screening, Assessment and Management of Developmental Dysplasia of the Hip. Clinical Practice Guideline: Resource Manual 5/05/2011″ Hunter New England Local Health District – Children, Young People & Families, NSW Health http://www.hnekidshealth.nsw.gov.au/client_images/1287736.pdf Accessed 12/4/2018

[4]ibid

[5]Paton RW. Screening in Developmental Dysplasia of the Hip (DDH). Surgeon 2017 Oct;15(5):290-96.

[6]”Screening, Assessment and Management of Developmental Dysplasia of the Hip”, 2011.

[7]Payne, J. “Developmental Dysplasia of the Hip” Patient https://patient.info/doctor/developmental-dysplasia-of-the-hip-pro Updated: 23 Sep 2016 Accessed 12/4/2018

[8]”Screening, Assessment and Management of Developmental Dysplasia of the Hip”, 2011.

[9]ibid

[10]Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics 2006 Mar;117(3):e557-76

[11]Paton RW. Screening in Developmental Dysplasia of the Hip (DDH). Surgeon 2017 Oct;15(5):290-96.

[12]Jackson JC, Runge MM, Nye NS. Common questions about developmental dysplasia of the hip. Am Fam Physician 2014 Dec 15;90(12):843-50

[13]Sensitivity is the probability of being test positive when the condition is present, or the ability of a test to correctly classify an individual as ′diseased′.  The positive predictive value is the percentage of patients with a positive test who actually have the disease ~ Parikh R, Mathai A, Parikh S, Chandra Sekhar G, Thomas R. Understanding and using sensitivity, specificity and predictive values. Indian J Ophthalmol 2008 Jan-Feb;56(1):45-50

[14]Paton, 2017

[15]Robinson R. Effective screening in child health. BMJ: British Medical Journal 1998;316(7124):1.

[16]Shipman et al, 2006

[17]ibid

[18]Shorter D, Hong T, Osborn DA. Cochrane Review: Screening programmes for developmental dysplasia of the hip in newborn infants. Evid Based Child Health 2013 Jan;8(1):11-54.

[19]Paton, 2017

[20]Jackson et al, 2014

[21]Paton, 2017

[22]ibid

[23]Lomax A. Examination of the newborn: an evidence-based guide (2ndEd). John Wiley & Sons; 2015 Aug 17: p146

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Thinking about suicide

Do you think about dying? I do, quite often.

In an article published last week in the Sydney Morning Herald, Daniel Mezrani wrote about his father’s suicide. Daniel’s tone was honest and heartfelt. His message was sobering. Daniel’s father was an emergency physician, highly respected, with “three teenage children, dozens of enamoured colleagues and an innumerable network of people he had touched with his generosity, humour and passion for social justice”, yet he ended his life.

Throughout the article, Daniel approaches suicide through a social framework. “I don’t think that suicide should be viewed as a purely psychiatric issue” he writes. “The idea that suicide is always the consequence of a definable mental illness continues to dominate the public consciousness despite a growing consensus among the academic community that there is much more at play.”

“We know that isolation significantly increases suicide risk, as do other social stressors such as unemployment and relationship failure. A new paradigm in suicide prevention emerges – if we begin to see people in context, we become privy to external factors that may be causing them distress and can thus look out for more subtle cues that they may be at risk.”

He’s not incorrect. Social factors are important to a person’s risk of suicide, though mental health is very important too.

“There is no simplicity in this conclusion, but there is promise. It means that anything we do to address stigma, discrimination and hardship at a systemic level has the potential to bring down our national suicide rate. If we really want to stop people dying in this most horrific way, we need to make it easier for them to live.”

True again. More suicides are prevented through decisions at a systems and government level than through direct personal intervention.

He concludes by saying, “They are tangible reminders that things can get better, and that we are never, ever alone.”

It’s a lovely way of rounding out an article on a very difficult topic, I give him credit for that. And for the average person, it seems like a very reasonable thing to say … things do get better, no one is ever truly alone.

