ADD: Fancy Name for Something we all have?

Okay, now you’re being a jerk. In addition to the cites you still need to bring, you now need to show where I said I was or wasn’t familiar with anything. What I did say is that rather than make an allusion to something in the guise of drawing me into an unframed debate, you have to illustrate what you’re talking about, why it’s relevant, and how it is supported. I will not guess as to your point and relevance to make these things for you. Retract this now.

But you said that it was all over the place only within the past decade. Should be easy to pull any one of those recent references.

You may be confused about them – your argument is all over the place and getting no better.
In fact, here is my bottom line, which I have contended all along. Clinical psychology is a science. It engages in empirical efforts to demonstrate whether the theories it employs are useful, valid and reliable. Our categorizations of disorder work better than anything else that is out there, but can and must be improved, whether by refining the symptoms that we have, or by improving our biological markers. There are many practitioners of clinical psychology in many variations and forms. Not all of them practice in a scientific manner, but this does not invalidate the field as a science. Claims that it is not a science should be supported by specific evidence.
In terms of this debate, the same is true for ADHD. We have refined the criteria to their present point. They work well. They are based on hundreds of studies. Children who meet the criteria are distinct from children who do not. Children who meet the criteria are distinct from children who meet criteria for other disorders. Like all psychiatric disorders, they are imperfect, and must be improved.

Your suspicions continue to be dubious. I have pretended nothing. Again, where did I say I was unaware of anything. Retract this or support it. The truth is that your argument is all over the board, including multiple disorders, multiple disciplines, multiple methodologies, and multiple levels of systems. It is disorganized, and near rambling, although you appear to be an intelligent person.

How about you get the info before introducing even further confusion to this and your own argument. Remember, your assertion was that the diagnostic standard was the application of stimulants.

As to your discussion of depression: Relevance, Mr. Vorlon? Rather than guess your point in relation to the main discussion, please show us. It feels more like a tangent.

Sorry, the above is in response to Vorlon.

To DSeid

All of these papers include comparative validity information, although this may not be included in the abstracts. However, you are right that they do not compare two independent professionals, but rather clinician diagnoses with other methods of rating the disorder. Perhaps the NIMH MTA study contains two clinical diagnoses that have been compared. I know that DISC reliability studies contain interrater reliability information. If I can find good studies specific to your point (clinician versus clinician reliability, rather than multi-method validation), I will bring you the references.

This differs greatly from what you said before.

I think the DSM is a good tool, but far from a great tool, and again, must be improved. I don’t think I’ve said otherwise. If I have appeared dogmatic, I feel bad about that. But in the context of arguing with a person making unsupported allegations about clinical psychology not being a science, I probably have taken up a broader and more unyielding position than I would in an argument about whether the ADHD criteria are perfect or not. I think, again, it is unfair to conflate your argument with me and Vorlon’s, but I think you have. At least, you seem to be saying things here that are in agreement with what I have said all along.

** Retract? Okay, fine. I’m not in the least surprised that you weren’t familiar with that issue and the professional questions it brings up, nor am I surprised that you now claim not to recognize the context in which that issue appeared. It’s exactly what I expected.

Happy?

** Online sources making this claim have become increasingly scarce, since it’s now well known to be erroneous.

How long have you been a psychological professional, Hentor? Even considering that I need cites to convince those less well-versed in the history of psychiatric treatment, shouldn’t you recognize this claim?

Oh, wait. Forgot. I’m not surprised by this in the least.

** Fine. We can debate whether the concepts defined in the DSM are useful, although since virtually all treatment milieus require a diagnosis from the DSM, and all research and treatment is based on the DSM diagnoses, we could say that they’re necessarily useful.

We can show that the diagnoses are reliable. That merely requires demonstrating that many different practitioners, acting independently, will assign the same label to any particular set of presenting symptoms. Trivial.

Now, validity is a completely different manner. We can determine how valid a diagnostic system is only by having objective means of determining whether a condition is actually present. For example, we can judge whether a particular method of cancer detection is valid by comparing it to a method of known accuracy – say, whether patients develop obvious cancer within the next ten years. Without the ability to make fiduciary observations, validity can’t be known.

These psychiatric conditions are defined entirely by collections of symptoms. The DSM criteria ARE their definitions. We have no objective, operational way to even think about them. Whether these conditions are valid is the one of the greatest unanswered questions in psychology, and the greatest in clinical psychology.

You can’t simply take the validity of these methods for granted when there is no way to establish their validity.

** According to what standard? You’re begging the question here.

** Studies of what? How do we evaluate the definitions we create?

** The criteria as given in the DSM? No. Those criteria reference concepts like “clinically significant” that are not operationally defined within the DSM, or explicitly defined anywhere. The only way practitioners can learn them is by absorbing them from other practitioners.

