ADD: Fancy Name for Something we all have?

From TAVA

Hardly irrelevant, since it clearly contradicts your assertion that clinical psychology is driven by available treatments. I am a clinical psychologist. I study disruptive behavior disorders. Relatively few good treatments for DBD are available. Your assertion didn’t get out of the gate.

How is this relevant to your argument about clinical psychology? Clinical psychologists (with very limited exceptions) cannot prescribe stimulants or any other medications. Can you give me any citations that support that at any time our diagnostic techniques consisted of prescribing stimulants?

Not to belabor the point, but bullshit. Again, we typically do not have the same type of markers that may be present for other types of disorders or diseases. But that does not mean our variables have no “true meaning.” Inference and increased errors mean that we have less precision than would be preferable, but do not mean that clinical psychology is not a science, nor that rigor is illusory. There are innumerable examples in other sciences wherein inference is required to support and to challenge theory about otherwise unobservable processes, yet only the zealot would suggest that they are not scientific.

Suggestion does not make something true or false. Suggestion puts forth a competing hypothesis to be tested. This is always my favorite part of your arguments: because there is a shred of evidence in support of competing theory B, it must mean that currently accepted theory A is wrong. You apparently love to discount evidence in support of psychological or psychiatric constructs by relying on evidence that is even less reliable or valid. Here’s a hint – your approach is not a scientific approach, but the grinding of an axe. If clinical psychology behaved as you did, we would fail to move forward for lack of critical evaluation of our constructs.

And some evidence suggests otherwise. Certainly very few would suggest that we know all we need to know about schizophrenia, depression, anxiety, or ADHD. Can you cite evidence that we are not looking at physiological distinctions? Would you prefer that we use no constructs, taxons, categorizations or diagnoses until the Ultimate and True Diagnostic and Statistical Manual XXIV falls fully formed into our laps?

I disagree. I would agree that clinical judgment is still required, which I believe is a good thing. However, the phrasing of symptoms is generally circumscribed and specific.

Very true

Very false. A trained professional should use clinical judgment to apply the standards of the DSM.

Again: bullshit. I think your problem is a result of, well, primarily not knowing what you are talking about, and secondarily, restricting your definition of clinical psychology to the less-than-rigorous applied practices of some or even many practitioners. This does not make clinical psychology less than a science. Please provide a definition of science that renders clinical psychology anything less.

Hentor, no offense, but bullshit back at ya.

How do you diagnose ADHD? Do you use some inventory checklist? “Sometimes true” “Often true” “impaired” … are subjective evaluations. What qualifies as outside the range for age? More to the point can you point me to a study that had some large number of clinical psychologists using DSM given a wide variety of real live patients to interview and which documented that they consistently attached the same labels to different patients? That would begin to make an argument for scientific validation of the tool.

The DSM is a wonderful attempt to give clinicians a common vocabulary. But that is all it is. An attempt. A start. Better than what was before but still very squishy even in the best of hands. It does not make the practice of clinical psychology scientific.

And if you are going to claim that schizophrenia (for example) is a single disease then I’d like to see you marshall the evidence to support such a hypothesis. Or do you accept it as the prevailing hypothesis exclusively because it is listed as a single disease in the DSM? Because I can easily do a literature search to document that schizophrenia has many different candidate genes that contribute vulnerability which to me implies clearly that schizophrenia is a common end phenotype (or group of phenotypes) of many different pathways of genotypes and/or genotype-environmental interactions.

If you want to be thought of as “scientific” start off with a healthy skepticism regarding the validity and limits of your tools.

Poly said

And sorry but that is another urban legend whether Discover said it or not. We get a lot of the claims that kids who skip crawling are at risk for all sorts of developmental problems … the most common myth is that they’ll have trouble reading. There is no evidence to support any of these claims.

Anybody else reminded of Woody Allen’s Sleeper?:smiley:

One of the best descriptions of ADD I’ve ever heard was about a boy who played great basketball during practice, but a real game he couldn’t do a thing. He observation as to why was:
“There’s so much noise I can’t see the basket.”
With ADD EVERYTHING has the same value; whether it a bus going by, the ceiling fan or the teacher’s voice.

OTOH TAVA

One couldn’t even begin to study fever, let alone its causes, until one agreed what fever was. What if researchers in one place called fever when the forehead felt warm, others took temps but anything over 99.5 was fever, and another group called it fever only when greater than 103? And there is a lot to be learned about how to treat the condition of fever that is true whatever the cause … prostaglandin pathways and so on. Likewise with mental health research. The DSM is an attempt to develop a mental health equivilant of a thermometer and to agree what qualifies as “fever.”