Except that’s not how someone who’s suicidal will see it.

Daniel succinctly encapsulated the essence of suicide earlier on in his article: “The final common pathway is not neurochemical disturbance or a discrete socioeconomic stressor, it is an anguish that feels otherwise inescapable; hopelessness manifest.”

I’ve battled with depression for a long time now, the chronic latent adversity of pathological hopelessness. Most of the time it sits on me like an emotional weight vest, making the simplest tasks feel like so much more of an effort, subtly stealing my energy, tempering my sense of joy. But there are times when I feel like I’m being crushed by a tonne of wet sand and I can’t move or breath or see. There are other times where I feel like someone has ripped out my heart and is pouring battery acid into my chest, and all I can feel is pain.

I think about suicide. Depending on where my mood is, there are times when I think about it a lot. The recurrent theme connecting all those times is hopelessness.

Shame brings isolation, inequality brings inertia, but it is hopelessness that finally destroys.

Most people have never felt the depths of despair that true hopelessness brings, and I hope they never do. Unless you’ve been there, it’s impossible to truly understand how overwhelming it is. The only way I think I could describe it would be to imagine that you’re out to sea and your boat sinks, leaving you stranded in the middle of the ocean at night in the middle of a storm – it’s dark, it’s disorientating, numbingly cold, fighting to try and keep your head above the water when the swells and the currents are constantly dragging you down.

Things can get better, and we are never alone, but when overwhelmed by deep existential despair, you can’t see it.

It might sound like I’m against addressing stigma, discrimination and hardship, but I’m not. The purpose of this article isn’t to advocate for one solution or another. I certainly don’t pretend to know all, or maybe any of, the answers. The purpose of speaking out like this is simple … I want to add to the conversation.

At the opening plenary of the conference I attended this weekend, Dr Geoff Toogood, a doctors mental health advocate, spoke about his own personal journey with mental illness as a way of starting the conversation. It’s a hard conversation, but it’s one we have to have, and it needs to be authentic if it’s going to have any real resonance. It would be much easier to simply hide away, masking the pain, pretending it’s not there, but lets face it, we’ve tried that strategy already and it’s killing us.

I can’t offer answers, but I do promise authenticity.

I also wanted to broach the key issue of hope. How do we give people hope? Hope doesn’t come from a pill or a program, but where does it come from? Can we mobilise hope? Can we give hope to the hopeless, and if so, how do we communicate hope to those who struggle the most to hear it?

I know there will be people reading this who have thought about, or might even be thinking about suicide. I know what you’re feeling. I know how hard it is.

Again, I don’t pretend to know all the answers. All I can say is that you’re not the only one, and you’re not alone. I know it’s not easy, but find even the faintest glimmer of hope – in your family, in your job, in people around you, in a faith. Hold on to it. The storm will pass and day will break.

Sometimes even the simplest connection to another person can help. If you need to talk to someone, there are always people that can help. In Australia, call Lifeline ~ 13 11 14, BeyondBlue ~ 1300 22 4636 or https://www.beyondblue.org.au/about-us/contact-us or the Suicide Callback Service ~ 1300 659 467 or https://www.suicidecallbackservice.org.au. In the USA, call the National Suicide Prevention Lifeline ~ 1-800-273-TALK (8255). In New Zealand, call Lifeline Aotearoa 24/7 Helpline ~ 0800 543 354. In the UK, call Samaritans ~ 116 123. For other countries, Your Life Counts maintains a list of crisis services across a number of countries: http://www.yourlifecounts.org/need-help/crisis-lines.

Kudos to Daniel Mezrani. It’s shattering to lose someone you love so much, and it takes a special kind of person to turn that tragedy into something that will help other people. I wish him and his family all the best as they continue on their difficult journey.

Stigma, discrimination and hardship do need to be addressed at a systemic level if we are going to help lower our nation’s suicide rate.