The behaviors which define ADD occur on a continuum; we’re not presented with discrete properties, here.

** By what standards are they imperfect? Improved according to what?

The DSM diagnostic criteria and listing of conditions is determined by vote. That’s how it’s revised! How do you think the definition of homosexuality was changed from a mental illness to a healthy difference in sexual orientation? In 1974, a vote among the members of the APA decided it: 5,854 to 3,810 against.

** The entire system is circular. The definitions of the conditions is based on clinical experience of people with those conditions. We assign the labels according to the definitions, which are based on the conditions, which are based on the definitions…

At no point does this chain of analysis ever point to objective entities. Well, that’s not quite true: we do observe that certain types of symptoms occur together frequently in presenting patients, but we merely attribute these patterns to underlying disease processes. We have no means of confirmation.

“Appear to be an intelligent person”? I suppose I should take that as a compliment.

** It was. Many practitioners used the response to stimulant drugs to determine if the condition was “actually” ADD. We now know that’s invalid.

It’s a much older recognized condition than ADD, is extremely common, and is frequently represented. It makes for a great example when discussing the problems with psychiatry and clinical psychology.

If you all get a chance, read the following article:
Time Magazine Article

You can probably find it at your local library, since you’d have to pay to access the online archive.

It’s an article from Time, so it’s not very sophisticated, and it’s definitely aimed towards the ignorant layperson. Still, it’s useful.

Also take a look at Blaming the Brain by Elliot Valenstein, a Professor Emeritus of Psychology and Neuroscience at the U. of Michegan. He’s also the president of the Comparative and Physiological Psychology Division of the APA and a fellow at both the Center for Advanced Study in the Behavioral Sciences and the National Humanities Center.

His book is excellent, non-proselytizing, fully backed up by research, easy to read and understand, and (IMO) quite convincing. Admittedly, I found and read it many years after I reached essentially the same conclusions about the problems with psycholgy, so I’m biased. Try it.

No, I consider it to be the lowest form of discourse. You’ve claimed I said something I didn’t. I asked you to cite where I said it or retract. You responded as above, continuing as if I said it. This speaks volumes about the nature and quality of your argument. You are not worthy of continued response.

Actually, if you’d bothered to read my statements properly, you’d see that I never claimed you weren’t familiar with the subject.

Your statement “Why don’t you make a point, explain its relevance, and provide evidence, and then we will be able to debate it.” is what’s so strange.

If we were discussing the degree to which the frontal lobes are the source of personality, and I mentioned Phineas Gage, virtually everyone with a basic education in psychology would understand the reference and what conclusions are generally drawn from it.

In a debate about the nature of psychiatric diagnosis, the relatively recent debate over the clinical implications of grief’s responsiveness to antidepressant treatment is a subject that any professional in clinical psychology should have at least heard of. Since you didn’t respond to any of the obvious issues it brings up, either you’re feigning ignorance in an attempt to strengthen your position by ignoring contradictory points, or you really haven’t kept up to date at all.

Run away if you wish, but I think you’re leaving because you’re losing the debate.

Y’all are free to draw whatever conclusions you like.

A chorus of wind chimes, and all that.

"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… 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.” – DSeid

Agreed. The medical folks need a focused, but arbitrary “term” of departure for investigations into ADD and other conditions that they don’t understand. But in the fuzzy case of ADD it is criminal for these mini-gods to dope up a large measure of an entire generation of children while they are considering cause and effect.
What arrogant jerks!

Here’s an aside…

The normal temperature of the human body was determined in the 1930’s by a large population study of temperatures and averaged out at 98.7 degrees. This was the medical benchmark for seventy years. Then a few years ago it was found to be wrong. It should have been 98.3 degrees.*******

The study was properly done, but someone made a mistake in division. No one had questioned or corrected the faulty math for several generations of pill-happy diagnosing doctors.

"And where dogma lives, science rarely flourishes." - DSeid

******* * Or vice versa or something else. I’m not sure about the actual numbers but then again neither were they.*

Now, now, Hentor. Pay attention. Are you familiar with the concept of a rhetorical question?

I certainly was not previously suggesting that you’re not familiar with the issue at hand; the implication was that you were deliberately feigning ignorance because you didn’t like the implications of the referenced events.

Now, I’m beginning to believe that you really weren’t aware of it. Methinks the lady doth protest too much, and all that.

For a supposed professional, you demonstrate a shocking lack of grasp of the fundamentals of scientific philosophy. Perhaps you should take a few courses in experimental design and inferential logic to bone up a bit.

