Aus der Praxis der Anthroposophischen Medizin | Pohl | Das Aufmerksamkeits -Syndrom
AD/HD is a controversial phenomenon with no certain etiology. Based on Rudolf Steiner's Curative Course, the disorder is explored with reference to the development of movement. This approach points the way towards new and understandable therapeutic avenues.
Cultivation of the Senses
According to estimates, 3-5 % of all children suffer from hyperkinetic syndrome, referred to in the English-speaking world as ADHD or ADD (Attention Deficit/Hyperactivity Disorder). The affected children are preponderantly boys. Hyperkinetic syndrome begins before the age of 6. Contrary to what was formerly supposed, the majority of affected children retain the disorder through adolescence and adulthood. In addition, it is estimated that about 1–4 % of all adults suffer from a hyperkinetic disorder.
The symptoms of Attention Deficit Disorder are extremely complex but can be reduced to four cardinal symptoms:
- The children are inattentive, distractible and disorganized. They have difficulty planning their work and using their time effectively. They fail to complete activities, have trouble following directions, are forgetful and prone to careless errors.
- The children are hyperactive (not an obligatory symptom), constantly in movement and practically incapable of calm activity.
- The children are impulsive and have a tendency to act without thinking, i.e. sometimes rashly and dangerously. They have a hard time controlling themselves and react to criticism with rage and argumentativeness.
- The children are emotionally labile; i.e. they are subject to unexpected mood changes.
In accordance with the diagnostic criteria of the American Psychiatric Association, these symptoms must continue for at least 6 months and occur in at least two areas of life (e.g. home and school). They must handicap the child in social or school functioning, and other psychiatric illnesses must be ruled out.
In the course of the disorder, an array of social and psychic complications arise: peer rejection, distractibility and poor academic performance, changing schools and repeating classes, oppositional and defiant behavior, alcohol and drug abuse, etc.
One thing is certain: A great deal of experience with behaviorally disturbed children is needed to be able to make a diagnosis. The child's living situation needs to be carefully observed and a total impression obtained, including input from caregivers as well as detailed observation of the child in various areas of life, before a child is categorized as suffering from ADD.
Attention Deficit Syndrome is a complex disorder that can cause suffering both to those affected by it and those close to them. From this perspective, an anthroposophical study of the illness seems called for.
In current discussions of this phenomenon, two extreme positions stand out. One adopts a sympathetic attitude, by which the actual problem tends to be glossed over played down. From this point of view there are no behaviorally challenged or psychically ill children?only special children. Such children possess special capacities and appear behaviorally different only because those in their social environment are not spiritual enough to honor their behavior for what it is. Proponents of this view prefer to speak of them as "star children" who are gifted with an excess of vital and spiritual energy and are attentive to those things that interest them (Georg Kühlewind: "Die Sternkinder und die schwierigen Kinder", Das Goetheanum No.11, March 11 2001).
On the other side of the issue is the view that attentional, behavioral and learning disorders in children are genetically based or caused by brain defects. Cordula Neuhaus, one of the best-known proponents of this mainstream view, writes in her book Das hyperaktive Kind und seine Probleme (p. 55): "Current research leaves no doubt as to the neurobiological causation of the syndrome." In her view, any hypothesis of "nurture-based causation is clearly refuted, given the primary inability to maintain adequate self-motivation and behave in situationally appropriate ways." (1)
Between these poles we are left with the question: Are these phenomena illnesses or behavioral and learning disorders, and do they necessarily require treatment?
In this context I find Rudolf Steiner's definition of illness illuminating: "The human being becomes ill when his organism accumulates that which is of a foreign nature, which has not been properly processed and contains an excess of the catabolic forces from the outer physical world that surrounds the human being in his environment on earth." (2)
In the framework of child development, the first years of life are devoted to imitation. A child will be at the mercy of "that which is foreign” unless he or she gets the support to properly process it, i.e. to digest foreign impressions and integrate them into his own being. In observing these children, I am particularly struck by the following:
- Their behavior resembles that of overtired children. Normal abilities and talents succumb to weakness of mind. What is striking is the motivational deficit that affects goal-oriented thinking. The children have difficulty learning through imitation; they act before thinking; they experience fear of failure when asked to perform tasks; they are anxious and sensitive; they are wounded inwardly by stimuli that a healthy child could process.