We also need to better understand hope, how to foster it in those whose hope is dormant, and how to help those who have lost all hope to find it again.

We need to keep talking too. The conversation is extremely challenging, but without an open and authentic dialogue, many will continue to suffer, silent and alone, instead of getting the help they deserve.

Fake science is no joke

Happy Easter everyone.

I went to church this morning, and came home to get a lamb ragu going in the slow cooker, and thought I would just hop onto Facebook to see what was going on in the world. I was greeted with this:

“Your body literally treats negative thoughts like an infection.” Dr Peter Amuaquarshie

Oh dear … oh dear, oh dear, oh dear …

Easter is meant to be about redemption, about hope, about God’s great love for us. Clearly #TheDrLeafShow isn’t any of that.

Unfortunately, this is more pseudoscience from Dr Leaf and her cabal.  And while it might also be April Fools Day, fake science is no joke.

Dr Peter Amua-Quarshie has been in cahoots with Dr Leaf since the beginning of her teaching. He has supplied most of the illustrations for Dr Leaf’s ministry over the years, so I’m sure he’s profiting handsomely from Dr Leaf’s enormous sales and influence.

It’s so sad to see academics trade their integrity and sell their soul for the sake of the ill-gotten gains of popular pseudoscience.

Your body doesn’t “literally” treat negative thoughts like an infection. Our thoughts have literally no bearing on our immune function. In research work that has intentionally studied thought separately to stress, thought has not been associated with any significant changes in stress or health behaviour [1]. It’s also been confirmed that thought alone does not lead to detrimental biological changes, such as significant changes in immune function [2].

If anything, it’s the other way around – our immune system and our thoughts respond to physical changes in our bodies internal milieu. For example, an adrenaline surge causes us to feel fear and engage in fight or flight behaviours, and to respond quickly to injury, the balance of our immune system’s cells and cytokines changes to prepare for possible injury.

Another example, a physical infection from a microbe of some kind (bacterial or virus) causes a flood of chemical mediators called cytokines to float around the blood stream. This inflammatory response leads to an immune system that is better able to fight off infection, but it also changes our feelings and our thoughts – this flood of cytokines is the reason why we feel tired, achey and miserable when we’re sick.

Having “negative thoughts” is not the same as having an infection. Infections are disease states, whereas “negative thoughts” are normal and more often than not, beneficial. It’s normal to feel sad. It’s normal to feel angry. It’s normal to feel disgusted or embarrassed. These feelings are adaptive. Without them, we wouldn’t grow or change. Without them, we couldn’t have a rich, full life.

Dr Leaf claims that her goal is to “equip and empower you to use your mind to overcome labels and mental ill health (depression, anxiety, etc) to live a more fulfilled and successful life.” It’s a bit hard to do that by promoting fake science.

For his part, Amua-Quarshie should know better. He’s a teaching academic by trade and has a medical degree from the University of Ghana, after all. Unfortunately, it appears that Dr Amua-Quarshie has been exiled from mainstream academia, leaving a full-time position as an Adjunct Professor (lecturer) at the University of Wisconsin-Stout in Menomonie, Wisconsin and is now working as a lecturer in a school for chiropractors (Parker University, Dallas, Texas).

Though that’s more of an aside. The bottom line here is that Dr Leaf might claim that she wants people to overcome ‘labels and mental ill health’ but she isn’t going to do that by promoting such obvious mistruths that mislead people into fearing normal, adaptive human emotions. She isn’t promoting a more fulfilled and successful life, she’s promoting imbalance. She’s promoting false hope.

I know it’s April Fools, but believe me, this is no joke.  Fake science is misleading and harmful.  If Dr Leaf really wants people to live a more fulfilled and successful life, she should refrain from using it.

References
1. Doom, J.R. and Haeffel, G.J., Teasing apart the effects of cognition, stress, and depression on health. Am J Health Behav, 2013. 37(5): 610-9 doi: 10.5993/AJHB.37.5.4
2. Segerstrom, S.C. and Miller, G.E., Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychol Bull, 2004. 130(4): 601-30 doi: 10.1037/0033-2909.130.4.601

More love, not less guns?