We may indeed be looking at common presentations of multiple different convergent pathways. But why do so many different pathways converge to the same points? How do these networks interact such that these are stable system states? Can we make progress in identifying the potentially many different causes of each mental illness (once defined), and will knowing such have clinical utility like knowing whether or not a particular bacteria is the cause of a fever does?

** Would you mind telling us about the recent debate in your field regarding the definition of “normal” grief and antidepressants?

** I’ll see if I can find them. It was a very common assertion about five to seven years ago.

** But those sciences do not present their assumptions as facts. Reading material presented to clients and patients quickly shows that such claims are made in clinical psychology – haven’t you seen those atrocious television commercials for psychiatric medications?

** No. In most of my claims, I dispute the widespread adoption of theory A by pointing out its flaws, as well as competing evidence that just as compellingly points to theory B. You are of course entitled to your own opinion of my positions, but I dispute their accuracy.

** “Moving forward” requires that your constructs actually match reality. While some uncertainty about the nature of the constructs exists in all sciences, psychology’s are relatively poorly supported by evidence and (IMO) are desperately clung to because without them the whole field loses the appearance of a science.

For God’s sake, there are still practicing Freudians, Hentor.

** Coming from a psychologist, this is grossly dishonest. You know perfectly well that the diagnostic criteria for these conditions do not rely on physiological data. They’re entirely symptom based.

Please, tell the boards about the distinction between exogenous and endogenous depression. Tell them about the dexamethasone suppression test’s effectiveness in diagnosing depression. Tell them how psychiatry explains the gap between neurotransmitter peaks and clinical recovery in antidepressive drug therapy.

** I would prefer that clinical psychology base its categories on actual medical data instead of group consensus and implicit standards.

** I disagree.

Many conditions must be distressing to those that have them or they don’t even exist. Others must be present for set lengths of time which are essentially arbitrary. There are scores of genuine medical conditions which can be present without obvious symptoms. Such is NOT the case with psychiatric conditions.

** Why? If the standards of the DSM are truly definitional, anyone should be able to use them to reach accurate diagnoses. My complaint is that they’re not truly definitions, and they’re sufficiently broad that they apply to a very wide range of conditions. By their definitions, almost anyone can be considered to have at least one mental disorder. It takes a trained professional who has been exposed to actual psychiatric standards of what is a problem and what isn’t to make judgments.

** I dispute your first contention. Your knowledge about clinical psychology as a practice is probably greater than mine, but I’d wager my knowledge of the discipline as a science is greater. I’ve studied the theory of medicine, off and on, for the past decade, and I know more about its limitations than most physicians, as far as I can tell.

Clinical psychology relies on human opinion as its ultimate guide, not observations of the systems it studies. Thus it is necessarily not a science.

I’ve been involved coaching kids soccer the past few years, for both my daughter and my son. Some kids it’s very easy to see that something is not right, and it’s quite easy to differentiate those from normal old inattentiveness.

What I would feel comfortable in would be classifying them as ADD or ADHD or Aspergers Syndrome, although I could probably take a first cut. These are not people like everyone else. Sometimes the parent knows (they usually would tell me after a while) and sometimes I think that they are oblivious. One girl a couple of seasons ago was probably ADHD, she was also asthmatic, which the parents didn’t recognize. I had to ask them about five times to take her to a doctor to get checked. Sure enough, she finally got checked and great surprise she was asthmatic. I’m just happy she didn’t keel over while she was running around. Sweet kid, but it was damned near impossible to teach her anything. It’s also often possible to see that the parents likely have some issues as well.

** True enough. But what if the doctors didn’t take into account that baseline body temperatures naturally vary from person to person? Some perfectly healthy people could be considered to have a fever when they didn’t, and some people with a high temperature wouldn’t be perceived as such because their baseline is lower than normal.

** But where it’s relatively easy to develop empirically justified standards of fever, even without baseline information for a particular individual, developing standards of mental “health” is much, much trickier.

But first we have to justify the existence of the category.

There are plenty of conditions which occur along a spectrum and lack clear dividing lines between “health” and “sickness”. High blood pressure, for example. But there are still objective measures of high blood pressure and the problems that it can cause.

So how do we distinguish between energetic kids, kids who are bored in school, and kids who are innately too distractable? At the moment, we don’t know that there’s any distinct, underlying neurological cause for the condition we call ADHD. There certainly might be, but there also might not. Neurological research has shown that there’s really no such thing as “normality” when it comes to neurology. It’s often the case that utterly normal and presumably healthy people have neurological and neurochemical states often associated with pathological mental conditions, and mentally ill individuals whose brains appear well within “normality”.