This changes what I said earlier - it is so convoluted and pathetic that it does merit a response. You’re suggesting that my choice not to respond to a rhetorical question (i.e. a question asked for effect, and not in search of a response) is indicative of what I know about a topic area? I give you the logic of the Vorlon, ladies and gentlemen. Vorlon, your thinking continues to be scattered around and away from the topic, convoluted and lacking in coherence. If you wish to regard this as evidence for your line of argument and my professional abilities, there is very little I can do about that. As you have said before, you probably would not want to seek treatment from me. Good luck, sir. May you someday experience lucidity!

Don’t be silly. The statement regarding the debate about whether grief should be considered a clinically treatable condition wasn’t rhetorical. The question about whether you were unfamiliar with the subject was.

Are you sure you’re a professional?

I know they are correlated in the general population because while no psychologist, I have as much interaction with the general population as the next person, and can make my own observations. This (i.e. the correlation between inattention and hyperactivity) also seems to be pretty widely accepted - I’m surprised that you would be challenging it.

It is not uncommon for personality issues to present themselves with different symptoms. If you take people who tend to get angry, for example, if you broke it down enough you could surely isolate different aspects of this trait that were not universally shared. This would not indicate completely different underlying conditions - only that people’s minds are complex, with myriad influences on their emotions, which can vary the way they feel.

Well I agree that the number of symptoms is significant, but not in isolating it as a “disease”; rather in gauging the scope of the problem.

For purposes of convenience it is easier to refer to it the way I did. No technical argument was intended with this.

Yes, I agree, that as a practical matter impairment matters. But it is not significant in terms of understanding the condition.

If you would agree with me that there is a fundamental difference - though not a practical one (they are equally impaired) - between an extremely short person from an extremely short family and an equally short person who suffered from some hormone deficiency, we can frame the issue using this analogy. The question WRT ADHD is whether it is more similar to the first short person or more similar to the second. Meaning the random result of the normal distribution in attention span and whatnot, or some illness skewing what would otherwise be this person’s “normal” traits.

Milum states

Your analogy may actually be quite apt although I disagree with you interpretation. For fevers the reality is that there is no normal temperature. Everybody has their own set point and a range that they typically go through throughout the day. And whether “normal” was declared 98.6 or whatever we treat fever a) as a sign of underlieing disease
b) for the discomfort that it causes.
Not because it is a point above some supposed normal value.

And so with ADD. First step: is this a sign of some underlieing problem? Family dysfunction or learning disability for example. Yes? Address those issues. No? Then Second step: If it is causing significant pain (impairment) then consider treating the discomfort, treating the symptom. And here we have the data. Meds work well. They do not “dope” kids up. They have known risks of side effects that we can inform patients about ahead of time so that they (and their families) can make informed decisions.

No, the practice of clinical psychology is not “scientific” (even though the research is, and I think some is this thread is the talking at cross purposes about clinical use and research) and I find that the fuzziness of these labels leads to poor reliability in real world situations (as opposed to research protocols.) But to me as a clinician (and I am very politically incorrect in this regard) the precision of the label is less important than if the intervention works. The labels are shorthands. Sometimes good shorthands but sometimes not. I’ve seen kids’ labels change* without really changing their care. And me? I care about whether or not they’ve had adequate testing for LDs and adequate remediation, if the family needs more support than they are getting, and if medication helps or not and with what side effects.

*And sometimes amazingly different; Sensory Integration Disorder (don’t get me going on this one) into ADD into Asperger’s into …

Milum states

Your analogy may actually be quite apt although I disagree with you interpretation. For fevers the reality is that there is no normal temperature. Everybody has their own set point and a range that they typically go through throughout the day. And whether “normal” was declared 98.6 or whatever we treat fever a) as a sign of underlieing disease
b) for the discomfort that it causes.
Not because it is a point above some supposed normal value.

And so with ADD. First step: is this a sign of some underlieing problem? Family dysfunction or learning disability for example. Yes? Address those issues. No? Then Second step: If it is causing significant pain (impairment) then consider treating the discomfort, treating the symptom. And here we have the data. Meds work well. They do not “dope” kids up. They have known risks of side effects that we can inform patients about ahead of time so that they (and their families) can make informed decisions.

No, the practice of clinical psychology is not “scientific” (even though the research is, and I think some is this thread is the talking at cross purposes about clinical use and research) and I find that the fuzziness of these labels leads to poor reliability in real world situations (as opposed to research protocols.) But to me as a clinician (and I am very politically incorrect in this regard) the precision of the label is less important than if the intervention works. The labels are shorthands. Sometimes good shorthands but sometimes not. I’ve seen kids’ labels change* without really changing their care. And me? I care about whether or not they’ve had adequate testing for LDs and adequate remediation, if the family needs more support than they are getting, and if medication helps or not and with what side effects.