Wow.

Just … wow.

Dr Caroline Leaf is no stranger to ignorance and controversy – she thinks that our minds can create matter, that our thoughts can control our genetic expression, and that psychiatric medications are a leading cause of death. So it should come as no surprise when she proves the Dunning-Kruger Effect over and over again.

Still, I found her podcast and meme today utterly breathtaking.

Dr Leaf, communication pathologist and self-titled cognitive neuroscientist-cum-life-guru continues to weigh in on the gun debate every time there’s a mass shooting. I wouldn’t if I were her, but fools rush in.

At least Dr Leaf has finally stopped blaming mental illness or psychiatric medication for causing such mass murders. That said, there’s still more twisting and contorting in her statement than at a pretzel convention.

Dr Leaf has relinquished one over-simplistic solution in favour of another. Yes, mass shootings aren’t related to mental illness, but can you really say with a straight face that mass shootings occur because of a lack of love? So we should all hold hands and sing Kumbayah? Have a few more hugs? Dr Leaf’s suggestion is childish and inane.

Since 1996, Australia’s number of mass shootings has been zero. Australia’s gun-related homicide and suicide rate also fell. Why? It’s not because we all started loving each other more down here after 1996. It’s because, amongst other reasons, the Australian government introduced gun law reform, drastically reducing the number of guns available within the general population.

Perhaps living in Texas has rubbed off on her, or perhaps Dr Leaf is an NRA sympathiser. I honestly don’t know why Dr Leaf is so afraid to speak directly to the problem. Most of the US and the entire rest of the world can see the issue for what it is. If it wasn’t so tragic, her dance around the issue would be comical.

Dr Leaf is welcome to her opinion, but she can not claim any level of moral or professional authority on this issue. Her “years of experience in the mental health field” are zero, as is her credibility as an expert. Encouraging more love with the same number of handguns and semi-automatics on the street is not going to prevent more casualties.

Stop mislabelling labels.

The last time I looked through the supermarket, I bought some baked beans. How did I know the can I took off the shelf was full of baked beans and not freshly harvested sheep’s innards? Because the label on the can said so.

Labels aren’t perfect of course. Every now and then, a can of something has the wrong label applied in the factory. Usually it’s nothing too sinister – no accidental swaps of some goat entrails instead of your tinned salmon. Instead, it’s usually something similar – tuna gets labelled as salmon and vice versa, and the worst that happens is that the tuna mornay you’ve just made had an unexpected flavour.  Even these sorts of mild mix ups are rare. Overall, we trust that the labels are guides and the information they provide us helps us make an informed decision about what do to with that particular can and its contents.

It would be pretty silly for some random person to preach out the front of the supermarket, ranting about how all labels for a particular thing are all wrong.

“Uh, just because the occasional can of tuna was accidentally filled with cat food doesn’t mean to say that all labels are wrong. And just because one person had a bad experience with the wrong label, the supermarket shouldn’t stop using them … otherwise how else is anyone supposed to manage their cans effectively without labels? Honestly, stop looking like a fool by preaching about labels and let the rest of us finish our shopping.”

Dr Caroline Leaf, communication pathologist, self-titled cognitive neuroscientist, and a self-elected champion of irrelevant mental health advocacy, has come out all guns ablazin’ over ADHD labels again. She needs to give it a rest – she’s just like the crazy person standing in front of the supermarket.

“Labels for ADHD are bad”, she says. “Look at Avery Jackson, who was labeled ADHD but did not accept the label. He went on to earn multiple degrees and become one of the top neurosurgeons in the U.S!”  The underlying message – labelling a child with ADHD will lock then into a life of pathetic excuses and they won’t ever reach their full potential until they renounce the curse of their ADHD label.