- The force of sympathy overwhelms the force of antipathy.
- The result is deficient guidance from the body-bound I-organization, which structures the relationship of the upper, nerve-sense system to the lower, metabolic-limb system by way of the rhythmic system, adjusting it appropriately to external situations.
The social experience of ADD-sufferers is practically confined to the area of movement; that is, it proceeds by way of the metabolism. The metabolic findings make sense only in the context of the four-fold human being. For a time the preferred thesis was that the children were subject to an allergy. The author and chief advocate of this thesis was Ben Feingold, an American pediatrician who devoted many years of observation to the question and eventually became convinced that it was not a true allergy, but that the human being had "no natural defense against synthetic additives." By eliminating the food additives provoking reactions, he succeeded in achieving striking improvements in severely hyperactive children, followed by recurrence of the symptoms when the synthetic substances were re-introduced.(3) The approach was taken up and confirmed by many parents, but it did not meet with corresponding official acceptance.
Pharmacist Hertha Hafer observed that the condition of her severely behaviorally disturbed child was significantly aggravated by sedatives, while stimulating remedies led to improvement. She finally discovered that a food additive, namely phosphates, triggered the symptom picture of this illness. Her experiences were reproduced by other parents of affected children. Biochemically, there is a connection of phosphorus with sugar, which must be phosphorylized in order for it to enter the metabolism and ATP to be formed.(4)
In the fifth lecture of his Curative Course, Rudolf Steiner gives an archetypal picture that casts light on the entire symptom picture of the affected patients. He gives a schematic picture of the human organization, clarifying the disposition of the higher members of being in relation to the upper, nerve-sense system and to the lower, metabolic-limb system, mediated by the centrally located rhythmic system.
The crucial point he makes is the complete polarity of the disposition of the higher members on either side of the mediating rhythmic organism. During the lecture Rudolf Steiner made a blackboard drawing which I would like to try to reproduce and comment on here.
Rudolf Steiner first asks us to picture a being in which the I-organization is on the outside, the astral organization further within, followed by the etheric organization and furthest inside the physical. Alongside of this he sets a drawing in which the order is reversed, so that we have two beings that are polar opposites. These two "beings," as he calls them, he then joins together and presents as the human organism, pointing to the process by which sense impressions are received and then spread. An impression in one I-organization will also resonate in the other I-organization; similarly, an impression in one astral organization will go on in the other astral organization. This, according to Steiner, is the basis for our memory, since all impressions which we take in from the outside have their mirror image in the metabolic-limb organization. When we receive an impression from outside, it disappears from the head organization, which is centripetally ordered from the physical without to the I within, and is transferred into the metabolic-limb system, from which it can be retrieved as a mental image in the act of memory.(5)
In picturing the reversed order of the 'bodies' in the upper and lower poles of the human being, it is helpful to think of their physical anatomy. In the head region, the bone?representing the physical body?is on the outside, while in the limb and metabolic region it is on the inside. The other bodies will also be found in this reverse-image order. It can happen, however, that the entire process is disturbed. The lower system, which is the polar opposite of the upper, can be too weak by nature. In this case, sense impressions do not imprint themselves deeply enough upon the lower system, so that they continually radiate back to the upper pole, where they remain circling as repeating mental images, unable to liberate sufficient attention for new sense impressions. Similarly, the upper system, i.e. the I and astral body, can be absorbed too much into the periphery and thus be too weak for the process of physical imprinting.
When we understand the dynamics referred to in this discussion, we will be able to better understand those affected and develop therapeutic options for them.