*And sometimes amazingly different; Sensory Integration Disorder (don’t get me going on this one) into ADD into Asperger’s into …

Well, your observations are great, as far as they go. I’m not arguing that they aren’t correlated (or that they are, either) - I asked, how do you know? I don’t. My own observations wouldn’t suitably address this question, and I don’t know of any general population studies of these things at the symptom level. And again, if they were all the same thing, we wouldn’t see variance within the symptoms demonstrated by children with ADHD. We do however, sufficient that we can distinguish typologies.

How do you know this? Again, I don’t know about subtyping among anger symptoms, but I wouldn’t expect that there would be 6 billion “types” of anger. The question would be: how many different types can be distinguished in such a way that the constructs of “anger typology” have utility for making any predictions (about consistency over time, outcomes, comorbid conditions, etc.)? If some utility could be gained, why not use it as a construct?

Oh, sorry.

Still not fully grasping your point, I would agree not that there was a fundamental difference, but an etiological one. The cause is different, but the “outcome” is essentially the same. But I am having trouble linking this to the discussion of the distribution. I think that in part, we are talking here again about equifinality, and if we knew the precise causes of ADHD, your analogy might be appropriate. We just don’t - it could be that excessive classical music in the womb caused ADHD for some kids, while paternal penis length causes ADHD for others. Unfortunately, right now all we can say is that the clustering of these behaviors, along with several other factors (age of onset, generalization across settings) is often associated with w, x, and y and is best addressed by doing z. Hopefully I haven’t mangled the gist of the point you were making.

Just to follow up, Dseid, as I suggested earlier, it is less common to have data from two clinicians than it is to compare a clinician rating to another measure, or to test interrater reliability for non-clinician raters. There are a few studies that do compare interrater agreement between two clinicians, but they are spread out over time, and therefore over DSM versions, and over age groups. Werry et al (1983), using DSM III criteria, found acceptable interrater agreement for ADD, with a kappa value of .76. Lavigne et al (1994) found that kappa agreement among children 5 or under, using DSM-III-R was .54, which is below what is generally considered a minimally acceptable level of reliability. Faries (2001), in a paper I have only been able to get the abstract for, indicates acceptable reliability of clinician ratings of severity on a specific ADHD measurement instrument. As an example of results using trained lay interviewers, Shaffer et al (1996) reported moderately good agreement (kappa=.84) for raters of symptom counts using the DISC based on parent report, and .65 when based on child reports (combined kappa = .79), and a combined parent and child kappa of .80 for criterion counts.

A host of other studies report interrater agreement. A review by Goldman et al in JAMA (1998) is interesting. He asserts that “Overall, ADHD is one of the best-researched disorders in medicine, and the overall data on its validity are far more compelling than for many medical conditions.” I would have liked to see him elaborate on this point, because he does not provide specific examples. But then again, Goldman is a physician, and may thus be prone to oversimplifying things.

But the problem is that the measures are always compared to other measures. There’s no way to compare the measures to an objective reality because there is none.

Without an objective definition of conditions like ADHD, all we can do is show that physicians agree with each other on what it is. We can’t show that physicians are accurate.

** Objection. This assertion is incorrect.

Research is often shaped by the DSM diagnoses. Studies must reply on operationalizations of the DSM criteria, and although they can show the degree to which those operationalizations match clinical judgment, they cannot show that they match an objectively existing condition.

Medical research can compare an operationalization of a condition to reality, at least in most cases.

** But how can you judge whether something has “helped” without standards for what is healthy and what isn’t?

And since the appropriateness of treatments is judged according to the supposed nature of the problem…

Hentor,

I agree that the outcome is the same - this is precisely my point. I just don’t consider someone who suffers from nothing more than being at the tail end of a normal distribution of human traits to be suffering from a disease. There’s tall people and short people and people with better and worse powers of concentration. As a practical matter two people may be the same and may be affected the same way, but it doesn’t compare with someone who has some malfunction.

And it also could be that no factor causes ADHD. Maybe it’s just natural that there are going to be some people who are worse than other people in this regard, just as there are going to be some people who are better. Unfortunately society has structured itself in such a way that those who are a lot worse are at a disadvantage in coping, which leads to the characterization of this situation as an illness. If society would restructure itself in such a way that these traits presented no problems, but that being very hairy would present problems, then you would - by the same process - characterize hirsuteness as being a “disease”. Meanwhile this has not happened, so we accept varying amounts of body hair as being simply normal variation while calling ADHD a disease. Fundamentally they may be the same.

(My initial point here was in response to your rebuttal of my example of ticklishness as being off-point because this does not present problems for people. My point is that the nature of a condition is not determined by whether it presents a problem for people or not - hence my example of ticklishness, then height and now hairiness).