For every scary anecdote about the evils of ADHD and the mental prison that everyone with such a label is supposed to find themselves in, there are ten more where the ADHD label helped them.  There are so many more people where the ADHD label helped them to finally understand their condition and receive the correct treatment, enabling them to reach their potential and improve their life in leaps and bounds.

Take, for example, one of my patients called Little Jimmy (not his real name). When Little Jimmy was in the early primary school grades, he was a bit of a fidgeter and couldn’t concentrate well enough at school or at home to complete his homework tasks. His mother took him to a naturopath who told him he had a disorder of “pyrolles disease”. Thankfully, mum brought him to see me, and after a careful history and a long chat, Little Jimmy went to see a specialist who diagnosed him with ADHD and commenced him on stimulant medications. Before his label, Little Jimmy’s reading levels were languishing at the bottom off his class after two years of stagnation.  He was more than a year behind in reading levels and going nowhere fast.  Two weeks after getting his label and the right medication, he went to the top three reading levels in the class.  His mother told me of the massive gains he made, and the flow-on effect this had to his self-esteem and confidence in other areas of his school work and school life. She cried as she recounted his story, and then I cried too.

So perhaps Avery Jackson became an orthopaedic surgeon because he chose to ignore his label of ADHD and worked hard anyway.  Good for him.  Little Jimmy got a label of ADHD and because of it, he learnt to read. Now he’s got the chance to follow in Avery Jackson’s footsteps, BECAUSE of his label.

Labels are important. Without them, we wouldn’t know how to know who needs which treatment. Labels can help people overcome some of the strongest barriers and connect with others for support.

And let’s face it, if someone really wanted to, they don’t need a label of ADHD to find excuses in life.

So labels are not a hinderance, but rather, they are a guide to help you know what’s going on so informed choices can be made. In Dr Leaf’s mind, those kids with ADHD are just naughty children, with bad parents, who are using the label of ADHD to cover their poor parenting and their bad behaviour. Clearly all they need to do is to stop their toxic thinking and they wouldn’t need their medications, but they would be cured.

Dr Leaf is wrong … she can stand and scream blue murder about labels and ADHD all she wants.  But just like the crazy random person screaming about labels in front of the supermarket, it means very little. It’s not helping her cause, and if anything, it’s sewing distrust in an system that, despite it’s flaws, works very well, and has helped thousands of children and adults alike to achieve their potential.

That’s the power of labels, and Dr Leaf would do herself and all her followers a favour if she stopped mislabelling them.

Dr Caroline Leaf – Inside Out and Back-to-Front

Dr Caroline Leaf, communication pathologist and self-titled cognitive neuroscientist, put this up on her social media pages this morning:

“Never feel bad for being sad. Emotions should not be kept inside because that will only make things worse. Talk to someone, cry, scream… whatever helps you feel better. One of my favorite movies is Inside Out because it really highlights the importance of letting yourself feel sad as part of the healing process. I really encourage all of you to not keep emotions bottled up. Let it out!”

Inside Out is one of my favourite movies too.  It is a rich layering of some complex psychology, told through a wonderfully relatable narrative that is beautifully told.

Inside Out is about the emotions that live inside us. Riley, an 11-year-old girl, moves from Minnesota to San Francisco, and the movie tells the story of her emotions as they deal with all of the conflicts and chaos that comes with adapting to such a big change.

The main characters are Joy and Sadness, which share “headquarters” with Anger, Fear and Disgust.  Each character has its own role to play, which Joy, as the main narrator of the movie, explains:

“That’s Fear.  He’s really good at keeping Riley safe.”
“This is Disgust. She basically keeps Riley from being poisoned, physically and socially.”
“That’s Anger. He … cares very deeply about things being fair.”

And Sadness?  “And you’ve met Sadness.  She … well, she … I’m not actually sure what she does …”

Dr Leaf explained that Inside Out, “… really highlights the importance of letting yourself feel sad as part of the healing process.”