What Rudolf Steiner describes corresponds with great exactness to the phenomena we encounter in this disorder. The imbalance between the upper and lower poles of the human organization, seen within the entire developmental context, must be the central focus of all therapeutic endeavors. The inadequate penetration, interconnection and mediation between processes in the higher and lower members will be the key to developing therapeutic approaches. The aim of the therapy must be to strengthen the I, guiding and drawing it into the physical in an age-appropriate way.
Sense Cultivation and Movement Draw the I into the Physical
At this point I would like to consider movement in particular and focus on the therapeutic significance of guided, perceived movement.
As we have determined, in a portion of these children?the hyperactive ones?the chief symptomatic factor relates to movement. At the same time, it strikes us that these children are characterized by a certain clumsiness: The frequency of injury among them is much higher; their fine motor skills are immature; goal-oriented coarse motor performance is uncertain; and altogether their motor function has a "somnambulistic quality." In movement and in its developmental stages we have an incomparable image of the child's soul life; in it, the I-nature of the human being expresses itself. Movement is always an expression of our relationship to the world and at the same time of our individual being. Through movement the world is experienced in its being, while the senses mediate pictures of the world.
In view of this, it is highly significant what a child experiences in moving and how this in turns affects his soul life. Rudolf Steiner speaks of the dual aspect of sensory experience. The human being never receives an impression through just one sense, but always at the same time through another sense that is intimately linked to one's own being. One sense enters into our ordinary awareness with particular clarity; the other remains dim. In other words, there is a difference among the senses: A certain number of them enable us to experience our relationship to the outer world as an essentially external one, while others bring it to us as something intimately linked with our own being. Senses closely linked with our own being are, for example, the sense of balance, the sense of movement, the sense of life, and also in fact the sense of touch. When the outer world through is perceived through such senses, our own being is always dimly sensed at the same time.
An object is seen. At the same time an impression is received through the sense of movement. Out of this, a mental image comes about of what was seen. The process appears to us as a single one, although it has resulted from two distinct sensory activities and is a dual relation. The dimly-aware, bodily component of this dual relation is the one that makes for the experience of reality. Such dual relations among the senses begin to develop during childhood and can remain incomplete. They are considered to be the most important source of human adaptive capacities. It is this connection between the dimly conscious senses mediating reality and the more wakeful ones mediating images that is crucial in Rudolf Steiner's portrayal. If the connection fails to develop adequately in the course of childhood, highly labile states of consciousness may arise as a result.
One of the fundamental concerns of curative education is to develop motor skills into a receptive instrument for experiencing the world. Sensory experience will always be enlivened by motor skills, just as motor progress naturally depends on the development of sensory processes. According to Steiner, the essential characteristic of motor activity is imitation of the world. The limbs are oriented more toward the outer world, the head more toward the individual human being himself. In this light movement appears in two aspects: On the one hand it is imitation of the world in the widest sense; on the hand it is an individualization of what was imitated. All movement takes place within in this field of tension. The essential lesson is that any narrowing or one-sidedness of motor development signifies an imitation disorder, whether in regard to the child's relationship to other human beings or to the world of things. (Georg von Arnim: Bewegung Sprache Denkkraft, Der geistige Impuls der Heilpädagogik.)
Course on Curative Education
June 30, 1924
Since the formative impulse proceeds from the head in the first seven years of life and works on the respiratory-heart system in the second seven-year period, this is the place where the therapy must begin. Accordingly, the child must be supported in taking hold of his body through intensive cultivation of the senses, particularly of the "lower senses" beginning with the sense of touch. The child's attention must be directed towards the experiencing of sensory impressions. Out of such experience it will be possible for the child to develop a representation of the world that is based in reality, while otherwise the world will be experienced like a film and the child's relationship to reality will not develop. The sense of movement, the sense of balance and the sense of life should be one of the prime focuses of education in the first years of life. The over-emphasis on the senses of sight and hearing in contemporary education bears partial responsibility for the pathological phenomena we have been describing. The media have a one-sided action on sensory experience, effectively eliminating the dual relation of the senses and making it unnecessarily difficult for the child to penetrate his body. Therapeutic interventions should always be brought to the child in an interesting way. Many children’s games embody patterns that are of great help in taking hold of the developing body.