This is a point that is infrequently brought up within the field and virtually never mentioned in lay treatments: the differences found between populations of people diagnosed with a condition and populations of normal people are often quite small. The variability within the normal population is extremely large.

And we can’t even determine whether the differences are the cause or the effect of the condition. Depressed people often have lower levels of neurotransmitters in certain regions of their brain on average, but that is often found in people experiencing prolonged stress.

I generally concur with your experiences, ShibbOleth, but I dispute your last statement.

The basic criterion for ADHD is, according to the APA, “a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development”.

Distinguishing between kids who are merely more distracted and impulsive than the mathematical norm and those who have ADHD is difficult precisely because it’s a continuum, not a discrete difference.

Well, I would submit here that ShibbOleth’s statement was deliberately general. He did say “SOME kids it’s easy very to see that something is not right.” Certainly he’s not claiming to be able to diagnose this at a glance. He’s saying you can sometimes tell something’s not right, even if you’re not entirely certain WHAT is not right. And it is easy to differentiate between normal inattentiveness and a problem - it does not immediately signify ADD/ADHD, but if there’s one particular child in a group that exhibits way more inattentiveness/impulsivity/inappropriate response, etc and more than one adult notices, I would consider that a red flag.

Someone in this thread noted that ADD/ADHD seems to be much more prevalent in boys than girls and I wanted to address that quickly, too. From what I know (and I am not a doctor, just another person dealing with ADD), boys tend to get the “H” in ADHD more frequently and more severely than girls do. Thus, they’re more quickly recognized because they’re generally louder! The quiet-but-spacey girl (or boy or that matter) will more likely be labeled a daydreamer and/or an underachiever and will be less likely to be diagnosed and treated.

Ah, but exhibiting signficantly more impulsivity than the children around you depends not only on your impulsiveness, but on that of the children around you.

What absolute standard do you use to measure impulsivity?

From Vorlon

Why don’t you make a point, explain its relevance, and provide evidence, and then we will be able to debate it.

That should make it easy to find some references. I look forward to it.

Now you are not only confusing clinical psychology (research versus practice) and psychiatry, but also pharmaceutical manufacturing and marketing. Please try to clarify your thinking and your arguments.

You are welcome to dispute their accuracy. I welcome anything that will improve our accuracy, and I never claim that our diagnoses, our methods, or our theories are full and complete. But I also do not have an agenda to prove that they are invalid and particularly unethical that makes me blind to various hypotheses. I just rely on evidence.

Which are poorly supported by evidence? Please show me the evidence that supports your claims, rather than promising some evidence and then throwing out more bullshit.

Yes, there are. And there are still flat earthers, and creationists, and psychic healers, and end-of-the-worlders. None of these things relate at all to the validity of various sciences. You seem to think that clinical psychology is not a science because some are not scientific in its application.

Again, you seem to want to limit the entirety of the practice of clinical psychology to diagnosis and treatment. My statement is not grossly dishonest because I never claimed that the diagnostic criteria were other than symptoms – but the field is looking at a host of other indicators through a variety of means, and when other reliable indicators are found, they will serve as diagnostic indicators.

Again, make a point. Then back it up. This is just ranting.

Me too. Good thing our categories are not based on group consensus and implicit standards, but on studies of validity and reliability.

Yes, they must cause impairment. This helps to avoid the concerns of the actual OP. Can you tell me which lengths of time have not been supported in validity studies? I am actually interested to hear. There is no doubt that they differ from medical conditions.

Really? Does it invalidate medical conditions, which you propose as a gold standard, that physicians are still needed to make a diagnosis? Or are lay diagnoses sufficient, in your opinion?

I think you have demonstrated otherwise here. I’ve also published as a clinical psychology researcher. What does that mean?

You do know a lot, as far as you can tell.

What? Too bad we can’t scientifically study black holes, planetary motion, evolution, the behavior of dinosaurs….