Well, that’s one way of putting it, but Inside Out is actually much much deeper.  The story of Inside Out demonstrates that all of our emotions are needed in order to be a healthy human being.

Joy thinks of herself as the primary emotion, and does her best to keep Sadness away from the control panel.  Over the arc of the story, Joy learns that Riley needs Sadness too – that some problems can’t be solved with distraction or a pop-psychology pep-talk and positive attitude.

By the end of the movie, Joy allows Sadness to take over, helping Riley to process all of the things she had been struggling with after the major life change of her move to San Francisco.

This is what Dr Leaf was referring to, I think.  Yes, sadness is part of healing from any major life change including grief.

What Dr Leaf didn’t discuss was the role of the other emotions in Riley’s life.  Yes, Joy and Sadness are important, but the movie demonstrated all the way through that Fear, Anger and Disgust were all just as important, and the end of the movie showed that Riley’s core memories, which each formed a different aspect of her personality, were various combinations of all of the emotions.

But that’s not what Dr Leaf teaches.  For decades, her teaching has been back-to-front, claiming that emotions like anger and fear are toxic, and that toxic emotions cause damage to your brain and damage to your health.  She tells her followers not to think toxic thoughts or to have toxic emotions, but to take control of your thought life.

“Toxic thoughts are thoughts that trigger negative and anxious emotions, which produce biochemicals that cause the body stress.” [1] (p19)

“Hostility and rage are at the top of the list of toxic emotions; they can produce real physiological reactions in the body and cause serious mental and physical illness.” [1] (p30)

“There are two groups of emotions that are polar opposites: positive, faith-based emotions and negative, fear-based emotions. Each has its own set of molecules and performs as spiritual forces with chemical and electrical representation in the body. Faith-based emotions are love, joy, peace, happiness, kindness, gentleness, self-control, forgiveness and patience.  These produce good attitudes and thoughts.  Fear-based emotions include hate, anxiety, anger, hostility, resentment, frustration, impatience and irritation. These produce toxic attitudes and create a chemical reaction in the body that can alter behavior.” http://tkr-onfire4him.blogspot.com.au/2009/01/controlling-toxic-thoughts-and-emotions.html

“When you think a toxic thought, or make a bad choice, or you hang on to anything that is negative—anger, bitterness, hurt, irritation, or frustration—it impacts the production of those chemicals.”
“Through an uncontrolled thought life, we create the conditions for illness; we make ourselves sick! Research shows that fear, all on its own, triggers more than 1,400 known physical and chemical responses and activates more than 30 different hormones. There are INTELLECTUAL and MEDICAL reasons to FORGIVE! Toxic waste generated by toxic thoughts causes the following illnesses: diabetes, cancer, asthma, skin problems and allergies to name just a few. Consciously control your thought life and start to detox your brain!” https://drleaf.com/about/toxic-thoughts/

So it’s really interesting to see Dr Leaf discuss a movie that promotes the exact opposite of her teaching.  Perhaps she’s finally coming around to what real neuroscientists and researchers have been saying for ages, that “adaptive coping does not rely exclusively on positive emotions nor on constant dampening of an emotional reaction … Adaptive coping profits from flexible access to a range of genuine emotions as well as the ongoing cooperation of emotions with other components of the action system.” [2]

If Dr Leaf is finally coming around to real science, then that’s great, but she can’t have it both ways … she can’t promote expressing your emotions on one hand and then suppressing them on the other.  If she wants to come back to the fold of real science, then she’s going to have to renounce her previous teaching, and take it down from her website.  Otherwise it ends up being conflicting and hypocritical as well as being downright confusing.

So, Dr Leaf, you’re welcome to use movies like Inside Out to illustrate good psychological principles, but if you want credibility, you should work on some consistency.

References
[1]       Leaf CM. Switch On Your Brain : The Key to Peak Happiness, Thinking, and Health. Grand Rapids, Michigan: Baker Books, 2013.
[2]       Skinner EA, Zimmer-Gembeck MJ. The development of coping. Annual review of psychology 2007;58:119-44.

