DSeid:
Yes, I understood that, sort of. But I was trying (perhaps unsuccessfully) to outline clear problems in the family situation that might not be so easy to dig up in course of a couple of clinical interviews. Do you often ask parents about their private family history, and the state of their current relationship, when assessing a child? Parents will be naturally a bit defensive about their child-rearing practices, and also tend to disavow or downplay anything about their history which might make them seem unusual, or potentially unsuitable, as parents. So there exists a good chance, I submit, that a cursory examination wouldn’t unearth a lot of these factors, with the possible exception of the problem concerning the lack of parental consistency in discipline. They are the sorts of problems that would perhaps require a few sessions of family therapy before surfacing.
And on what basis do you diagnose the parents, and determine that their symptoms are also genetic, rather than the result of ego defenses against painful childhood experiences?
Precisely. But my example relies on my assertion that the sorts of problems I’ve outlined above are rendered “invisible,” in standard clinical practice, by the DSM’s focus on a descriptive report of a hypothetical “disorder.” When you meet Joey’s parents, you meet two people who, for all the world, appear quite normal. You may notice that Joey’s father seems a bit intense, but he certainly doesn’t suffer from ADD in any classical sense. Joey’s mother will not want to discuss her alcoholic father with you, nor does she perceive a connection between Joey’s condition and her aversion to peas.
In other words, I’m not convinced that Joey is “disordered” in the sense one might generally conceive of the term. Rather, he’s simply reacting to a dysfunctional situation that, if we apply DSM criteria for diagnosis, would not be noticed. This is the weakness of the DSM that I hoped my example would illustrate – but yeesh are you guys a tough audience!
To try to put it another way: one child, suffering from “real,” genetically determined ADHD, comes from a family that displays none of the dysfunctional dynamics I outlined above. Another, who would otherwise develop quite “normally,” suffers from symptoms much like ADHD because of family problems. But both display behavior that is consistent with the DSM criteria for the disorder, and I suspect that both will receive the same treatment. In the best case scenario, that treatment would begin with therapeutic interventions; in Joey’s case, those interventions would bear fruit, but in the case of the second child, suffering from a biological problem, they would not. (Even that is an oversimplification, because therapy can help children who suffer from the biological disorder as well.) But in the worse case scenario, Joey’s physician gives the family a little advice, puts Joey on medication, and either way, there appears to be a marked improvement.
Hentor:
I didn’t realize I was being so “non-committal,” but anyway the example is hypothetical. I would be very interested to read your review, if you care to post the specifics (or you can send them to me by email).
Yes, that sounds like a very good approach. But I must confess that in my professional experience, I’ve never seen it.
I have only anecdotal evidence from my practice (and in my circle of friends), where similar cases are occasionally discussed. In those cases, almost exclusively, prescriptions of medication are virtually invariably the first line of response. After all, therapy is demanding, time-consuming, expensive, and cannot guarantee significant improvement. In addition, it may result in the revelation of “uncomfortable truths” that the entire family system is basically designed to keep hidden. By contrast, medicine is cheap, usually effective, promises quick results, and doesn’t “rock the boat,” if you get what I mean.
Yes, it’s my contention that Joey’s situation would “mimic” ADHD, without necessarily requiring a biological component. As far as I’m aware, however, that doesn’t contradict the DSM-IV, which specifically seeks to avoid causal explanations and holds itself to a strictly descriptive delineation of mental disorders. In other words, as far as I know, the DSM-IV does not rule out the possibility that symptoms of ADHD could in some cases be the result of environmental factors exclusively. Is that incorrect?
As I stated, Joey’s mother gave him a 5, his father a 6, and his teacher a 9 on the Connor’s scale. Just to keep my scenario consistent, let’s say he falls into the “hyperactive-impulsive” subtype. I’m not sure what you mean by “adequate historical review,” since the diagnosis (as explicated in the DSM-IV) doesn’t stipulate anything about the sufferer’s history other than the fact that his symptoms should not be explicable as a “culturally sanctioned” response to emotional trauma or something along those lines. No one close to Joey has died. He meets the criteria of the disorder, and the DSM makes no mention of considering the state of his family relations.
That’s a very good question.
But let’s ask it this way: let’s say that Joey’s family goes into therapy, and they respond positively. As a result, Joey’s symptoms gradually disappear. Would that mean that he did not have ADHD?
It’s my contention that the symptoms of ADHD may in some case be the result of a biological disorder, in some cases a result of environmental problems, and in some cases a result of both working together. I also think that:
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It’s inappropriate to address Joey’s family problems by medicating Joey;
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It’s inappropriate to address the problems of a child with a “biological” ADHD disorder with family therapy.
So, ideally, the diagnosis should be able to differentiate between the two.