To ShibbOleth, you said:

That’s funny, according to the DSM-IV, of the APA, your quote is the “essential feature” under the expanded description. The “basic criteria” are A. The symptoms I identified before; B. The presence of symptoms and impairment before age 7; C. impairment in two or more settings; D. Evidence of impairment in social academic or occupational functioniong; and E. the symptoms occur outside of the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder, and are not better accounted for by another mental disorder

From DSeid:

None taken, but largely because you really seem to be responding to internal stimuli (i.e. a different argument altogether). Or at least I can only infer that it comes from my response to TvAA when he claimed:

, although I didn’t call bullshit on this one. Nor did I claim that subjective determination or clinical judgment is not necessary; in fact I said that it was preferable. But the content of the symptoms is specific. For example, “Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)” APA, 1994, p. 84. I agree that “often” is a subjectively determined quality. Otherwise, I see this as specific.

I use a checklist and a clinical interview to follow up so as to confirm positive checklist reports.

Do you mean “maladaptive and inconsistent with developmental level”? Okay, yes, this also must be based on a clinical judgment, given knowledge of development.

How about the DSM IV Field Trials. You can start with some of Ben Lahey’s papers:
Applegate B, Lahey BB, Hart EL et al. (1997), Validity of the age of onset criterion for attention-deficit/hyperactivity disorder: a report from the DSM-IV field trials. J Am Acad Child Adolesc Psychiatry 36:1211–1221
2. Lahey BB, Applegate B, McBurnett K et al. (1994), DSM-IV field trials for attention deficit/hyperactivity disorder in children and adolescents. Am J Psychiatry 151:1673–1685
3. Lahey BB, Flagg EW, Bird HR et al. (1996), The NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study: background and methodology. J Am Acad Child Adolesc Psychiatry 35:855–864
4. Lahey BB, Pelham WE, Stein MA et al. (1998), Validity of DSM-IV attention-deficit/hyperactivity disorder for younger children. J Am Acad Child Adolesc Psychiatry 37:695–702

I would suggest that we are already well past the beginning.

I do not think you have read any of the literature demonstrating the validity and reliability of the existing diagnostic criteria within the DSM-IV.

What is squishy? DSM II might have been a start. DSM III was an improvement, III-R a further improvement, IV still greater refinement. But it could very definitely be further improved. Doesn’t mean that it is not the result of scientific exercise. Its poor application doesn’t mean that it cannot be scientifically applied. Please educate yourself about the nature of the science behind it.

I never claimed schizophrenia was or was not a single disease. Again, which debate are you watching? My point is that schizophrenia is a taxon that has demonstrated validity and reliability. It may be an equifinal outcome of a number of different processes, or different conditions that happen to hang together more often than not, or a single process. But as a diagnostic category, it has utility.

I do maintain a healthy skepticism. That doesn’t mean I have to tolerate ignorance regarding what is known and what is not. If you want to put forth arguments about whether something is a science or not, you should read and understand what the current literature is.

** Then you’re not familiar with the debate over whether grief reactions should be considered clinically pathological and treated? I find this surprising, coming from a professional.

** Challenge accepted. It’s gonna take me a while, though – the best available sources no longer mention the defective criteria.

** The problem is that the distinction between those things is already confused.

** Accurate according to what? I don’t have an “agenda” – I reached my conclusions rather reluctantly. The problem is that the existing theories are supported by frighteningly little evidence – they’re mostly suppositions, and data acquired on the assumption of those suppositions.

** I haven’t promised anything. I note you haven’t pulled out evidence examining the essential validity of your position, either. Citing the DSM is a poor way to demonstrate its validity.

** Most are not scientific in its application.

Look carefully at those diagnostic criteria. They’re not operationalized, which makes them impossible to study in their current form. The criteria rely mainly on professional opinion, which history has shown to be a poor judge of validity.

Reliable indicators of what? The indicators are chosen based on their ability to segregate cases in the same way that professionals exercising their judgment subjectively do. The professionals are the ultimate standard here.

What are the objective properties that these indicators are supposed to be a guide to? We don’t know them! Do you have any idea how many physiological explanations have been excitedly proposed as the “actual” causes of depression? Do you have any idea of how many times such premature theorizing has been shot down?

** You do have any idea on how the DSM criteria are reached? Voting.

** Define impairment. Actual known physical diseases do not necessarily cause impairment. Why are psychiatric “diseases” any different?

** Any of them.

Tell me, what’s the difference between a person who suffers the symptoms of depression for a week and one who suffers from them for three weeks? Why isn’t it possible to experience a short burst of depression?

** Medicine is also often non-scientific. Thankfully, that’s begun to change in the past twenty years or so – diagnoses and treatments are now based on actual scientific understanding and analysis, instead of tradition.

** I beg to differ. You don’t seem to understand how psychology actually works, and then you call those who do ignorant because their claims don’t match your illusions. Nice.