The lost art of joy – Something to look forward to

Bacon.

With only about eight hours left in 2017, I should be contemplating bigger things … the lessons learnt from the year gone by, what did I achieve, where did I fall down, what can I learn from those experiences.

Instead, I feel like bacon, so I’m cooking bacon.

Bacon is delectable. It’s one of those foods that proves God’s love. On it’s own, it’s special, but you can also add bacon to almost any other food and it will add to the gustatory experience of pleasure. The auditory and olfactory stimulation of bacon frying is distinctly pavlovian – I’m drooling just thinking about the culinary delights that await me.

As I was standing over the frypan, listening to the crackling and popping, smelling the juicy aroma and mopping up my hypersalivation, it also stimulated the rusty gears of my cognition.

Why do I drool when bacon is cooking? For all I know, the bacon could be rancid, or I could have cooked it wrong, or it could be too salty, or it could be pigeon meat in disguise.

But I have hope.

I can’t say, rationally and with certainty, that “the bacon will be good” because there are lots of reasons why it might be bad, but I have hope that the bacon will be delicious.

Hope. It is “the quintessential human delusion, simultaneously the source of your greatest strength, and your greatest weakness.
Hope is “being able to see that there is light, despite all of the darkness”. (Desmond Tutu)
Hope “smiles from the threshold of the year to come, whispering, ‘It will be happier.’” (Alfred Lord Tennyson)

Like we discussed yesterday, happiness is someone to love and something to do. Happiness is also something to look forward to.

Hope is like joy’s air. In order for joy to breathe, it has to be surrounded by hope. Without hope, joy can not survive.

Research bears this out. Numerous studies over the years have shown that those with higher levels of hope had higher academic and sports achievements. Lower levels of hope correlate to general maladjustment and thoughts of suicide. Hope is a crucial factor in dealing with major life stressors and traumas, such as cancer and old age. The impact of hope on depression and adjustment was studied in people with traumatic spinal cord injuries, and it was found that those with higher levels of hope had less depression and greater overall mental and social adjustment irrespective of how long it had been after the injury. In another study, lower levels of hope was related to higher levels of depressive symptoms in general.

Hope is applied optimism. Optimism is the general expectancy that good rather than bad will happen. Hope is “the belief that the future will be better than the present, along with the belief that you have the power to make it so.”  Hope is the ultimate fusion of acceptance, values and committed action – knowing which direction you want to go in, having a path leading in that direction and then going, not knowing what will happen but accepting that not everything will be perfect but believing that it will be better.

So what about 2018? I can’t say, rationally and with certainty, that “2018 will be a great year” because there are lots of reasons why it might be bad.

Still, I have hope that 2018 will be a great year.

Do you have hope? Do you believe 2018 will be a better year? Do you believe that you have the power to make it so? Over the last month, we’ve explored the lost art of joy; the ingredients of joy and how these can shape our lives; the things that can suffocate joy and the things that can help joy flourish. Do you believe that you can apply these principles to experience a life of greater joy, a richer life of deeper meaning and fulfilment? In all sincerity, I hope you can.

Thank you for coming on my journey with me. On the 1st of December when I had the bright idea of writing a blog post a day for a whole month, I thought it would be easy. When I got to the 5th of December, I thought I was going to run out of ideas and I should have thought twice before committing to such a huge project. Now, on the 31st of December, I’m glad I made that ill-considered commitment. It has challenged me for sure. It’s helped me to clarify concepts, to grow in knowledge and make me that little bit more proficient as a writer.

My hope is that my 31-day challenge will not just help me, but help others who are struggling to see the light and to experience the warmth of joy in their souls. “These things have I spoken unto you, that my joy might remain in you, and that your joy might be full.

Happy New Year! May you all have a safe, prosperous, and joyous 2018.

Oh, and by the way, the bacon was delicious.