Future school-readiness depends on the establishment of rhythm at a very early point in the child’s life: In the first weeks a feeding rhythm will help the child regulate his digestion; subsequently the rhythms of daily life will help the child to better take hold of his body. Let me not fail to mention that an essential element of the Waldorf School curriculum for the first grades is a consideration of rhythm in the course of schooling. As a form of movement, eurythmy too offers an ideal therapeutic support.
The desire of these children for sweets is understandable in view of their metabolism, and it should by all means be accomodated: Let them eat generously of sweet fruits—indeed, this can be a dietetic indication. Chiefly, however, sugars should arise through the digestion of natural carbohydrates (grains) and the experience of sweetness should come about only gradually, through prolonged chewing, in order to have the desired therapeutic effect. The blockages in the connection of the upper nerve-sense system to the lower metabolic-limb system are frequently easy to observe in the form of tension around the base of the neck, leading to headaches which further aggravate the suffering of these children. As a supportive therapy to relieve these, the mother can apply a gentle embrocation. Both medicinal and dietetic stimulation of the digestion can also have beneficial effects that are not to be underestimated.
Given the hypersensitivity and high energy level of these children, consistent behavior is important in those around them. The ambivalent and contradictory behavior models often experienced by children in separation situations of the parents are counterproductive.
Amid the differing descriptions attempted, I believe that the approach outlined here is a help in understanding these children. It also offers a perspective from which these various views and therapeutic approaches can be understood. Imbalance and overtaxing of the metabolism, whether it is due to idiosyncratic food reactivity or possible allergic reaction to foreign substances, leads to a situation in which metabolic activity can no longer be penetrated by the upper “man” and therefore manifests itself as compulsive unrest. Similarly, psychic traumas lead to mental over-activity. Forces which in childhood should still be tied to bodily activity (in the metabolic-limb region) are released into body-free, soul-spiritual activity. At this developmental stage, however, the formative forces of the head have not yet been adequately penetrated.
Results observed from the wide-spread therapy with Ritalin are consonant with this image. As we know, it produces a temporary improvement of the symptom picture but not a cure. A one-sided stimulation in the nerve-sense region that is limited to the physical level and bypasses the higher members—astral body and I—is unable to replace the requisite formative and developmental process and, apart from the well-known side-effects, remains therapeutically ineffective. Furthermore, as one might predict from the insights we have developed, the most recent studies show Ritalin treatment associated with considerable risk in view of the elevated accident-proneness of children treated with it. A large-scale study found that serious injuries in children were associated with Ritalin use at a frequency rate of 6.3 over the control group.(6)
Furthermore, another recent study showed that when family-oriented interventions were made with preschool children, medical treatment became unnecessary.(7)
These children, who present such a challenge to those around them, need help. What they need from us is understanding and a primary sense of acceptance. Are they not often just a bit ahead of their time, suffering from a developmental acceleration for which we are responsible?
A broad and fundamental change in attitude is needed if we are not to see further increases in this pathology which children suffer in relation to the world and to themselves. These thin-skinned, sensitive young people are often enviably good-natured. Hidden beneath their rough shell is a heart force of which we are sorely in need. An intensified spirituality and an intensified, embodied materialism have come together in our times.
Dr. med Walter Pohl
Literature and Notes
- Neuhaus C, Das hyperaktive
Kind und seine Probleme,
5. Auflage 1999
- Steiner R, Erdenwissen und
Vortrag Dornach 11. Febr. 1923
- Feingold, B. S., Why Your Child Is
Hyperactive. Random House,
New York 1974
- Hafer H, Die heimliche Droge,
- Steiner R, Course on Curative Education, GA 317 Lecture in Dornach of June 30 1924
- Grützmacher H, Unfallgefährdung
bei Aufmerksamkeits- und
Ärzteblatt Jg. 98 Heft 34-35
27. Aug. 2001
- Döpfner et al., Hyperkinetische