** There are ways to scientifically study all of those things. First, it’s useful to show that they exist.

Hentor asks

and so on.
Care to tell me which of these papers meets my challenge? I’ve looked through the abstracts on them and none do what I asked to my read. Perhaps I missed something. Or perhaps you should try again. Take a bunch of real patients: patients who emphasize different aspects of their story on each retelling like in real life; patients with a variety of diagnoses - and see if a bunch of different real psychologists using the DSM agree on their labels blinded to each others assessments.

The reality is that these diagnostic groupings have very fuzzy borders and much overlap. They blur into each other and into normal. Some people are far removed from those blurry edges but many are not. But the alternative is to have no common vocabulary at all. So the DSM is good thing.

I do believe that clinical psychology research is scientific, but not because I believe that the DSM is such a great tool. I believe it because psychological research is trying to develop better models and is willing to modify or discard hypotheses as more data becomes available. Because it is trying to measure in meaningful ways even if it has not got it right yet. That process is scientific.

OTOH, the impression that you give, whether intended or not, is dogma. And where dogma lives, science rarely flourishes.

Can we at least agree that, although the brain is a complex mechanism, incompletely understood, disorders of it have complex ramifications that require human interpretation and judgement to identify, that these interpretations are subject to human error, despite all that the underlying medical situation is nonetheless real? Gravity existed before Newton, after all.

Part of the problem with this debate is that I’m having trouble believing that a professional in the field isn’t actually aware of some of these issues. This causes me to suspect that Hentor is deliberately pretending ignorance in order to more convincingly argue his position.

I’m going to go search for documentary evidence of the past ADHD beliefs. Since they’re wrong, they’ll not be part of recent materials, but I think I can dig up some turn-of-the-decade materials that included them. 1990 or so should do it.

In the meantime, consider this:

A few years ago, some psychologists noted that antidepressant drugs significantly reduced the grief reaction. Note: we’re not talking about grief combined with depression, or grief that becomes depression over time. We’re talking about the supposedly “normal” grieving process people commonly go through after a death or major loss.

They then proposed that grief be considered a clinical condition with a specific treatment method: antidepressants. They argued that the mathematical normality of a condition does not imply that it is psychologically healthy or normal in the “socially appropriate” sense (rather like obesity, which is increasingly common but considered unhealthy). Since grief involves suffering and emotional pain, and the antidepressants signficiantly reduced the intensity and duration of the painful emotions associated with grief, they claimed they possessed a duty to treat it as any other mental illness.

Now, were they wrong? If so, why were they wrong? Just claiming that grief is “obviously” not an illness doens’t cut it – when it meets the same criteria for a mental disorder as dozens of other conditions, why should it be considered normal?

What debate am I watching? Well I responded to this interchange, in which Hentor objected to characterization of mental illness diseases as sympyoms.

But I guess Hentor was really just being argumentitive and I misunderstood what was really meant since the last posts state

And

And here Hentor and I can, I think, agree with Elvis above. Yes they are symptoms groupings of a very complex system that is incompletely understood, and atttempting to group what you observe into patterns that have predictive value is the way you approach studying such scientifically.

Alchemy has demonstrated validity and reliability.

They suck, but it has them.

If I may briefly remind us all of the definitons of these terms:

Reliability refers to the degree to which a measurement or interpretation can be repeated. If presented with a particular patient, the criteria for a mental illness must be sufficiently clear that multiple professionals can likely reach the same diagnosis.

Reliability is fairly easy to reach. The problem with the DSM is that the criteria as written aren’t particularly reliable, because they rely heavily on judgment calls and subjective interpretation on the part of the examiner. (What I consider to be a disruption of someone’s everyday life might not be seen as a symptom by someone else.) This problem is avoided by teaching psychological professionals the same implicit criteria by exposing them to other professionals making “correct” decisions. That’s what “professional experience” is, and why it’s not considered correct for non-professionals to apply the standards of the DSM on their own.

(In the more objective parts of medicine, expert computer systems often perform more accurately, judging from outcomes, than humans do. But I digress.)

Validity requires that your definition match the actual concept. This is much harder to attain, and it’s fiercely debated in psychology. Is there a single disease process that we call ‘schizophrenia’ and which we merely need to find better and better symptomatic definitions for, or are there multiple conditions being given the same name? Are the states identified as ‘depression’ necessarily illnesses, or can some of them be considered normal and healthy states that merely lie at the extremes of experience? Are they sometimes, never, or always biologically initiated? Psychologically initiated? What should be considered a sufficiently negative effect on functioning?